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Objective: The aim of the study was to examine the association of tested TSH with age, gender, and diabetes in a large population-based cohort without evidence of thyroid disease., Design: Record-linkage technology was used retrospectively to identify people without evidence of thyroid disease in the general population of Tayside, Scotland, from July 1, 2003, to December 31, 2009., Cohort: All Tayside residents who had thyroid function tests performed were identified. Using a unique patient identifier, data linkage enabled a cohort without thyroid disease to be identified by excluding anyone with thyroid or antithyroid prescription, thyroid-related admission or surgery, treatment with radioactive iodine and/or positive thyroid antibodies. Cases below 18 years of age were also excluded., Outcome Measures: We measured TSH distribution among different age groups and by gender., Results: We identified the latest TSH measurements in 153127 people from the reference population after applying the exclusion criteria. There was a significant increase in median TSH (1.58 mU/L at 31-40 y to 1.86 mU/L at >90 y; P < .001) and 97.5th centile TSH (3.98 to 5.94 mU/L, respectively) with increasing age. The 2.5th centile decreased with age (0.51 to 0.31 mU/L). Patients with diabetes had marginally higher TSH concentration (1.80 vs 1.70 mU/L; P < .001)., Conclusion: The use of these age-specific reference intervals for TSH, especially in those over 70 years old, would result in the reclassification of many TSH results from "abnormal" to "normal" (within the 95th centile reference interval) and avoid unnecessary treatment.

Background: In the UK, clinicians usually make treatment decisions based on total cholesterol (TC) at the same time supplemented with high-density lipoprotein cholesterol (HDL-C) measurements. We evaluated statin-associated TC concentration change and its impact on cardiovascular (CV) risk reduction in diabetic patients in the setting of usual care., Methods: In a population-based cohort study using a record-linkage database in Tayside, Scotland. we studied 6,697 diabetic patients who had at least two separate TC measurements between 1993 and 2007. Patients were categorized into statin-exposed and statin-unexposed groups according to statin use status during the follow-up. The main outcomes were TC concentration change from baseline, CV events, and all-cause mortality during the follow-up. Multivariate Cox regression models with a time-dependent variable for statins were employed to assess outcome risk., Results: Statin-associated TC concentrations decreased by 1.64 mmol/L (28%) in patients without CV disease (CVD) (5,984) and 1.19 mmol/L (23%) in patients with CVD (713) from 5.90 mmol/L and 5.20 mmol/L at baselines, respectively. Statin use reduced incident and recurrent CV events by 39% and 41%, respectively [adjusted hazard ratio (HR) 0.61, 95% confidence interval (CI) 0.57-0.66; 0.59 95% CI 0.47-0.76) per millimole of TC reduction. For all-cause mortality, the adjusted HRs were 0.39 (95% CI 0.32-0.47) in primary prevention and 0.58 (95% CI 0.42-0.80) in secondary prevention., Conclusion: Statin use was as effective in diabetic patients in the setting of usual care, as in the clinical trials, in both primary and secondary prevention. TC changes can be used as a measure of statin efficacy in the absence of low-density lipoprotein cholesterol (LDL-C) in diabetic patients.

Objective: To describe mortality and disease-specific morbidities in patients with mild primary hyperparathyroidism (PHPT)., Design: Retrospective population-based observational study., Setting: Tayside, Scotland, from 1997 to 2006., Participants: Patients with mild PHPT were selected from a predefined PHPT cohort between 1997 and 2006., Main Outcome Measures: Standardised mortality ratios (SMRs) were examined for all-cause mortality, as well as cardiovascular and cancer mortality. Standardised morbidity ratios and standardised incidence ratios were also calculated for eleven observed co-morbidities., Results: In total, there were 1683 (69.1% female) patients identified with mild PHPT in Tayside. Patients were found to have an increased risk of all-cause mortality and cardiovascular mortality (SMR-all cause 2.62, 95% CI 2.39-2.86; SMR-cardiovascular 2.68, 95% CI 2.34-3.05). Patients with mild PHPT had a significantly increased risk of developing cardiovascular and cerebrovascular disease, renal dysfunction and fractures compared to the age- and sex-adjusted general population., Conclusions: Mortality and morbidity were increased for patients with mild untreated PHPT, which is similar to more severe PHPT.

Objective: To evaluate prevalence and incidence of diagnosed primary hyperparathyroidism (PHPT) in adults between 1997 and 2006 in Tayside, Scotland, UK., Design: Population-based incidence and prevalence study., Patients: All Tayside residents aged 20 years and over with an increased serum calcium level (> 2.55 mmol/l) between 1997 and 2006 were included as potential participants. Using a unique patient identifier, data-linkage enabled a data set of PHPT patients to be created from an algorithm of biochemistry records, nuclear scan records, histology records, hospital clinic letters and community based prescription records. Persons having tertiary hyperparathyroidism (14.0%) were also identified and were excluded., Outcome Measures: Age and sex adjusted incidence density and period prevalence were calculated for each year., Results: We identified 2709 patients (70.8% female) diagnosed with PHPT by the end of 2006. The mean age of women (68 years SD = 14) was older than that of men (64 years SD = 15) at baseline. The prevalence of diagnosed PHPT in Tayside increased from 1.82 per 1000 population in 1997 to 6.72 per 1000 population in 2006 (P < 0.001). Prevalence of PHPT is higher in females, and the female preponderance increases with age; the annual prevalence ratio between women and men is stable at around 2.5 each year. There was a 3-4-year cyclical incidence rate varying from 4.13 to 11.30 per 10 000 person-years., Conclusion: We observed a general increase in the prevalence of diagnosed PHPT in Tayside, Scotland. The incidence of diagnosis is greater in females than in males and increases with age. The annual incidence followed an apparent cyclic curve during the study period.

What Is Already Known About This Subject: * Statins reduce cholesterol concentrations and cardiovascular events in randomized clinical trials. * Much less is known about their impact in the setting of normal care., What This Study Adds: * This is the first study to assess the effectiveness of lipid-lowering treatment in the general population. * We have also estimated the resultant impact on major vascular events. * We have examined the actual and potential impact of lipid-lowering treatment., Aims: To evaluate the impact of lipid-lowering treatment on cholesterol concentrations in the setting of normal care., Methods: This was a retrospective review of all cholesterol measurements made in Tayside, Scotland, between 1993 and 2002, linked to dispensed prescribing data for lipid-lowering drugs. It was conducted in the setting of normal care and included all patients who underwent cholesterol measurement. The main outcome measure was cholesterol concentration., Results: A total of 401,489 cholesterol measurements were made on 128,240 patients over the study period. Measurements were categorized as treated and untreated according to whether patients were exposed to lipid-lowering treatment at the time the total cholesterol concentration was measured. Those categorized as untreated fell by 0.86 mmol l(-1) (13.9%) and those categorized as treated by 1.45 mmol l(-1) (23.5%). The difference between baseline and follow-up cholesterol concentrations in intention-to-treat patients was 1.53 mmol l(-1) (24%) in 2002. In the same year, mean cholesterol concentration was 4.71 mmol l(-1) (a fall of 1.65 mmol l(-1) or 25.9%) in patients judged to be taking their lipid-lowering medication, compared with 5.20 mmol l(-1) (a fall of 1.16 mmol l(-1) or 18.2%) in those judged not to be taking treatment. Cholesterol fell by 0.38 mmol l(-1) (6.3%) in a cohort of never treated patients (n = 33,679) between 1993 and 2002., Conclusions: The impact of lipid-lowering drugs on population cholesterol concentrations in the setting of normal care was significant and comparable with the cholesterol reductions seen in the setting of major statin trials, despite a significant proportion of the population receiving low dose treatment. In those subjects judged to be taking their medication, the benefits achieved were substantial. The impact of nondrug factors is indicated by the fall in population cholesterol seen in the absence of lipid-lowering treatment.

Background: Student selected components (SSCs) represent a significant component of medical curricula in the UK and a new approach in medical education. Despite the prominence given to SSCs by the General Medical Council in each of its seminal papers regarding undergraduate medical education, there remains a diverse view of the purpose, outcomes, structure and assessment of SSCs. Many Schools have adopted their own perspective of SSCs and created different but often innovative courses., Aims: This article brings together the Scottish Medical Schools and their experience in organising SSCs, highlights some of the challenges and offers possible solutions to some of the difficulties encountered., Method: The SSC Director from each of the Scottish medical schools each contributed their own '12 Tips'. From these a consensus was achieved., Results: Even though the Scottish medical schools have a wide range of curriculum and timetable formats, there was a great deal of agreement in the challenges and problems encountered in their SSC programmes, as expressed through these 12 Tips., Conclusion: There is much diversity in SSC programmes at different medical schools, although there is also much commonality in the challenges that arise. We hope that this paper will promote thought and discussion amongst those involved, and be useful to those involved in curriculum and programme development and also to those new to medical education.