The PRIME study: classical risk factors do not explain the severalfold differences in risk of coronary heart disease between France and Northern Ireland. Prospective Epidemiological Study of Myocardial Infarction.
(1/723)We are studying the contribution of risk and genetic factors, and their interaction, to the development of ischaemic heart disease (IHD) and other cardiovascular endpoints. The study is prospective, based in three centres in the south, east and north of France and in Northern Ireland. A total of 10,592 men aged 50-59 years were recruited from 1991 to 1993, and examined for evidence of IHD at baseline. Subjects are followed annually by questionnaire. Clinical information is validated from hospital and GP records. Demographic characteristics were similar in all four centres. Body mass index was highest in Strasbourg (mean 27.4 kg/m2 vs. 26.3 kg/m2 in Toulouse and Belfast), but total cholesterol, triglyceride and fibrinogen were highest in Belfast. In Belfast, 6.1% reported having had a coronary angiogram, compared to 3.0% in Toulouse. Conversely, 13.8% in Toulouse reported taking lipid-lowering drugs vs. 1.6% in Belfast. As predicted, a history of myocardial infarction (MI) was highest in Belfast (6.1%) and lowest in Toulouse (1.2%). Some 7.1% of Belfast men reported a medical diagnosis of angina vs. 1.5% in Toulouse. Subjects showing evidence of pre-existing IHD will be studied prospectively but treated in the analysis as an additional variable. These results provide a measure of reassurance that these cohorts are representative of the communities from which they are drawn and provide a reliable baseline for prospective evaluation and cross-sectional comparisons. The levels of the classical risk factors found in this study, particularly when examined in combination, as multiple logistic functions based on previous British studies, are very similar between centres and cannot explain the large differences in the incidence of IHD which exist. Additional risk factors may help explain, at least in part, the major differences in incidence of IHD between these study centres. (+info)
Coeliac disease detected by screening is not silent--simply unrecognized.
(2/723)Coeliac disease (CD) is associated with a wide spectrum of clinical presentation and may be overlooked as a diagnosis. There is some evidence that untreated CD is associated with a doubling of mortality, largely due to an increase in the incidence of malignancy and small intestinal lymphoma, which is decreased by a strict gluten-free diet. We studied the clinical features of screening-detected coeliacs compared to age- and sex-matched controls as a 3-year follow-up to a population screening survey, and followed-up subjects who had had CD-associated serology 11 years previously to determine whether they have CD or an increased mortality rate compared to the general population. Samples of the general population (MONICA 1991 and 1983) were screened for CD-associated serology and followed-up after 3 and 11 years, respectively, and assessed by a clinical questionnaire, screening blood tests and jejunal biopsy. Mortality rates for 'all deaths' and 'cancer deaths' were compared in subjects with positive serology in 1983 with reference to the general population. Thirteen coeliacs were diagnosed by villous atrophy following screening, compared to two patients with clinically detected CD, giving a prevalence of 1:122. Clinical features or laboratory parameters were not indicative of CD compared to controls. Subjects with positive serology followed up after 11 years did not have an excess mortality for either cancer deaths or all causes of death. Screening-detected CD is rarely silent and may be associated with significant symptoms and morbidity. In this limited study with small numbers, there does not appear to be an increased mortality from screening-detected CD, although the follow-up may be too short to detect any difference. (+info)
Stress and morale in general practice: a comparison of two health care systems.
(3/723)BACKGROUND: Poor morale and high levels of stress among general practitioners (GPs) are causing concern. Little research has previously been carried out to study possible differences in morale and stress between GPs working in two different but geographically similar health care systems. AIM: To compare perceived levels of stress and morale between GPs working in two different health care systems--one having a state monopoly (Northern Ireland) and the other having mixed private and state funding (Republic of Ireland)--and to look for factors that might help explain any differences in stress levels and morale between the two systems. METHOD: Anonymous and confidential questionnaires were sent to all 986 National Health Service (NHS) GPs in Northern Ireland (NI) and a random sample of 900 GPs in the Republic of Ireland (ROI). A common set of core questions on demographic details, partners and work patterns, perceived levels of stress and morale, safety, violence, and complaints were asked. RESULTS: Response rates were high in both areas: 91% in NI and 78% in the ROI. GPs in NI had significantly higher stress levels and significantly lower levels of morale than GPs in the ROI. The NI sample expect matters to get worse over the following year. Doctors in the ROI were more likely to be single handed and to work from two sites. Also, more GPs in ROI had fears for their safety and had been the subject of physical violence, but fewer had received complaints and medico-legal actions than in NI. CONCLUSIONS: A significant proportion of both groups of doctors report feeling highly stressed but GPs in NI appear more unhappy and have a poorer outlook for the future. It is suggested that the structure, management, and expectations of the NHS have taken a severe toll on its GPs, whereas a system in which doctors have less practice support but more control is good for morale. (+info)
Patient removals from general practitioner lists in Northern Ireland: 1987-1996.
(4/723)BACKGROUND: Being struck off a general practitioner's list is a major event for patients and a subject for much media attention. However, it has not hitherto received much research attention. AIMS: To quantify the numbers of patients removed at doctors' request in Northern Ireland between 1987 and 1996. To describe the characteristics of those removed and to determine if the rate of removal has increased. METHODS: This is a descriptive epidemiological study involving a secondary data analysis of records held by the Central Services Agency. RESULTS: Six thousand five hundred and seventy-eight new patients were removed at general practitioner (GP) request between 1987 and 1996. This equated to 3920 removal decisions, a rate of 2.43 per 10,000 person-years. The very young and young adults had the highest rates of removal; most of the young being removed as part of a family. Ten point six per cent of removed patients had a repeat removal, and 16.3% of first removal decisions required an assignment to another practice. Family removals have decreased and individual removals have increased over the 10 years. Disadvantaged and densely populated areas with high population turnover were associated with higher rates of removal, though heterogeneity is evident between general practitioners serving similar areas. Compared to the period 1987 to 1991, removal rates for the years 1992 to 1993 were reduced by 20.0% (95% confidence interval (CI) for rate ratio (RR) 0.73-0.87), and those for the years 1994 to 1996 increased by 8% (95% CI = 1.01-1.16). The greatest increase was in the over-75 years age group (standardized RR = 1.60; 95% CI = 1.57-1.62). CONCLUSIONS: Removals are relatively rare events for both patients and practices, though they have been increasing in recent years. Further research is needed to understand the processes that culminate in a removal. (+info)
Teenage mothers and their peers: a research challenge.
(5/723)Recent reports have highlighted the adverse health experience of teenage mothers. The question of how these mothers' perceptions of their own health status and social networks differ from those of their nulliparous peers is explored in this pilot study, which highlights some practical problems associated with research in this important field. (+info)
Epidemiology of Chlamydia pneumoniae infection in a randomly selected population in a developed country.
(6/723)This cross-sectional study of 400 sera from a randomly selected adult population in Northern Ireland, using a microimmunofluorescence assay, demonstrated high overall seropositivity (70%) for IgG Chlamydia pneumoniae antibodies in developed populations. Seropositivity was shown to be unrelated to gender, age or smoking but there was an inverse trend between infection and educational level achieved as a measure of socio-economic status. IgG levels were also higher during the winter months suggesting seasonal variation of Chlamydia pneumoniae infection. The high prevalence of evidence of exposure to Chlamydia pneumoniae as described in this study may have implications for prevention of cardiovascular disease if further evidence conclusively determines that infection with this organism is a risk factor for cardiovascular disease. (+info)
Referrals for coronary angiography in a high risk population.
(7/723)OBJECTIVES: To examine variations in referral for coronary angiography within Northern Ireland and relate these to local death rates from coronary artery disease (ICD rubrics 410-414). DESIGN: A descriptive retrospective analysis of aggregate hospital activity data for 1979-88 and corresponding mortality rates in the local population. SETTING: Two regional referral hospitals and 26 local district council areas. PATIENTS: 5173 patients aged 35-74 years with an underlying diagnosis of ischaemic heart disease, whose records contained complete information on their age, sex, and home address. MAIN MEASURES: Age-standardised angiography rates and corresponding standardised death rates derived from the registrar general's reports. RESULTS: Among the 26 constituent district council areas there was significant heterogeneity in the angiography rates, ranging from 62 to 335/100,000 in men and from 7 to 62/100,000 in women (likelihood ratio statistic 856 and 359 respectively). There was no significant association between these angiography rates and the local death rates from ischaemic heart disease. CONCLUSION: The results suggest a non-uniform threshold for referral for angiography. IMPLICATIONS: Clinicians need to examine the appropriate indications for referral for invasive investigation. (+info)
Is choice of general practitioner important for patients having coronary artery investigations?
(8/723)OBJECTIVE: To determine whether particular sociodemographic characteristics of patients with stable angina affected their general practitioners' (GPs') decisions to refer them for revascularisation assessment. DESIGN: Postal questionnaire survey. SETTING: Collaborative survey by the departments of public health medicine in each of the four health boards in Northern Ireland, serving a total population of 1.5 million. SUBJECTS: All (962) GPs. MAIN MEASURES: The relation between GPs' referral decisions and patients' age, sex, employment status, home circumstances, smoking habits, and obesity. RESULTS: 541 GPs replied (response rate 56%). Most were "neutral" towards a patient's sex (428, 79%), weight (331, 61%), smoking habit (302, 56%), employment status (431, 80%), and home circumstances (408, 75%) in making decisions about referral. In assigning priority for surgery most were neutral towards the patient's sex (459, 85%), employment status (378, 70%), and home circumstances (295, 55%). However, most GPs (518, 95%) said that younger patients were more likely to be referred, and a significant minority were less likely to refer patients who smoked (202, 37%) and obese patients (175, 32%) and more likely to refer employed patients (97, 18%) and those with dependents (117, 22%) (compared with patients with otherwise comparable clinical characteristics); these views paralleled the priority which GPs assigned these groups. The stated likelihood of referral of young patients was independent of the GPs' belief in ability to benefit from revascularisation, but propensity to refer and perception of benefit were significantly associated for all other patient characteristics. CONCLUSION: GPs' weighting of certain characteristics in reaching decisions about referral for angiography is not uniform and may contribute to unequal access to revascularisation services for certain patient groups. (+info)