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Background Women who have had gestational diabetes during pregnancy are at very high risk of developing type 2 diabetes later in life, but their understanding of the risks is often limited. In this study we explored the views of health care professionals regarding offering brief opportunistic advice to women after their pregnancy, during unrelated consultations in primary care, relating to reducing diabetes risk. Methods The study took place in three Health Boards in Scotland. We conducted semi-structured one-to-one interviews (either face-to-face or telephone) with two health visitors, three practice nurses, two GPs, two diabetes consultants and two obstetricians. A focus group with five health visitors was also held. A topic guide was followed, covering the feasibility and acceptability of delivering brief opportunistic advice during a routine consultation, the optimal way to identify and recall women with previous gestational diabetes, and the possible content and timing of any such intervention. A thematic approach was used to analyse the qualitative data generated. Results The interviews/discussion lasted from 15 to 51 min. There was widespread support from all participants for offering opportunistic advice, and general consensus that health visitors would be best placed to do this as part of the Universal Health Visiting Pathway in Scotland. Thematic analysis generated three significant points of discussion: implications for training of health visitors, the need for a systematic approach to identifying women with gestational diabetes, and the optimal timing of delivery. Despite an already demanding schedule of providing advice and education to women, health visitors were confident that they could offer educational advice, provided that they received appropriate training to do so. However, there would need to be a watertight system for identifying women in their care who had had gestational diabetes. In terms of timing, later visits around 6–8 months after delivery were considered most suitable. Conclusions There is support from health care professionals, and most pertinently from health visitors, that the frequency of routine visits with women during the Universal Health Visiting Pathway programme in Scotland provides potential opportunities for education around future diabetes risk to women who have had gestational diabetes.

Background: People’s personal perceptions, or illness representations, of type 2 diabetes can act as barriers to successful self-management. Introduction: Understanding patients’ subjective perceptions of type 2 diabetes can aid the design of evidence-based care and appropriate educational programmes. This scoping review provides a narrative account of previous knowledge of patients’ illness representations of type 2 diabetes. Methods: Quantitative and qualitative studies that explored patients’ illness representations of type 2 diabetes, as defined by Leventhal’s Common Sense Model, were included. Results: Thirty four studies were identified for this review, but only 14 studies were carried out in a general population of people with diabetes. Illness representations varied across study populations. While it is clear that the perceptions of ethnic minorities and marginalised groups are embedded in their historical and cultural backgrounds, it is also important to understand the views of the wider population. Conclusion: The review highlights the need for self-management interventions to reflect the target population’s representations of type 2 diabetes in order to inform interventions and clinical practice.

AIMS To explore the experiences and perceptions of gestational diabetes mellitus reported by women within online parental-support forums and, specifically, to analyse what women say about a diagnosis of gestational diabetes, their future risk of type 2 diabetes, and lifestyle behaviour for management of gestational diabetes and prevention of type 2 diabetes. METHODS The discussion boards of two parenting websites (Mumsnet and Netmums) were searched using the search term 'gestational diabetes or GD' in February 2019. Relevant posts made by users with gestational diabetes on or after 1 January 2017 were retained for analysis. Framework analysis using pre-existing framework from a previous study was used to organize and analyse the data. RESULTS A total of 646 posts generated by 282 unique users were included in the analysis. Analysis of the online content identified three important implicit messages that may be being conveyed to readers. The first is that gestational diabetes is not a serious diagnosis that warrants undue concern. Secondly, few users recognized the importance of their own behaviours or lifestyle, with others minimizing personal responsibility or attributing gestational diabetes to non-modifiable factors. Finally, there was a lack of acknowledgment of heightened risk of type 2 diabetes. These three messages will all directly mitigate against the efforts of clinicians (and others) to encourage women with gestational diabetes to improve their lifestyle behaviours in the longer term. CONCLUSIONS These findings highlight messages that are being widely disseminated and that are unlikely to support prevention of type 2 diabetes.

Aims Estimates of the prevalence of gestational diabetes vary widely. It is important to have a clear understanding of the prevalence of this condition to be able to plan interventions and health care provision. This paper describes a meta-analysis of primary research data reporting the prevalence of gestational diabetes mellitus in the general pregnant population of developed countries in Europe. Methods Four electronic databases were systematically searched in May 2016. English language articles reporting gestational diabetes mellitus prevalence using universal screening in general pregnant population samples from developed countries in Europe were included. All papers identified by the search were screened by one author, and then half screened independently by a second author and half by a third author. Data were extracted by one author. Values for the measures of interest were combined using a random effects model and analysis of the effects of moderator variables was carried out. Results A total of 3258 abstracts were screened, with 40 studies included in the review. Overall prevalence of gestational diabetes mellitus was 5.4% (3.8–7.8). Maternal age, year of data collection, country, area of Europe, week of gestation at testing, and diagnostic criteria were found to have a significant univariate effect on GDM prevalence, and area, week of gestation at testing and year of data collection remained statistically significant in multivariate analysis. Quality category was significant in multivariate but not univariate analysis. Conclusions This meta-analysis shows prevalence of GDM that is at the upper end of previous estimates in Europe.

Background: The benefits of physical activity are well established, yet large numbers of people are not sufficiently\ud active to gain health benefits. Certain population groups are less physically active than others, including older\ud women from areas of high economic deprivation. The Well!Bingo project was established with the aim of engaging\ud such women in the development of a health promotion intervention in a bingo club. This paper reports on the\ud assessment of health status, physical activity and sedentary behaviour of women attending a bingo club in central\ud Scotland, UK as part of the Well!Bingo project.\ud Methods: Women attending the bingo club were invited to provide information on demographic characteristics, and\ud self-reported physical activity and sedentary behaviour via a self-complete questionnaire as part of a cross-sectional\ud study (n = 151). A sub-sample (n = 29) wore an accelerometer for an average of 5.7 ± 1.4 days. Differences between\ud younger (under 60 years) and older adults (60 years and over) were assessed using a chi-square test for categorical\ud data and the independent samples t-test was used to assess continuous data (p < 0.05).\ud Results: The mean age was 56.5 ± 17.7 years, with 57% living in areas of high deprivation (Scottish Index of Multiple\ud Deprivation quintile one and two). Sixty-three percent of women (n = 87) reported they were meeting physical activity\ud guidelines. However, objective accelerometer data showed that, on average, only 18.1 ± 17.3 min a day were spent in\ud moderate to vigorous physical activity. Most accelerometer wear time was spent sedentary (9.6 ± 1.7 h). For both\ud self-report and accelerometer data, older women were significantly less active and more sedentary than younger women.\ud On average, older women spent 1.8 h more than younger women in sedentary activities per day, and took part in 21 min\ud less moderate to vigorous physical activity (9.4 mins per day).\ud Conclusion: The findings of this study suggest that bingo clubs are settings that attract women from areas of high\ud deprivation and older women in bingo clubs in particular would benefit from interventions to target their physical activity\ud and sedentary behaviour. Bingo clubs may therefore be potential intervention settings in which to influence these\ud behaviours.

Introduction Type 2 diabetes is a chronic health condition that requires ongoing self-management. This often includes changes in diet, which may be open to influences from relatives. Family support in terms of diet may be linked with gender and the assumption that meal preparation is a traditionally female activity. This article looks at the role of gender in diet management in people with type 2 diabetes and their relatives. Methods Seventeen semi-structured interviews were conducted with 23 participants (10 people with type 2 diabetes, 13 relatives of people with type 2 diabetes) in Scotland, UK. The aim was to uncover changes people have made to their diet following diagnosis of type 2 diabetes in oneself or a family member. Data were analysed using Framework Approach. Findings: Female relatives were more likely to manage the patient’s diet while male relatives provided support but were less likely to monitor the person’s diet. Female patients may prioritise the needs of their family while male patients are more likely to rely on their female relatives in terms of diet management. Discussion The study findings have implications for family-based interventions as gender may play a crucial role in the management of type 2 diabetes.

The study aim was to collect data on the health and health-related behaviours of undergraduate nursing students at a Higher Education Institution in Scotland, to identify the need for potential health behaviour change interventions as part of their undergraduate course. An anonymous self-report questionnaire (with questions about physical activity, diet, sleep, alcohol, smoking, mental health) was administered to first year nursing students at a Scottish university. The response rate was 88%, with 207 respondents (26 male, 178 female, 3 other). Age ranged from 16 to 45 years (mean 24.5 years). Overall, 48 (23.1%) students rated their physical health as excellent/very good, and 100 (48.3%) their mental health as such. 157 (76.2%) students were achieving 150 min of physical activity per week. There were 48 (29%) and 30 (18.2%) overweight and obese students respectively. 129 (62.6%) students viewed a mobile device for >30 min before sleep. 176 (86.3%) students consumed alcohol, with 32 (15.4%) reporting binge drinking. The prevalence of current smoking was 24.8%. The students’ health behaviour profile was therefore broadly similar to that of the general population in Scotland, but smoking, diet, sleep practices and binge-drinking were identified as priority areas for health education and intervention.

Background People experiencing a mental health crisis receive variable and poorer quality care than those experiencing a physical health crisis. Little is known about the epidemiology, subsequent care pathways of mental health and self-harm emergencies attended by ambulance services, and subsequent all-cause mortality, including deaths by suicide. This is the first national epidemiological analysis of the processes and outcomes of people attended by an ambulance due to a mental health or self-harm emergency. The study aimed to describe patient characteristics, volume, case-mix, outcomes and care pathways following ambulance attendance in this patient population. Methods A linked data study of Scottish ambulance service, emergency department, acute inpatient and death records for adults aged ≥16 for one full year following index ambulance attendance in 2011. Results The ambulance service attended 6802 mental health or self harm coded patients on 9014 occasions. This represents 11% of all calls attended that year. Various pathways resulted from these attendances. Most frequent were those that resulted in transportation to and discharge from the emergency department (n = 4566/9014; 51%). Some patients were left at home (n = 1003/9014 attendances, 11%). Others were admitted to hospital (n = 2043/9014, 23%). Within 12 months of initial attendance, 279 (4%) patients had died, 97 of these were recorded as suicide. Conclusions This unique study finds that ambulance service and emergency departments are missing opportunities to provide better care to this population and in potentially avoidable mortality, morbidity and service burden. Developing and testing interventions for this patient group in pre-hospital and emergency department settings could lead to reductions in suicide, patient distress, and service usage.

Aims To explore the potential of type 2 diabetes diagnosis to be a “teachable moment”. Methods Semi-structured interviews were conducted with 23 participants (10 people with type 2 diabetes, 13 relatives of people with type 2 diabetes) in Scotland, UK. They explored cognitive, emotional and behavioural changes following diagnosis of type 2 diabetes in oneself or in a relative. Data were analysed using Framework approach. Results Strong emotional responses are not always related to the occurrence of a teachable moment. Risk perception and outcome expectancy were found to be teachable moment factors for patients with type 2 diabetes and their offspring, but not their partners. Change in self-concept increases the likelihood of type 2 diabetes diagnosis to be a teachable moment for patients but not for relatives. In some cases, type 2 diabetes is perceived as incompatible with current roles thus hindering diabetes self-management. Relatives often engage in caring for patients and “policing” their behaviour but did not report perceived changes in social roles. Conclusions The study suggests that diagnosis of type 2 diabetes is a teachable moment for some patients and their relatives. These findings have implications for interventions to address diabetes self-management in patients and primary prevention in their relatives.

Background Recent violence reduction initiatives in Glasgow have led to a reduction in recorded levels of violent crime.1 This study evaluates the impact of these initiatives on assault-related emergency department attendances and admissions. Methods A retrospective observational study conducted in Glasgow Royal Infirmary’s emergency department comparing assault-related emergency department attendances and hospital admissions over two 30-day study periods (April 2010 and April 2012). The primary outcome measure was the change in assault-related emergency department attendances. The secondary outcome measure was the impact on assault-related hospital and critical care admissions. Results In April 2010, there were 6098 emergency department attendances, 301 (4.9%) were due to assault. In April 2012, there were 7236 emergency department attendances, 263 (3.6%) were due to assault, representing a significant reduction in assault-related attendances ( p Conclusions Violence reduction initiatives in Glasgow have contributed to a reduction in assault-related emergency department attendance at Glasgow Royal Infirmary. The reduction in hospital admissions, in particular critical care admissions, suggests a reduction in morbidity and cost to the National Health Service.

The relatives and partners of people with type 2 diabetes are at increased risk of developing type 2 diabetes. This systematic review examines randomized controlled trials, written in English that tested an intervention, which aimed to modify behaviors known to delay or prevent type 2 diabetes, among the relatives or partners of people with type 2 diabetes. Study quality was assessed using the Cochrane Collaboration's tool for assessing risk of bias. Seven studies met the inclusion criteria. The majority of studies were at low risk of bias. Six studies tested an intervention in first-degree relatives of people with type 2 diabetes and one in partners. Intervention components and intervention intensity across studies varied, with those targeting diet and physical activity reporting the most significant changes in primary outcomes. Only one study did not observe significant changes in primary outcomes. There were three main recruitment approaches: advertising in the community, recruiting people through their relatives with diabetes, or identifying people as high risk by screening of their own health care contacts. Some evidence was found for potentially successful interventions to prevent type 2 diabetes among the relatives and partners of people with type 2 diabetes, although finding simple and effective methods to identify and recruit them remains a challenge. Future studies should explore the effect of patients' perceptions on their family members' behavior and capitalize on family relationships in order to increase intervention effectiveness.

Despite the established benefits of cardiac rehabilitation (CR) attendance rates remain variable. Physical barriers to attendance have been extensively investigated but relatively less is known about the relationship between attendance at CR and psychosocial variables such as illness perceptions and social isolation.To examine the influence of socio-demographic factors, illness perceptions and social isolation on patient attendance at cardiac rehabilitation.All individuals offered CR over a two-year period were invited to take part in a postal survey. The survey collected socio-demographic data and included completion of the Friendship Scale, to assess social isolation, and the Brief Illness Perceptions Questionnaire. Parametric and non-parametric statistical tests were used as appropriate.One hundred and twenty-eight (47%) questionnaires were returned. Non-attendees reported higher total illness perception scores and those who attributed their illness to non-modifiable factors were significantly less likely to attend CR (p = 0.042). Attendees reported lower levels of social isolation; however, this finding was not statistically significant. No differences were found between attendees and non-attendees in terms of their age, gender, educational status or proximity to cardiac rehabilitation centre.Psychosocial barriers, specifically illness perceptions and attributions, were found to be significant with patients who did not attend CR reporting more negative illness perceptions. Distance to CR was not a significant factor influencing attendance. Early screening of perceived causal attributions may help to identify those who would benefit from early and targeted intervention to increase participation in CR. Future prospective studies would permit testing of screening approaches and early interventions.

Analysis of a diabetes clinical information system in Tayside, Scotland, shows that a significant proportion of insulin-treated patients with diabetes are not self-monitoring blood glucose according to current clinical guidance and recommendations, with some not self-monitoring their blood glucose at all. Although there has been an increase in the number of reagent strips dispensed over the past decade, this increase is mainly accounted for by increased testing frequency among people with diabetes already testing.

Background\ud Our aim was to use participatory methods to investigate the feasibility and acceptability of using Bingo clubs for the design and delivery of an evidence-based physical activity and/or healthy eating intervention to socio-economically disadvantaged women. This paper describes the participatory process that has resulted in a physical activity intervention for women aged >55 years, ready for pilot-testing in a Bingo club setting.\ud \ud Methods\ud Studies using different quantitative and qualitative approaches were conducted among customers and staff of a Bingo club in a city of 85,000 inhabitants in central Scotland. These were designed to take the views of different stakeholders into account, with a view to enhancing uptake, engagement and effectiveness with any proposed intervention.\ud \ud Results\ud Sixteen relevant studies were identified in a literature review that generated ideas for intervention components. A questionnaire completed by 151 women in the Bingo club showed that almost half (47 %) aged >55 years were not meeting physical activity guidelines; evidence backed up by accelerometer data from 29 women. Discussions in six focus groups attended by 27 club members revealed different but overlapping motivations for attending the Bingo club (social benefits) and playing Bingo (cognitive benefits). There was some scepticism as to whether the Bingo club was an appropriate setting for an intervention, and a dietary intervention was not favoured. It was clear that any planned intervention needed to utilise the social motivation and habitual nature of attendance at the Bingo club, without taking women away from Bingo games. These results were taken forward to a 5-h long participative workshop with 27 stakeholders (including 19 Bingo players). Intervention design (form and content) was then finalised during two round table research team meetings.\ud \ud Conclusions\ud It was possible to access and engage with women living in areas of socio-economic disadvantage through a Bingo club setting. A physical activity intervention for women >55 years is realistic for recruitment, will address the needs of potential recipients in the Bingo club, appears to be feasible and acceptable to club members and staff, and has been designed with their input. A pilot study is underway, investigating recruitment, retention and feasibility of delivery.

Type 2 diabetes mellitus (DM) plus chronic heart failure (CHF) is a common but lethal combination and therapeutic options are limited. Metformin is perceived as being relatively contraindicated in this context, although mounting evidence indicates that it may be beneficial. This study was carried out to investigate the use of metformin therapy for treating patients with DM and CHF in a large population-based cohort study. The Health Informatics Centre-dispensed prescribing database for the population of Tayside, Scotland (population ∼400,000) was linked to the Diabetes Audit and Research in Tayside Scotland (DARTS) information system. Patients with DM and incident CHF from 1994 to 2003 receiving oral hypoglycemic agents but not insulin were identified. Cox regression was used to assess differences in all-cause mortality rates between patients prescribed metformin and patients prescribed sulfonylureas with adjustment for co-morbidities and other therapies. Four hundred twenty-two study subjects (mean ± SD 75.4 ± 0.5 years of age, 46.2% women) were identified: metformin monotherapy (n = 68, mean age 75.5 ± 1.1 years, 48.5% women), sulfonylurea monotherapy (n = 217, mean age 76.7 ± 0.7 years, 45.2% women), and combination (n = 137, mean age, 73.4 ± 0.7 years, 46.7% women). Fewer deaths occurred in metformin users, alone or in combination with sulfonylureas, compared to the sulfonylurea monotherapy cohort at 1 year (0.59, 95% confidence interval 0.36 to 0.96) and over long-term follow up (0.67, 95% confidence interval 0.51 to 0.88). In conclusion, this large observational data suggest that metformin may be beneficial in patients with CHF and DM. These findings need to be verified by a prospective clinical trial.

Objectives: (1) To compare the experiences of people who are affected by diabetes-related hypoglycaemia and either do or do not require an emergency attendance and (2) to measure the prevalence of impaired awareness of hypoglycaemia in patients who are attended by an ambulance service due to a severe hypoglycaemic event.\ud \ud Design: A sequential mixed-methods study.\ud \ud Setting: A qualitative interview study was undertaken with 31 people with diabetes (types 1 and 2) resident in the central belt of Scotland. A national prevalence survey of 590 Scottish Ambulance Service patients who had recently experienced a severe hypoglycaemic emergency requiring ambulance clinicians attendance. Impaired awareness of hypoglycaemia was measured using two standardised measures.\ud \ud Results: Considerable differences in impaired awareness of hypoglycaemia were found in the experiences of participants who did or did not require the ambulance service to treat their severe hypoglycaemic events. Those who required an ambulance reported fewer warning signs and symptoms. The prevalence of impaired awareness of hypoglycaemia in ambulance service call-outs as assessed by two standardised measures was 53% and 60%, respectively.\ud \ud Conclusions: The prevalence of impaired awareness of hypoglycaemia among those who require an ambulance following a hypoglycaemic event is more than twice that found in the general population of people with diabetes. This may be because the experiences of impaired awareness in people who require an ambulance following a severe hypoglycaemic event differ to those who do not. This study provides important information to guide future prehospital clinical practice, and to develop and evaluate theoretically informed interventions. Improvements in prehospital care for this patient population could lead to global improvements in health outcomes and decreased service costs.

Among 207 non-insulin using patients with type 2 diabetes in Tayside, Scotland, who self-monitored blood glucsoe, we present evidence that many are tolerant of higher blood glucsoe levels that are clinically advisable; this may explain the lack of empirical evidence for the clinical benefits of self-monitoring in this group.

Introduction Recent evaluations of IT innovations in primary care have highlighted variations between centres and practices in uptake and use. We evaluated whether structural characteristics of a general practice were associated with variations in use of a web-based clinical information system underpinning a Managed Clinical Network in diabetes, between the years 2001 and 2003. Methods Using a computerised audit trail, we calculated the numbers of web-based operations that occurred in each practice, stratified by staff type and year, and adjusted for the numbers of registered diabetic patients. In regression analyses, we determined whether total use was associated with structural characteristics of the practice (total list size, training status, numbers of GPs (general practitioners), mean age of the GPs, numbers of female GPs, level of deprivation of the population and whether staff had received advanced training in diabetes care). Results Initially there were a few practices which made very frequent use of the information system, with relatively high numbers of practices using the facility infrequently. However, overall use gradually became more evenly spread. This effect was particularly evident among nurse users. Frequent use by GPs was evident in only a smallnumber of practices, with meanGPuse decreasing over the three years. In linear regression analyses, none of the general practice variableswere associatedwithonlineuse, either overall or stratified by staff type, except for the numbers of diabetes-educated staff. This was consistently associated with increased use by nurses and GPs. Conclusions The analyses show that structural characteristics of a practice are not associated with uptake of a new IT facility, but that its use may be influenced by post-graduate education in the relevant clinical condition. For this diabetes system at least, practice nurse use was critical in spreading uptake beyond initial GP enthusiasts and for sustained and rising use in subsequent years.

Although the disease burden of liver cirrhosis in Egypt is high and there are few resources for its management, there is limited research on the health-related quality of life (HRQOL) of Egyptian patients with liver cirrhosis.To describe the HRQOL of liver cirrhotic patients in Egypt and to analyse factors associated with this construct.A cross-sectional study with a convenience sample of 401 patients from three hospitals in Cairo, Egypt, was carried out in June-August 2011. Patients were interviewed to complete a background data form, Short Form-36, the Liver Disease Symptom Index-2.0 and the Multidimensional Scale of Perceived Social Support.Patients had low HRQOL, with mental health perceived to be poorer than physical health. In regression analyses, severity of symptoms, disease stage, comorbidities and employment status were associated significantly with physical health, accounting for 19% of the variance. For mental health, 31.7% of the variation was explained by severity of symptoms, employment status and perceived spouse and family support.These findings highlight the needs of patients with liver cirrhosis in Egypt. Engaging the patients' family in care planning may decrease patients' burden and improve their HRQOL. This study also provides a rationale to develop future research in symptom management to enhance HRQOL.

Background Socially disadvantaged men are at a substantially higher risk of developing alcohol-related problems. The frequency of heavy drinking in a single session is high among disadvantaged men. Brief alcohol interventions were developed for, and are usually delivered in, healthcare settings. The group who binge drink most frequently, young to middle-aged disadvantaged men, have less contact with health services and there is a need for an alternative method of intervention delivery. Text messaging has been used successfully to modify other adverse health behaviours. This study will test whether text messages can reduce the frequency of binge drinking by disadvantaged men. Methods/design Disadvantaged men aged 25 to 44 years who drank >8 units of alcohol at least twice in the preceding month will be recruited from the community. Two recruitment strategies will be used: contacting men listed in primary care registers, and a community outreach method (time-space sampling). The intended sample of 798 men will be randomised to intervention or control, stratifying by recruitment method. The intervention group will receive a series of text messages designed to reduce the frequency of binge drinking through the formation of specific action plans. The control group will receive behaviourally neutral text messages intended to promote retention in the study. The primary outcome measure is the proportion of men consuming >8 units on at least three occasions in the previous 30 days. Secondary outcomes include total alcohol consumption and the frequency of consuming more than 16 units of alcohol in one session in the previous month. Process measures, developed during a previous feasibility study, will monitor engagement with the key behaviour change components of the intervention. The study will incorporate an economic evaluation comparing the costs of recruitment and intervention delivery with the benefits of reduced alcohol-related harm. Discussion This study will assess the effectiveness of a brief intervention, delivered by text messages, aimed at reducing the frequency of binge drinking in disadvantaged men. The process measures will identify components of the intervention which contribute to effectiveness. The study will also determine whether any benefit of the intervention is justified by the costs of intervening. Trial registration ISRCTN07695192. Date assigned: 14 August 2013.

Background Early aggressive therapy can reduce the mortality associated with severe sepsis but this relies on prompt recognition, which is hindered by variation among published severity criteria. Our aim was to test the performance of different severity scores in predicting mortality among a cohort of hospital inpatients with sepsis. Methods We anonymously linked routine outcome data to a cohort of prospectively identified adult hospital inpatients with sepsis, and used logistic regression to identify associations between mortality and demographic variables, clinical factors including blood culture results, and six sets of severity criteria. We calculated performance characteristics, including area under receiver operating characteristic curves (AUROC), of each set of severity criteria in predicting mortality. Results Overall mortality was 19.4% (124/640) at 30 days after sepsis onset. In adjusted analysis, older age (odds ratio 5.79 (95% CI 2.87-11.70) for ≥80y versus 21d versus

The aim of the study was to evaluate the risks of hospitalisation and death due to hypersensitivity reactions associated with the NSAIDs naproxen and ibuprofen, using a record-linkage database for Tayside, Scotland (population 400,000). Cohorts of patients exposed to naproxen (n=54,038) and ibuprofen (n=79,513) were assembled. There were no deaths due to hypersensitivity. There was an increased risk of unvalidated hypersensitivity reactions during periods on-drug versus off-drug in patients exposed to naproxen and ibuprofen. However, after checking medical records, none of the three valid cases of hypersensitivity in the naproxen cohort and neither of the two in the ibuprofen cohort were judged to be due to NSAID exposure. A "worst-case" scenario gave an adjusted rate-ratio of on-drug with naproxen versus on-drug with ibuprofen of 1.63 (0.50, 5.29). The study shows that hypersensitivity reactions associated with NSAID use are rare, and provides no evidence that the risks of hypersensitivity reactions differ between naproxen and ibuprofen.

End-stage renal disease is a complex, progressive and debilitating illness that affects patients' quality of life, physical and mental health, well-being, social functioning and emotional health. A cross-sectional survey was carried out in renal dialysis centres in Scotland to assess patients' health status and the impact of haemodialysis treatment on quality of life and well-being. Participants scored considerably lower than the UK general population in all domains of health-related quality of life, although mental health components were nearer to general population norms than physical health components. However, nearly half of the participants achieved a score on a general well-being questionnaire that was indicative of stress and anxiety. Increasing age was associated with better overall mental health but worse physical functioning. Increasing levels of hope and support were associated with improved general well-being.

Objectives: To investigate patterns of self monitoring of blood glucose concentration in diabetic patients who use insulin and to determine whether frequency of self monitoring is related to glycaemic control. Setting: Diabetes database, Tayside, Scotland. Subjects: Patients resident in Tayside in 1993-5 who were using insulin and were registered on the database and diagnosed with insulin dependent (type 1) or non-insulin dependent (type 2) diabetes before 1993. Main outcome measures: Number of glucose monitoring reagent strips dispensed (reagent strip uptake) derived from records of prescriptions. First recorded haemoglobin A1c concentration in the study period, and reagent strips dispensed in the previous 6 months. Results: Among 807 patients with type 1 diabetes, 128 (16%) did not redeem any prescriptions for glucose monitoring reagent strips in the 3 year study period. Only 161 (20%) redeemed prescriptions for enough reagent strips to test glucose daily. The corresponding figures for the 790 patients with type 2 diabetes who used insulin were 162 (21%; no strips) and 131 (17%; daily tests). Reagent strip uptake was influenced both by age and by deprivation category. There was a direct relation between uptake and glycaemic control for 258 patients (with recorded haemoglobin A1c concentrations) with type 1 diabetes. In a linear regression model the decrease in haemoglobin A1c concentration for every extra 180 reagent strips dispensed was 0.7%. For the 290 patients with type 2 diabetes who used insulin there was no such relation. Conclusions: Self monitoring of blood glucose concentration is associated with improved glycaemic control in patients with type 1 diabetes. Regular self monitoring in patients with type 1 and type 2 diabetes is uncommon. Key messages Several studies have indicated the importance of self monitoring of blood glucose concentration for prevention of complications in patients with diabetes Uptake of reagent strips for self monitoring of blood glucose among diabetic patients who used insulin was low, with only 20% of patients with type 1 diabetes and 17% of those with type 2 diabetes obtaining enough strips to test blood glucose concentration once daily Reagent strip uptake depends on characteristics such as age and social deprivation category, and patient groups with low uptake should be identified and targeted There was a direct association between strip uptake in the previous 6 months and glycaemic control in patients with type 1 diabetes but not in those with type 2 diabetes

This cohort study examined the relationship between newly prescribed NSAIDs (none in the previous six months) and upper gastrointestinal hemorrhage and perforation in Tayside, Scotland. Exposure was classified by prescription duration. The study population consisted of the population of Tayside. A Comparator Group was chosen at random (within age and sex strata). Two hundred re-sampled comparator groups were created. Statistical analyses were carried out by Poisson regression (repeated for each of the re-samples). The analyses controlled for age, sex, prior hospitalization for upper gastrointestinal events, prior endoscopy, and the use of ulcer healing drugs. There were 78,191 subjects in the NSAID group, and 78,207 in each of the comparator groups. The increased risk with NSAIDs was only apparent for subjects without a history of upper gastrointestinal events; univariate rate ratio = 2.76 (1.90, 4.01). The final, re-sampled estimate of NSAID risk was rate ratio = 2.48 (1.87, 3.29).

This study assessed incidence of impaired glucose regulation (IGR) and progression to type 2 diabetes (T2D) in adults in one region of Scotland using routinely collected health-care data. Incidence of IGR was 2720 per 100,000 person years. Nine percent of IGR patients progressed to T2D in a mean time of 34 months.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are very widely prescribed but they have a poor tolerability profile, with a range of potential adverse effects. NSAIDs that are used in topical formulations have been developed in the past 15 years and their use is increasing. The purpose is to achieve a high local concentration of the active ingredient at the affected site, with as low a plasma concentration as possible to minimise possible systemic adverse effects. The gastrointestinal and renal toxicity of topical NSAIDs has recently been highlighted in the medical literature. The elderly seem to be more sensitive to the adverse effects of NSAIDs than younger individuals, and this may also be true for topical NSAIDs. More formal epidemiological evaluation of the safety of topical NSAIDs is required in the postmarketing situation, as the main source of information regarding adverse drug reactions to topical NSAIDs in the UK has been spontaneous reporting data.

Aim To investigate self-monitoring of blood glucose (SMBG) behaviour among non-insulin treated patients with type 2 diabetes mellitus, and to evaluate associations with glycaemic control. Methods Eligible patients in 23 GP practices in Tayside, Scotland, were identified (18–75 years, no insulin treatment, SMBG reagent strips dispensed in 2009). Consenting patients were administered questionnaires addressing SMBG behaviour: these primary data were record-linked to clinical data (including HbA1c) from a validated population-based diabetes clinical information system, then anonymised. Results Among 629 eligible patients, 207 were interviewed and analysed. Mean SMBG reagent strips dispensed in 12 months was 268. In response to a perceived high test result, 80 (38.8%) patients took no action or simply checked later with most of them (61.3%) indicating they did not know what action to take. Of the 126 (61.2%) patients who took some action, 101 made changes to diet, 12 increased physical activity, 10 made changes to medication and 12 mad a HCP appointment. A high score on a Diabetes Knowledge Test was a statistically significant predictor of taking action (odds ratio: 2.07). However, neither taking action nor increased SMBG frequency was associated with improved glycaemic control. Conclusions Responding to SMBG test results and increased testing frequency were not associated with improved glycaemic control in the short-term. There is a lack of knowledge surrounding SMBG in non-insulin treated patients.

The Liver Disease Symptom Index (LDSI) 2.0 is a simple, short and specific liver disease questionnaire in English, but an Arabic version does not exist, therefore we translated the LDSI-2.0 into Arabic and tested its psychometric properties in a pilot cross-sectional study. A convenience sample of 38 patients with liver cirrhosis from one hospital in Cairo, Egypt, were interviewed for approximately 45 min. Patients completed a background data sheet, the translated LDSI-2.0 and the Short Form (SF)-36v(2). Construct convergent validity was examined by correlating LDSI-2.0 items with the SF-36v(2) eight domains. Reliability was estimated using measures of internal consistency, test-retest reliability and internal consistency reliability. Median completion time was 10 min. The correlation between the translated LDSI-2.0 items and the SF-36 domains confirmed that there was moderate to high overlapping between the two measures, suggesting convergent validity of the LDSI-2.0. The LDSI-2.0 showed good to very good retest reliability (kappa value 0.62-0.94). Chronbach's alpha coefficient for the multi-item scales ranged from 0.73 to 0.96. The Arabic LDSI-2.0 therefore has satisfactory validity, retest reliability and internal consistency.

This paper considers socioeconomic inequalities in self-assessed health amongst people with and without a history of cancer using representative data from Scotland.A cross-sectional analysis using the Scottish Health Survey was done. Cancer survivors were identified using linked Cancer Registry data. Bivariate and multivariate analysis was used to compare and contrast self-assessed health amongst those with a history of cancer to those without.Of the 17,505 survey participants, 432 (2.5 %) had a history of cancer. After taking into account potential confounders, those in the lowest socioeconomic group were more likely to report poor health than those in the highest group amongst those with a history of cancer [odds ratio, 2.96; confidence interval (CI), 1.82-4.80] and those with no history of cancer (odds ratio, 2.45; CI, 2.21-2.71). Those in the lowest socioeconomic group with no history of cancer had a greater propensity to report poor health than any of the highest groups that did have a history of cancer (p 0.01). Differences in propensities to indicate poor health were particularly marked amongst those 4 years or more post-cancer diagnosis.Findings underline the scale of socioeconomic gradients in health. That disparities were so wide amongst those most temporally distant from initial diagnosis is particularly a concern given improving survival after a cancer diagnosis.Socioeconomic circumstances have a considerable influence on health and well-being. Practitioners and policy makers should consider socioeconomic circumstances in considering approaches to health and social care of cancer survivors.

Background Due to improvements in cancer survival the number of people of working age living with cancer across Europe is likely to increase. UK governments have made commitments to reduce the number of working days lost to ill-health and to improve access to vocational rehabilitation (VR) services. Return to work for people with cancer has been identified as a priority. However, there are few services to support people to remain in or return to work after cancer and no associated trials to assess their impact. A pilot randomised controlled trial among women with breast cancer has been designed to assess the feasibility of a larger definitive trial of VR services for people with cancer. Methods Patients are being recruited from three clinical sites in two Scottish National Health Service (NHS) Boards for 6 months. Eligible patients are all women who are: (1) aged between 18 and 65 years; (2) in paid employment or self-employed; (3) living or working in Lothian or Tayside, Scotland, UK; (4) diagnosed with an invasive breast cancer tumour; (5) treated first with surgery. Patients are randomly allocated to receive referral to a VR service or usual care, which involves no formal employment support. The primary outcome measure is self-reported sickness absence in the first 6 months following surgery. Secondary outcome measures include changes in quality of life (FACT-B), fatigue (FACIT-Fatigue) and employment status between baseline and 6- and 12-months post-surgery. A post-trial evaluation will be conducted to assess the acceptability of the intervention among participants and the feasibility of a larger, more definitive, trial with patients with lung and prostate cancer. Discussion To our knowledge this is the first study to determine the feasibility of a randomised controlled trial of the effectiveness of VR services to enable people with cancer to remain in or return to employment. The study will provide evidence to assess the relevance and feasibility of a larger future trial involving patients with breast, prostate or lung cancer and inform the development of appropriate VR services for people living with cancer. Trial Registration ISRCTN: ISRCTN29666484 Registration date: 07/10/10; Randomisation of first patient: 03/12/10

Background: For many regularly used drugs, evidence for safe use in pregnancy has not been established. Despite this, international studies have identified high levels of drug prescribing among pregnant women. Objective: To investigate the patterns of prescribing of drugs to women who gave birth in Tayside, Scotland, in 2007. Methods: Scottish maternity records were linked to dispensed prescribing data for all women who gave birth in Tayside in 2007. Drugs prescribed were coded according to the US FDA classification for risks of drugs in pregnancy. Patterns of prescribing were investigated during the 3 trimesters of pregnancy and the 3 months prior to conception. Results: Prescribing in pregnancy was common, with 21 093 prescriptions dispensed to 3356 (85.2%) of the 3937 women. The most frequently prescribed drugs were antacids, antibacterials, oral iron, folic acid preparations and analgesics. Category A drugs (positive evidence of safety in pregnancy) and Category B drugs (some evidence of safety in pregnancy) accounted for 19.6% and 26.9% of all prescriptions dispensed, respectively. Prescribing of Category X drugs (evidence of risk to the fetus; use contraindicated in women who are or may become pregnant) during pregnancy was rare, with 112 prescriptions dispensed to 68 women (1.7%). Most of these were oral contraceptives or sex hormones. Prescribing of Category X drugs fell markedly during the first trimester and remained very low thereafter. Category D drugs (evidence of risk to the fetus but benefits of therapy may outweigh the potential risk) [432] were dispensed to 166 women (4.2%) during pregnancy. The most commonly prescribed Category D drugs were anxiolytics, nicotine replacement therapy and antiepileptic drugs. The frequency of prescribing of Category D drugs reduced in the third trimester. Prescribing of Category C drugs (insufficient evidence to know whether they are harmful) was common. Thirty percent of women received a total of 3641 Category C prescriptions, which accounted for 17.3% of all prescriptions issued during pregnancy. Prescribing of Category C drugs showed only a very modest decline during pregnancy. No FDA code was available for 4035 prescriptions issued (87 different items), the majority of which were for antacids and preparations for indigestion. More than 40% of women received such medications. Conclusions: Prescribing of drugs during pregnancy was very common, but the levels of prescribing of drugs that are known to be harmful were low. Much of the prescribing was for drugs related to the pregnancy. While this study provides some evidence that primary-care prescribers in Tayside are prescribing potentially harmful drugs appropriately and with caution during pregnancy, safety data during pregnancy are unavailable for many drugs that are commonly prescribed.

Problem: System-wide improvement of chronic disease care is challenging because it requires collaboration and communication across organisational and professional boundaries. Managed clinical networks are one potential solution, but there is little evidence of their effectiveness. Design and setting: Retrospective, mixed-methods evaluation of the form and impact of quality improvement in the Tayside Diabetes Managed Clinical Network (MCN) 1998–2005. Strategies for change: Progressive implementation of multiple quality improvement strategies predominately directed at individuals and clinical teams (guideline development and dissemination, education, clinical audit, encouragement of multidisciplinary team working, task redesign). Information technology played an important role in supporting QI activity, but participants identified it as facilitative rather than delivering QI by itself. More important was achieving widespread clinical engagement through persuasion and appeal to shared professional values by clinical leaders. Effects of change: Simple process measures such as glycated haemoglobin measurement rapidly improved. More complex process measures such as eye screening improved more slowly, and were more dependent on redesign of the care pathway. Improvement was greater for type 2 than type 1 diabetes. Significant shifts of care for type 2 diabetes into primary care were achieved, but were harder to achieve without additional resources. Lessons learnt: Delivering better care to whole populations across organisational and professional boundaries required sustained work over long periods, and at all levels of the system of care. Past network focus on clinical collaboration has been effective at improving clinical process and outcome, and the network is now prioritising work with managers and patients to support future redesign.

Whether there was an increased prevalence of cancer associated with insulin use was questioned in the early twentieth century (Marble, 1934), and there is a growing body of evidence suggesting that diabetes increases the risk of the incidence and mortality from certain cancers. These include pancreatic and liver cancer, colorectal cancer, breast cancer, bladder cancer, cancer of the kidney and endometrial cancer (Wideroff et al, 1997; Coughlin et al, 2004; Rousseau et al, 2006; Kuriki et al, 2007). However, the results of studies of diabetes and cancer have been very mixed with many not distinguishing between type 1 and type 2 diabetes (Wideroff et al, 1997), or have defined groups according to treatment (Swerdlow et al, 2005). In some studies, the basis for diabetes diagnosis is self-report (Coughlin et al, 2004), in others it is clinical (Saydah et al, 2003). Studies have been both retrospective (Kuriki et al, 2007) and prospective, with some prospective studies following up from diagnosis of diabetes (Ragozzino et al, 1982); another followed up a cross-sectional sample of patients (Swerdlow et al, 2005). In this study, we present the risks of different cancers following diagnosis of type 2 diabetes in Tayside, Scotland, using a standardised methodology.

BackgroundGrowing evidence suggests that perinatal depression is associated with disrupted mother–infant interactions and poor infant outcomes. Antenatal depression may play a key role in this cycle by disrupting the development of a maternal response to infant stimuli. The current study therefore investigated the impact of depressive symptoms on the basic cognitive processing of infant stimuli at the beginning of pregnancy.MethodA total of 101 women were recruited by community midwives and tested at an average gestation of 11 weeks. An established computerized paradigm measured women's ability to disengage attention from infant and adult faces displaying negative positive and neutral emotions. Depressive symptoms were measured using a computerized interview (the Clinical Interview Schedule).ResultsThe effect of infant emotion on women's ability to disengage from infant faces was found to be influenced by depressive symptoms. Non-depressed pregnant women took longer to disengage attention from distressed compared with non-distressed infant faces. This bias was not, however, seen in women experiencing depressive symptoms. There was a difference of −53 (s.d.=0.7) ms (95% confidence interval −90 to −14, p=0.007) between those with and without depressive symptoms in this measure of attentional bias towards distressed infant faces.ConclusionsOur results suggest that depressive symptoms are already associated with differential attentional processing of infant emotion at the very beginning of childbearing. The findings have potential implications for our understanding of the impact of depressive symptoms during pregnancy on the developing mother–infant relationship.

Background: It has been suggested that diabetes is under-recorded on death certificates. Methods: We examined the death certificates of 1,872 people with type 2 diabetes in Tayside, Scotland, to determine how frequently diabetes was recorded. Results: Diabetes was mentioned on the certificates of 42.8% and was the underlying cause of death for 6.4%. There was mention of diabetes for 51.3% of the 811 people for whom cardiovascular disease was the underlying cause of death. Being male was associated with less frequent mention of diabetes, with more frequent mention associated with increasing duration of diabetes, increasing age and underlying cardiovascular cause of death. Conclusions: This study highlights the limitations of using routine mortality data for monitoring the burden of diabetes in populations.

To develop and test a set of measures of quality of care in the process of sepsis management, to determine the inter-rater reliability of case-note review in assessment of these measures and to assess our current standard of care.Five measures of process of care and one of outcome were identified from the literature review and previous experience. Failure modes and effects analysis was used by a multidisciplinary team to validate these measures and prioritize them in terms of associated risk. Forty sets of case notes were reviewed by two independent teams and the inter-rater reliability was determined using observed percentage agreement and the kappa statistic. We used the data to calculate the proportion of patients in whom we are currently meeting targets for good quality of care.The multidisciplinary team did not identify any additional areas of concern and assigned the highest risk priority to a delay of over 4 h from recognition of sepsis to antibiotic administration. The inter-rater agreement was80% for four of the measures, but was only 62.5% for appropriateness of antibiotic therapy. Room for improvement in practice exists, for example, antibiotic administration within 4 h was not achieved in 40% of patients.Four of our five measures of care are suitable for use in assessing the effect of interventions aimed at improving sepsis management, with at least moderate inter-rater reliability. Specific areas where increased clarity should improve agreement further have been identified.

Aims/hypothesis We examined incidence, prevalence and mortality from type 2 diabetes mellitus in a Scottish population over 12 years, and evaluated the effects on prevalence of increasing incidence and decreasing mortality. Materials and methods We used a diabetes clinical information system in Tayside (population 387,908), Scotland, to identify new cases of type 2 diabetes between 1993 and 2004 and to calculate incidence rates and mid-year prevalence. We defined mortality rates as the number of deaths of diabetic people divided by mid-year prevalence. We used logistic and Poisson regression to analyse trends. We then modelled the increase in prevalence for each year for three scenarios, based on whether mortality or incidence rates remained unchanged from 1993. Results There was a doubling in incidence and prevalence of type 2 diabetes in Tayside over the 12 years, with statistically significant increasing trends of 6.3 and 6.7% per year respectively. The mortality rate decreased. If incidence and mortality had remained at 1993 levels, there would have been an increase in prevalence of 855 per 100,000 in 2003, accounting for 60.1% of the actual increase of 1,423 per 100,000. If there had been no mortality decrease, prevalence in 2003 would have been very similar to the actual prevalence observed. Conclusions/interpretation Decreasing mortality rates in Tayside had less effect on the increase in prevalence than did increasing incidence. Even if incidence and mortality remain unchanged, prevalence will increase by over 20% in the next decade.

Objectives To review all published observational studies reporting on all-cause mortality in patients with type 2 diabetes to determine the degree of increased mortality when diagnosed at an older age. Design Systematic literature search. Setting The review included studies carried out in populations from Germany, United Kingdom, United States, Japan, Italy, Western Australia, Netherlands and Sweden. Measurements Medline, CINAHL, EMBASE, National Research Register and Cochrane Reviews were systematically searched from 1975 to 2004. We identified observational studies that reported overall mortality for people diagnosed with type 2 diabetes when they were over the age of 60, compared with a non-diabetic population. Outcome measures were expressed as risk ratios or relative risks. Results Among 14 eligible studies, one study reported reduced mortality for patients diagnosed with type 2 diabetes over the age of 60, whereas another found virtually no increased risk of mortality. However, 7 of the 14 studies reported increased mortality in all patients diagnosed when older, and 5 studies for certain subgroups only. A meta-analysis showed the combined relative risks (with 95% CI) of increased mortality for men diagnosed between the ages of 60 and 70 to be 1.38 (1.08-1.76) and 1.13 (0.88-1.45) for men diagnosed aged 70 years or older. A similar pattern was found for the same age groups for women, with combined relative risks of 1.40 (1.10-1.79) and 1.19 (0.93-1.52) respectively. Conclusion Increased mortality associated with a diagnosis of type 2 diabetes at an older age is lower than that reported for the general older diabetic population.

The aim of this study was to evaluate the risk of adverse cardiovascular outcomes in patients with type 2 diabetes newly treated with sulfonylureas and metformin.The Diabetes Audit and Research in Tayside Scotland (DARTS) diabetes information system and the Medicines Monitoring Unit (MEMO) dispensed prescribing database for the population of Tayside, Scotland (400,000 people) were employed. Patients newly prescribed with oral hypoglycaemic agents between 1994 and 2001 were classified into five study cohorts according to the treatment received: metformin only, sulfonylureas only, sulfonylureas added to metformin, metformin added to sulfonylureas, and both drugs simultaneously. In Cox regression analyses, we estimated relative risks for all-cause mortality, cardiovascular mortality and cardiovascular hospital admission for patients in the five study cohorts, with metformin monotherapy as the reference group.Of the 5,730 study patients, 1,000 died during a maximum of 8 years follow-up. Patients in the sulfonylureas only cohort had increased risks of mortality and cardiovascular mortality, with unadjusted relative risks of 3.12 (95% CI 2.54-3.84) and 3.71 (95% CI 2.64-5.22), respectively. After adjusting for differences between groups (age, sex, duration of diabetes, blood pressure, cholesterol, HbA(1c), smoking, previous hospital admission, treatment with cardiovascular medication), these relative risks were 1.43 (95% CI 1.15-1.77) and 1.70 (95% CI 1.18-2.45), respectively. Patients in the combination cohorts had significantly increased risks of cardiovascular hospital admission, as well as increased risks of mortality and cardiovascular mortality.In this cohort study of patients newly treated with oral hypoglycaemic agents, those treated with sulfonylureas only, or combinations of sulfonylureas and metformin, were at higher risk of adverse cardiovascular outcomes than those treated with metformin alone.

Metformin, widely given to patients with type 2 diabetes, works by targeting the enzyme AMPK (AMP activated protein kinase), which induces muscles to take up glucose from the blood. A recent breakthrough has found the upstream regulator of AMPK to be a protein kinase known as LKB1.1 2 LKB1 is a well recognised tumour suppressor. Activation of AMPK by metformin and exercise requires LKB1, and this would also explain why exercise is beneficial in the primary and secondary prevention of certain cancers.3 We hypothesise that metformin use in patients with type 2 diabetes may reduce their risk of cancer. We tested this hypothesis using record linkage databases developed in Tayside, Scotland: a diabetes clinical information system (DARTS) and a database of dispensed prescriptions (MEMO).4 We did a pilot case-control study using previously validated methods.5 From 314 127 people who were resident (or died) in Tayside in …

Aim The DARTS diabetes register was used to determine incidence rates of diabetes and related complications in 1997. Methods The diabetes register records detailed clinical information for all patients diagnosed with diabetes in Tayside, Scotland. The study population included patients who were alive and registered with a Tayside GP for the duration of 1997 or who died in Tayside during this time. Patients who had diabetes prior to 1997, those who developed diabetes in 1997, and those who developed diabetic complications in 1997, were identified. Results In the Tayside population of 385 774 at the start of 1997, there were 942 and 6632 patients with Type 1 and Type 2 diabetes, with a further 29 and 744 patients diagnosed in 1997. The incidence rates (with 95% confidence intervals) of diabetic complications per 1000 patients with Type 1 and Type 2 diabetes, respectively, were: angina 8.8 (4.5–17.3) and 38.4 (33.4–44.2); myocardial infarction 8.6 (4.4–16.9) and 21.9 (18.4–25.9); cerebrovascular accident 1.1 (0.3–6.0) and 14.2 (11.6–17.5); lower extremity amputation 3.2 (1.2–9.4) and 3.1 (2.1–4.8); peripheral vascular disease 5.5 (2.4–12.8) and 13.6 (11.0–16.8); registered blindness 1.1 (0.3–5.9) and 1.6 (0.9–2.9); end-stage renal failure 6.4 (3.0–13.8) and 5.0 (3.6–7.0). Mortality was 14.6 per 1000 (9.6–25.7) in Type 1 diabetes and 50.0 per 1000 (45.1–55.3) in Type 2 diabetes. Conclusion This study provides baseline figures for rates of diabetic complications for Type 1 and Type 2 diabetes, and confirms the increased burden of macrovascular disease in Type 2 diabetes.

To compare the mortality of people who were diagnosed with type 2 diabetes over 65 years of age with that of nondiabetic individuals.Using a population-based diabetes information system for an observational cohort study in Tayside, Scotland, people who were diagnosed with type 2 diabetes over the age of 65 years between 1993 and 2002 were identified. Nondiabetic comparators, matched for age and sex, were identified from the nondiabetic population. The two cohorts were followed up for mortality and cardiovascular mortality according to death certification records.There were 3,594 people with type 2 diabetes (48% male) and 7,188 matched comparators identified in the study. Over a mean follow-up period of 4.6 +/- 2.9 years for 3,594 people with type 2 diabetes and 7,188 comparators, 909 (25.3%) patients in the diabetic cohort and 1,651 (23.0%) in the nondiabetic cohort died. The adjusted relative risk for mortality in the diabetic cohort compared with the nondiabetic cohort was 1.06 (95% CI 0.94-1.19) for men and 1.29 (1.15-1.45) for women. Cardiovascular deaths accounted for 49.4% of the deaths in people with and 45.2% in those without diabetes (adjusted relative risk 1.01 [0.93-1.10]).Men diagnosed with type 2 diabetes over the age of 65 years have no excess mortality compared with their nondiabetic counterparts, a finding that was not replicated for women.

Aim To investigate whether patients require insulin as a result of poor adherence to oral hypoglycaemic agents (OHAs) in Type 2 diabetes. Methods A diabetes information system and a database of drugs dispensed for the study period 1993–1996 were used in Tayside, Scotland (population 400 000). Patients aged over 34 years with Type 2 diabetes who had at least 6 months exclusive therapy with OHAs (sulphonylureas or metformin) prior to insulin treatment were identified. Intended duration of every OHA prescription was calculated from prescription details. Adherence was estimated by dividing total intended duration of OHA therapy by study time for each patient, and compared between those who did and did not convert to insulin. Results There were 2537 patients on sulphonylureas (51% male, mean age 67 years). There was improved adherence in the 262 patients who commenced insulin, who had mean adherence of 88.3% (95% confidence interval (CI) 85.9–90.6%) compared with the remaining 2275 patients whose mean adherence was 87.4% (95% CI 86.7–88.2%). In a logistic regression analysis, the adjusted odds ratio (OR) for commencing insulin was 1.20 (95% CI 1.07–1.35) for a quartile increase in adherence. There were 1519 patients on metformin (49% male, mean age 64 years). Mean adherence was 79.7% (95% CI 76.4–83.1%) and 83.1% (95% CI 82.0–84.1%) in 169 patients who did and 1350 who did not commence insulin, respectively, with an adjusted OR for a quartile increase in adherence of 0.91 (95% CI 0.78–1.07). Conclusion Despite suboptimal adherence to OHAs in Type 2 diabetes, this is not associated with subsequent requirement for insulin. Diabet. Med. 19, 685–688 (2002)

Record-linkage refers to the linking together of data relating to the same individual from separate source files. In this paper, we discuss ways in which the technique can enhance observational prescribing research in large populations. We draw upon the work of the Medicines Monitoring Unit (MEMO), University of Dundee, to illustrate its contribution to prescribing research.

Problem Antibiotic administration to inpatients developing sepsis in general hospital wards was frequently delayed. We aimed to reproduce improvements in sepsis management reported in other settings. Context Ninewells Hospital, an 860-bed teaching hospital with quality improvement (QI) experience, in Scotland, UK. The intervention wards were 22 medical, surgical and orthopaedic inpatient wards. Design A multifaceted intervention, informed by baseline process data and questionnaires and interviews with junior doctors, evaluated using segmented regression analysis of interrupted time series (ITS) data. Measures for improvement Primary outcome measure: antibiotic administration within 4 hours of sepsis onset. Secondary measures: antibiotics within 8 hours; mean and median time to antibiotics; medical review within 30 min for patients with a standardised early warning system score ≥4; blood cultures taken before antibiotic administration; blood lactate level measured. Strategies for change The intervention included printed and electronic clinical guidance, educational clinical team meetings including baseline performance data, audit and monthly feedback on performance. Effects of change Performance against all study outcome measures improved postintervention but differences were small and ITS analysis did not attribute the observed changes to the intervention. Lessons learnt Rigorous analysis of this carefully designed improvement intervention could not confirm significant effects. Statistical analysis of many such studies is inadequate, and there is insufficient reporting of negative studies. In light of recent evidence, involving senior clinical team members in verbal feedback and action planning may have made the intervention more effective. Our focus on rigorous intervention design and evaluation was at the expense of iterative refinement, which likely reduced the effect. This highlights the necessary, but challenging, requirement to invest in all three components for effective QI.

OBJECTIVE: Utilization and costs of prescription drugs were investigated in diabetic and nondiabetic patients. RESEARCH DESIGN AND METHODS: The study was carried out in Tayside, Scotland, U.K. A validated population-based diabetes register was used to identify patients with type 1 and type 2 diabetes, and a database of all prescriptions dispensed in the community was used to investigate drug utilization in 1995. RESULTS: In a population of 406,526, there were 974 (0.2%) with type 1 diabetes and 6,869 (1.7%) with type 2 diabetes. The mean dispensed prescribing rates for all drugs (excluding antidiabetic medication) were higher across all age-groups for diabetic patients. After adjusting for age, patients with type 1 diabetes were 2.07 times (95% CI 2.03-2.11) more likely and patients with type 2 diabetes were 1.70 times (1.69-1.71) more likely to be dispensed a drug item than people without diabetes. This likelihood was increased in every drug category, even those not directly related to diabetes, and the proportion and cost of drug items dispensed to diabetic patients was therefore higher than expected given the prevalence of diabetes. Upon projecting these results to the U.K. population, it was discovered that nearly 8% of the U.K. drug budget (Pound Sterling 350 million) is accounted for by patients with diabetes (90% of that by patients with type 2 diabetes). CONCLUSIONS: This study highlights the increased usage and cost of prescription drugs in diabetes, with type 2 diabetes constituting a particular burden. It was discovered that 1.4% of drug usage in the entire population can be accounted for by the increased prescribing rate of diabetic patients compared with that of nondiabetic patients.

Record-linkage is the linkage of patient-specific information that is stored separately. Recent advances in computerization have meant that record-linkage techniques in medical research are increasingly being used and refined. In particular, they have made a significant contribution to pharmacovigilance, which involves linking drug exposure to outcomes data. In this article, the contribution of record-linkage in Scotland to medical research is described. The two organizations that utilize record-linkage techniques are the Medicines Monitoring Unit (MEMO) of the University of Dundee and the Information and Statistics Division (ISD) of the NHS in Scotland. Pharmacovigilance is MEMO's main concern (using data from the Tayside region of Scotland), while ISD link health care datasets for Scotland for general health care research. The experience of the two groups is now being combined to carry out drug safety studies in the entire population of Scotland.

BACKGROUND: To evaluate the relation between non-steroidal anti-inflammatory drugs (NSAIDs) and colitis due to inflammatory bowel disease. METHODS: A case-control study was conducted using a prospectively constructed, record linkage database containing hospital event and dispensed drug data (1989-93). The study population consisted of 319,465 people resident in Tayside in January 1989, and still resident (or dead) in October 1994. RESULTS: Of the 785 patients admitted to hospital as emergencies with colitis between July 1989 and June 1993, 200 fulfilled the case criterion of colitis due to inflammatory bowel disease. A further 1198 persons were used as community controls. Odds ratios were calculated for three exposure periods (current, recent, and past exposure). The overall odds ratios (with 95% confidence intervals) for current and recent exposure to NSAIDs were 1.77 (1.01 to 3.10) and 1.93 (1.20 to 3.09) respectively. Current and recent exposure to NSAIDs was also associated for incident cases, with odds ratios of 2.96 (1.32 to 6.64) and 2.51 (1.13 to 5.55). There was a trend for recent exposure among non-incident cases. CONCLUSION: The use of NSAIDs may be associated with an increased risk of emergency admission to hospital for colitis due to inflammatory bowel disease, particularly among patients with no previous history.

Background There is a paucity of methodologically robust vocational rehabilitation (VR) intervention trials. This study assessed the feasibility and acceptability of a VR trial of women with breast cancer to inform the development of a larger interventional study. Methods Women were recruited in Scotland and randomised to either a case management VR service or to usual care. Data were collected on eligibility, recruitment and attrition rates to assess trial feasibility, and interviews conducted to determine trial acceptability. Sick leave days (primary outcome) were self-reported via postal questionnaire every 4 weeks during the first 6 months post-surgery and at 12 months. Secondary outcome measures were change in employment pattern, quality of life and fatigue. Results Of the 1,114 women assessed for eligibility, 163 (15%) were eligible. The main reason for ineligibility was age (>65 years, n = 637, 67%). Of those eligible, 111 (68%) received study information, of which 23 (21%) consented to participate in the study. Data for 18 (78%) women were analysed (intervention: n = 7; control: n = 11). Participants in the intervention group reported, on average, 53 fewer days of sick leave over the first 6 months post-surgery than those in the control group; however, this difference was not statistically significant (p = 0.122; 95% confidence interval −15.8, 122.0). No statistically significant differences were found for secondary outcomes. Interviews with trial participants indicated that trial procedures, including recruitment, randomisation and research instruments, were acceptable. Conclusions Conducting a pragmatic trial of effectiveness of a VR intervention among cancer survivors is both feasible and acceptable, but more research about the exact components of a VR intervention and choice of outcomes to measure effectiveness is required. VR to assist breast cancer patients in the return to work process is an important component of cancer survivorship plans. Trial registration ISRCTN29666484