Effect of socioeconomic deprivation on waiting time for cardiac surgery: retrospective cohort study

OBJECTIVE: To determine whether the priority given to patients referred for cardiac surgery is associated with socioeconomic status. DESIGN: Retrospective study with multivariate logistic regression analysis of the association between deprivation and classification of urgency with allowance for age, sex, and type of operation. Multivariate linear regression analysis was used to determine association between deprivation and waiting time within each category of urgency, with allowance for age, sex, and type of operation. SETTING: NHS waiting lists in Scotland. PARTICIPANTS: 26 642 patients waiting for cardiac surgery, 1 January 1986 to 31 December 1997. MAIN OUTCOME MEASURES: Deprivation as measured by Carstairs deprivation category. Time spent on NHS waiting list. RESULTS: Patients who were most deprived tended to be younger and were more likely to be female. Patients in deprivation categories 6 and 7 (most deprived) waited about three weeks longer for surgery than those in category 1 (mean difference 24 days, 95% confidence interval 15 to 32). Deprived patients had an odds ratio of 0.5 (0.46 to 0.61) for having their operations classified as urgent compared with the least deprived, after allowance for age, sex, and type of operation. When urgent and routine cases were considered separately, there was no significant difference in waiting times between the most and least deprived categories. CONCLUSIONS: Socioeconomically deprived patients are thought to be more likely to develop coronary heart disease but are less likely to be investigated and offered surgery once it has developed. Such patients may be further disadvantaged by having to wait longer for surgery because of being given lower priority

Classification and Protection Status of Remnant Natural Plant Communities in Arkansas

A classification and inventory of Arkansas\u27s remaining tracts of relatively undisturbed vegetation was initiated in 1979. Based on extensive literature surveys and field work, the classification includes five physiognomic classes, 17 cover classes, and 46 cover types, arranged hierarchically. High quality examples of ten of the cover types have been located in designated wilderness or state natural areas, where they are protected by law, while an additional three occur in research natural areas or Forest Service special interest areas. The remaining 33 cover types have no known long-term protection. Lands having wilderness, state natural area, research natural area, or special management area status total nearly 51,000 acres in the state. No more than one-tenth of this area, however, supports vegetation in relatively undisturbed condition

Angioplasty, bypass surgery or medical treatment: how should we decide?

Coronary revascularisation continues to be underused despite evidence that this results in poorer outcome

Birth order, gestational age, and risk of delivery related perinatal death in twins: retrospective cohort study

Objective: To determine whether twins born second are at increased risk of perinatal death because of complications during labour and delivery. Design: Retrospective cohort study. Setting: Scotland, 1992 and 1997. Participants: All twin births at or after 24 weeks' gestation, excluding twin pairs in which either twin died before labour or delivery or died during or after labour and delivery because of congenital abnormality, non-immune hydrops, or twin to twin transfusion syndrome. Main outcome measure: Delivery related perinatal deaths (deaths during labour or the neonatal period). Results: Overall, delivery related perinatal deaths were recorded for 23 first twins only and 23 second twins only of 1438 twin pairs born before 36 weeks (preterm) by means other than planned caesarean section (P>0.99). No deaths of first twins and nine deaths of second twins (P=0.004) were recorded among the 2436 twin pairs born at or after 36 weeks (term). Discordance between first and second twins differed significantly in preterm and term births (P=0.007). Seven of nine deaths of second twins at term were due to anoxia during the birth (2.9 (95% confidence interval 1.2 to 5.9) per 1000); five of these deaths were associated with mechanical problems with the second delivery following vaginal delivery of the first twin. No deaths were recorded among 454 second twins delivered at term by planned caesarean section. Conclusions: Second twins born at term are at higher risk than first twins of death due to complications of delivery. Previous studies may not have shown an increased risk because of inadequate categorisation of deaths, lack of statistical power, inappropriate analyses, and pooling of data about preterm births and term births

Tuberculosis in Scottish military veterans: evidence from a retrospective cohort study of 57 000 veterans and 173 000 matched non-veterans

Objective: Tuberculosis was a major cause of morbidity and manpower loss in the Armed Forces during World War II. Military control programmes commenced in the 1950s but were initially limited in scope by the many recruits who were already tuberculin positive on enlistment. The aim of our study was to examine whether veterans have an increased risk of tuberculosis compared with non-veterans. Methods: Retrospective cohort study of 57 000 veterans born 1945–1985, and 173 000 people with no record of military service, resident in Scotland, matched for age, sex and area of residence, using Cox proportional hazard analysis to compare the risk of tuberculosis overall, by birth cohort, length of service and year of diagnosis and to examine comorbidities. Results: Over mean 29 years follow-up, 69 (0.12%) veterans were recorded as having tuberculosis, compared with 267 (0.15%) non-veterans (unadjusted HR 0.90, 95% CIs 0.69 to 1.19, p=0.463). Only the 1945–1949 veterans' birth cohort was at higher risk, unadjusted HR 1.54, 95% CIs 0.98 to 2.45, p=0.061, although the difference in risk did not achieve significance. Veterans born from 1950 were at significantly reduced risk of tuberculosis compared with non-veterans after adjusting for deprivation, HR 0.67, 95% CI 0.47 to 0.95, p=0.026. The most common comorbidities were smoking-related and alcohol-related disease. The risk of comorbid hepatitis B or C was very low, in both veterans and non-veterans. No length of service was associated with an increased risk of tuberculosis in comparison with non-veterans. Conclusions: Scottish veterans born before 1950 are at moderately increased risk of tuberculosis compared with age, sex and geographically matched civilians with no record of service, although the difference is not statistically significant. Scottish veterans born from 1950 show a reduction in risk compared with civilians. Tuberculosis should be considered in the differential diagnosis of respiratory disease in the older veteran

Percutaneous coronary intervention in the elderly: changes in case-mix and periprocedural outcomes in 31758 patients treated between 2000 and 2007

<p>Background: The elderly account for an increasing proportion of the population and have a high prevalence of coronary heart disease. Percutaneous coronary intervention (PCI) is the most common method of revascularization in the elderly. We examined whether the risk of periprocedural complications after PCI was higher among elderly (age ≥75 years) patients and whether it has changed over time.</p> <p>Methods and Results: The Scottish Coronary Revascularization Register was used to undertake a retrospective cohort study on all 31 758 patients undergoing nonemergency PCI in Scotland between April 2000 and March 2007, inclusive. There was an increase in the number and percentage of PCIs undertaken in elderly patients, from 196 (8.7%) in 2000 to 752 (13.9%) in 2007. Compared with younger patients, the elderly were more likely to have multivessel disease, multiple comorbidity, and a history of myocardial infarction or coronary artery bypass grafting (χ2 tests, all P<0.001). The elderly had a higher risk of major adverse cardiovascular events within 30 days of PCI (4.5% versus 2.7%, χ2 test P<0.001). Over the 7 years, there was a significant increase in the proportion of elderly patients who had multiple comorbidity (χ2 test for trend, P<0.001). Despite this, the underlying risk of complications did not change significantly over time either among the elderly (χ2 test for trend, P=0.142) or overall (χ2 test for trend, P=0.083).</p> <p>Conclusions: Elderly patients have a higher risk of periprocedural complications and account for an increasing proportion of PCIs. Despite this, the risk of complications after PCI has not increased over time.</p&gt

Suicide in Scottish military veterans: a 30-year retrospective cohort study

Background: Although reassuring data on suicide risk in UK veterans of the 1982 Falklands conflict and 1991 Gulf conflict have been published, there have been few studies on long-term overall suicide risk in UK veterans. Aims: To examine the risk of suicide in a broad population-based cohort of veterans in Scotland, irrespect ive of length of service or exposure to conflict, in comparison with people having no record of military service. Methods: A retrospective 30-year cohort study of 56205 veterans born 1945–85 and 172741 matched non-veterans, using Cox proportional hazard models to compare the risk of suicide and fatal self-harm overall, by sex, birth cohort, length of service and year of recruitment. Results: There were 267 (0.48%) suicides in the veterans compared with 918 (0.53%) in non-veterans. The difference was not statistically significant overall [adjusted hazard ratio (HR) 0.99; 95% confidence interval (CI) 0.86–1.13]. The incidence was lower in younger veterans and higher in veterans aged over 40. Early service leavers were at non-significantly increased risk (adjusted HR 1.13; 95% CI 0.91–1.40) but only in the older age groups. Women veterans had a significantly higher risk of suicide than non-veteran women (adjusted HR 2.44; 95% CI 1.32–4.51, P < 0.01) and comparable risk to veteran men. Methods of suicide did not differ significantly between veterans and non-veterans, for either sex. Conclusions: The Scottish Veterans Health Study adds to the emerging body of evidence that there is no overall difference in long-term risk of suicide between veterans and non-veterans in the UK. However, female veterans merit further study

Secondhand smoke exposure and risk of incident peripheral arterial disease and mortality: a Scotland-wide retrospective cohort study of 4045 non-smokers with cotinine measurement

Background: Active smoking is an important risk factor for all-cause mortality and peripheral arterial disease (PAD). In contrast, published studies on the associations with secondhand smoke (SHS) are limited. The aim of this study was to examine the associations between SHS exposure and incident PAD, as well as mortality, among middle-aged non-smokers. Methods: We undertook a retrospective, cohort study using record linkage of the Scottish Health Surveys between 1998 and 2010 to hospital admissions and death certificates. Inclusion was restricted to participants aged > 45 years. Cox proportional hazard models were used to examine the association between SHS exposure and incident PAD (hospital admission or death) and all-cause mortality, with adjustment for potential confounders. Results: Of the 4045 confirmed non-smokers (self-reported non-smokers with salivary cotinine concentrations < 15 ng/mL), 1163 (28.8%) had either moderate or high exposure to SHS at baseline. In men, high exposure to SHS (cotinine ≥2.7 ng/mL) was associated with increased risk of all-cause mortality (fully adjusted hazard ratio [HR] 1.54, 95% CI 1.07–2.22, p = 0.020) with evidence of a dose-relationship (p for trend = 0.004). In men, high exposure to SHS was associated with increased risk of incident PAD over the first five years of follow-up (fully adjusted HR 4.29, 95% CI 1.14–16.10, p = 0.031) but the association became non-significant over longer term follow-up. Conclusions: SHS exposure was independently associated with all-cause mortality and may be associated with PAD, but larger studies, or meta-analyses, are required to confirm the latter

Predicting cesarean section and uterine rupture among women attempting vaginal birth after prior cesarean section

<p><b>Background:</b> There is currently no validated method for antepartum prediction of the risk of failed vaginal birth after cesarean section and no information on the relationship between the risk of emergency cesarean delivery and the risk of uterine rupture.</p> <p><b>Methods and Findings:</b> We linked a national maternity hospital discharge database and a national registry of perinatal deaths. We studied 23,286 women with one prior cesarean delivery who attempted vaginal birth at or after 40-wk gestation. The population was randomly split into model development and validation groups. The factors associated with emergency cesarean section were maternal age (adjusted odds ratio [OR] = 1.22 per 5-y increase, 95% confidence interval [CI]: 1.16 to 1.28), maternal height (adjusted OR = 0.75 per 5-cm increase, 95% CI: 0.73 to 0.78), male fetus (adjusted OR = 1.18, 95% CI: 1.08 to 1.29), no previous vaginal birth (adjusted OR = 5.08, 95% CI: 4.52 to 5.72), prostaglandin induction of labor (adjusted OR = 1.42, 95% CI: 1.26 to 1.60), and birth at 41-wk (adjusted OR = 1.30, 95% CI: 1.18 to 1.42) or 42-wk (adjusted OR = 1.38, 95% CI: 1.17 to 1.62) gestation compared with 40-wk. In the validation group, 36% of the women had a low predicted risk of caesarean section (<20%) and 16.5% of women had a high predicted risk (>40%); 10.9% and 47.7% of these women, respectively, actually had deliveries by caesarean section. The predicted risk of caesarean section was also associated with the risk of all uterine rupture (OR for a 5% increase in predicted risk = 1.22, 95% CI: 1.14 to 1.31) and uterine rupture associated with perinatal death (OR for a 5% increase in predicted risk = 1.32, 95% CI: 1.02 to 1.73). The observed incidence of uterine rupture was 2.0 per 1,000 among women at low risk of cesarean section and 9.1 per 1,000 among those at high risk (relative risk = 4.5, 95% CI: 2.6 to 8.1). We present the model in a simple-to-use format.</p> <p><b>Conclusions:</b> We present, to our knowledge, the first validated model for antepartum prediction of the risk of failed vaginal birth after prior cesarean section. Women at increased risk of emergency caesarean section are also at increased risk of uterine rupture, including catastrophic rupture leading to perinatal death.</p&gt