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

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

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

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

Peripheral arterial disease in Scottish military veterans: a retrospective cohort study of 57 000 veterans and 173 000 matched non-veterans

Background: While traumatic limb loss in military personnel is widely known, the threat posed by peripheral arterial disease (PAD) in those who have served is less well recognized. The aim of our study was to examine the risk of PAD in a Scotland-wide cohort of veterans who served between 1960 and 2012. Methods: Retrospective 30-year cohort study of 56 205 veterans born 1945–85, and 172 741 non-veterans, matched for age, sex and area of residence, using Cox proportional hazard models to examine the association between veteran status, birth cohort, length of service and risk of PAD leading to hospitalization or death. Results: Overall, veterans were at increased risk of PAD compared with non-veterans, unadjusted hazard ratio (HR) = 1.46, 95% confidence intervals (CI): 1.33–1.60, P < 0.001. The highest risk was in veterans born between 1950 and 1954, HR = 1.76, 95% CI: 1.50–2.07, P < 0.001, and in those with the shortest service (early service leavers), HR = 1.84, 95% CI: 1.49–2.27, P < 0.001. Conclusions: The findings provide evidence for a hidden burden of life- and limb-threatening PAD in older veterans and are consistent with the higher rates of military smoking which have been reported previously. The study emphasizes the need for vascular preventive measures in this group

Association between grip strength and diabetes prevalence in black, South Asian, and white European ethnic groups: a cross-sectional study of 418,656 UK Biobank participants

Aims: To quantify the extent to which ethnic differences in muscular strength might account for the substantially higher prevalence of diabetes in black and South-Asian compared with white European adults. Methods: This cross-sectional study used baseline data from the UK Biobank study on 418 656 white European, black and South-Asian participants, aged 40–69 years, who had complete data on diabetes status and hand-grip strength. Associations between hand-grip strength and diabetes were assessed using logistic regression and were adjusted for potential confounding factors. Results: Lower grip strength was associated with higher prevalence of diabetes, independent of confounding factors, across all ethnicities in both men and women. Diabetes prevalence was approximately three- to fourfold higher in South-Asian and two- to threefold higher in black participants compared with white European participants across all levels of grip strength, but grip strength in South-Asian men and women was ~5–6 kg lower than in the other ethnic groups. Thus, the attributable risk for diabetes associated with low grip strength was substantially higher in South-Asian participants (3.9 and 4.2 cases per 100 men and women, respectively) than in white participants (2.0 and 0.6 cases per 100 men and women, respectively). Attributable risk associated with low grip strength was also high in black men (4.3 cases) but not in black women (0.4 cases). Conclusions: Low strength is associated with a disproportionately large number of diabetes cases in South-Asian men and women and in black men. Trials are needed to determine whether interventions to improve strength in these groups could help reduce ethnic inequalities in diabetes prevalence

Chronic obstructive pulmonary disease in Scottish military veterans

Introduction: Smoking is a major risk factor for chronic obstructive pulmonary disease (COPD). Serving military personnel have previously been shown to be more likely to smoke, and to smoke more heavily, than civilians, but there is no clear consensus as to whether in later life, as veterans, they experience a higher prevalence and mortality from COPD than do non-veterans. We examined the risk of COPD in Scottish veterans and assessed the impact of changes in military smoking. Methods: Retrospective 30-year cohort study of 56 205 veterans born 1945–1985, and 172 741 people with no record of military service, matched for age, sex and area of residence, using Cox proportional hazard models to examine the association between veteran status, birth cohort, length of service and risk of COPD resulting in hospitalisation or death. Results: There were 1966 (3.52%) cases of COPD meeting the definition in veterans, compared with 5434 (3.19%) in non-veterans. The difference was statistically significant (p=0.001) in the unadjusted model although it became non-significant after adjusting for deprivation. The highest risk was seen in the oldest (1945–1949) birth cohort and in veterans with the shortest service (Early Service Leavers). The risk was significantly reduced in veterans born from 1960, and in those with over 12 years' service. Conclusions: Our findings are consistent with falling rates of military smoking since the 1960s, and with the reduction in smoking with longer service. The oldest veterans, and those with the shortest service, are least likely to have benefited from this, as reflected in their higher risk for COPD

Healthy workers or less healthy leavers? Mortality in military veterans

Background: The ‘healthy worker effect’ predicts that longer employment is positively associated with reduced mortality, but few studies have examined mortality in military veterans irrespective of exposure to conflict. Aims: To examine mortality in a large national cohort of Scottish veterans by length of service. Methods: Retrospective cohort study comparing survival in up to 30-year follow-up among 57 000 veterans and 173 000 people with no record of service, matched for age, sex and area of residence, who were born between 1945 and 1985. We compared antecedent diagnoses in the two groups to provide information on probable risk factors. Results: By the end of follow-up, 3520 (6%) veterans had died, compared with 10 947 (6%) non-veterans. Cox proportional hazard analysis confirmed no significant difference overall unadjusted or after adjusting for deprivation. On subgroup analysis, those who left prematurely (early service leavers) were at significantly increased risk of death (hazard ratio (HR) 1.16, 95% confidence interval (CI) 1.09–1.24, P < 0.001), although the increase became non-significant after adjusting for socioeconomic status (HR 1.05, 95% CI 0.99–1.12). Longer-serving veterans were at significantly lower risk of death than non-veterans; the risk decreased both with length of service and in more recent birth cohorts. Smoking-related disease was the greatest contributor to increased mortality in early leavers. Conclusion: Among longer-serving veterans, there was evidence of a HWE partly attributable to selective attrition of early service leavers, but birth cohort analysis suggests improvements over time which may also reflect a causal effect of improved in-service health promotion