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Background: Few studies have examined whether UK military veterans are at an increased risk of dementia. We explored the risk of dementia in Scottish military veterans aged up to 73 years in comparison with people who have never served. Methods: Retrospective cohort study of 78 000 veterans and 253 000 people with no record of service, matched for age, sex and area of residence, with up to 37 years follow-up, using Cox proportional hazard analysis to compare risk of dementia in veterans and non-veterans, overall and by subgroup. Results: Dementia was recorded in 0.2% of both veterans and non-veterans overall, Cox proportional hazard ratio 0.98, 95% confidence interval (CI) 0.82–1.19, p = 0.879 (landmark age: 50 years), with no difference for men but increased risk in veteran women and Early Service Leavers. Post-traumatic stress disorder (PTSD) was associated with a higher risk of dementia in both veterans and non-veterans, although possibly to a lesser degree in veterans. A history of mood disorder was strongly associated with developing dementia, greater in veterans than in non-veterans, odds ratio 1.54, 95% CI 1.01–2.35, p = 0.045. Conclusions: There was no evidence to suggest that military service increased the risk of dementia, although this may change as the cohort ages. The well-documented association with PTSD shows no evidence of being stronger in veterans; by contrast, the association of mood disorder with dementia is much stronger in veterans. Healthcare providers should carefully assess the cognitive status of older veterans presenting with depressive illness in order to identify early dementia and ensure optimum management. [ABSTRACT FROM AUTHOR]

Objective: Use of the Growth Assessment Protocol (GAP) has increased internationally under the assumption that it reduces the stillbirth rate. The evidence for this is limited and based largely on an ecological time-trend study. Discordance in the uptake of the GAP program between Scotland and England/Wales enabled us to assess the assertion that implementation of GAP leads to a reduced stillbirth rate.Methods: We analyzed data from the National Records for Scotland and the Office for National Statistics on the number of singleton maternities and stillbirths in Scotland and in England and Wales, respectively, from 1 January 2000 to 31 December 2015. National uptake of the GAP program over time in each of the regions was recorded. Stillbirth rate per 1000 maternities was calculated, according to year of delivery, and compared between Scotland and England/Wales.Results: During the study period, there were 870 632 singleton maternities in Scotland, of which 4243 were stillbirths, and there were 10 469 120 singleton maternities in England and Wales, of which 51 562 were stillbirths. There was a marked difference in uptake of the GAP program between the two regions, with substantially fewer maternity units in Scotland implementing the program. Stillbirth rates were static up to 2010, with a decline thereafter in both regions, to 3.75 (95% CI, 3.25-4.30) per 1000 maternities in Scotland and 4.30 (95% CI, 4.15-4.46) per 1000 maternities in England and Wales in 2015. From 2010 onwards, the decline in Scotland was faster, equating to 48 (95% CI, 47.9-48.1) fewer stillbirths per 100 000 maternities in Scotland than in England and Wales from 2010 to 2015 compared with 2000 to 2009.Conclusions: We observed a decline in stillbirth rate in England and Wales, which coincided with implementation of the GAP program. However, a concurrent decline in stillbirth rate was observed in Scotland in the absence of increased implementation of GAP. The secular rates of change in stillbirth rate in England and Wales cannot be used to infer efficacy of the GAP program. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

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

Objective: To determine whether caesarean delivery in the first pregnancy is a risk factor for unexplained antepartum stillbirth in a second pregnancy.Design: A population-based retrospective cohort study and meta-analysis.Setting: All maternity units in Scotland.Participants: A cohort of 128 585 second births, 1999-2008.Methods: Time-to-event analysis and random-effects meta-analysis.Main Outcome Measure: Risk of unexplained antepartum stillbirth in a second pregnancy.Results: There were 88 stillbirths among 23 688 women with a previous caesarean delivery (2.34 per 10 000 women per week) and 288 stillbirths in 104 897 women who had previously delivered vaginally (1.67 per 10 000 women per week, P = 0.002). When analysed by cause, women with a previous caesarean delivery had an increased risk of unexplained stillbirth (hazard ratio, HR 1.47; 95% confidence interval, 95% CI 1.12-1.94; P = 0.006) and, as previously observed, the excess risk was apparent from 34 weeks of gestation onwards. The risk did not differ in relation to the indication of the caesarean delivery, and was independent of maternal characteristics and previous obstetric complications. We identified three other comparable studies (two in North America and one in Europe), and meta-analysis of these studies showed a statistically significant association between previous caesarean delivery and the risk of antepartum stillbirth in the second pregnancy (pooled HR 1.40; 95% CI 1.10-1.77; P = 0.006).Conclusions: Women who have had a previous caesarean delivery are at increased risk of unexplained stillbirth in the second pregnancy.Tweetable Abstract: Caesarean first delivery is associated with an increased risk of unexplained stillbirth in the next pregnancy. [ABSTRACT FROM AUTHOR]

BackgroundThe evidence is conflicting as to whether body mass index (BMI) is associated with mental health and, if so, to what extent it varies by sex and age. We studied mental health across the full spectrum of BMI among the general population, and conducted subgroup analyses by sex and age.MethodWe undertook a cross-sectional study of a representative sample of the Scottish adult population. The Scottish Health Survey provided data on mental health, measured by the General Health Questionnaire-12 (GHQ), BMI, demographic and life-style information. Good mental health was defined as a GHQ score <4, and poor mental health as a GHQ score ⩾4. Logistic regression models were applied.ResultsOf the 37 272 participants, 5739 (15.4%) had poor mental health. Overall, overweight participants had better mental health than the normal-weight group [adjusted odds ratio (OR) 0.93, 95% confidence interval (CI) 0.87–0.99, p = 0.049], and individuals who were underweight, class II or class III obese had poorer mental health (class III obese group: adjusted OR 1.26, 95% CI 1.05–1.51, p = 0.013). There were significant interactions of BMI with sex (p = 0.013) and with age (p < 0.001). Being overweight was associated with significantly better mental health in middle-aged men only. In contrast, being underweight at all ages or obese at a young age was associated with significantly poorer mental health in women only.ConclusionsThe adverse associations between adiposity and mental health are specific to women. Underweight women and young women who are obese have poorer mental health. In contrast, middle-aged overweight men have better mental health. [ABSTRACT FROM PUBLISHER]

Objective To determine whether maternal serum levels of alphafetoprotein (α-FP) and human chorionic gonadotrophin (hCG) at 15–21 weeks provided clinically useful prediction of stillbirth in first pregnancies. Design Retrospective study of record linkage of a regional serum screening laboratory to national registries of pregnancy outcome and perinatal death. Setting West of Scotland, 1992–2001. Population A total of 84 769 eligible primigravid women delivering an infant at or beyond 24 weeks of gestation. Methods The risk of stillbirth between 24 and 43 weeks was assessed using the Cox proportional hazards model. Logistic regression models within gestational windows were then used to estimate predicted probability. Screening performance was assessed as area under the receiver operating characteristic (ROC) curve. Main outcome measure Antepartum stillbirth unrelated to congenital abnormality. Results The odds ratio (95% CI) for stillbirth at 24–28 weeks for women in the top 1% were 11.97 (5.34–26.83) for α-FP and 5.80 (2.19–15.40) for hCG. The corresponding odds ratios for stillbirth at or after 37 weeks were 2.44 (0.74–8.10) and 0.79 (0.11–5.86), respectively. Adding biochemical to maternal data increased the area under the ROC curve from 0.66 to 0.75 for stillbirth between 24 and 28 weeks but only increased it from 0.64 to 0.65 for stillbirth at term and post-term. Women in the top 5% of predicted risk had a positive likelihood ratio of 7.8 at 24–28 weeks, 3.7 at 29–32 weeks, 5.1 at 33–36 weeks and 3.4 at 37–43 weeks, and the corresponding positive predictive values were 0.97, 0.33, 0.47 and 0.63%, respectively. Conclusions Maternal serum levels of α-FP and hCG were statistically associated with stillbirth risk. However, the predictive ability was generally poor except for losses at extreme preterm gestations, where prevention may be difficult and interventions have the potential to cause significant harm. [ABSTRACT FROM AUTHOR]

Objective: To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium-term events, and whether any associations are independent of differences in case mix. Design: Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six-year period. Methods: All PCIs in Scotland during 1997-2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models. Results: Of the 17 417 PCIs, 4900 (28%) were in low-volume hospitals and 3242 (19%) in high-volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high-volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p = 0.002). Over two years, patients in high-volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p = 0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events. Conclusion: Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high-volume hospitals. Over two years, patients treated in high-volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery. [ABSTRACT FROM AUTHOR]

Examines the prospective audit of carotid endarterectomy (CEA) in Scotland. Nature of vascular surgical services; Improvement of the effectiveness of CEA; Reduction in the delays to surgery.

The article presents a study on the hospital burden of suspected acute coronary syndromes (ACS) in Scotland. The aim of the study was to describe the changing burden of suspected ACS on the hospital sector of the National Health Service in Scotland over the period 1990-2000. The study used the record linkage system for discharges from hospitals in Scotland to identify all emergency hosptialisations of patients. The results of the study was discussed.

Objective: To determine whether exposure to secondhand smoke is associated with early prognosis following acute coronary syndrome. Design, setting and participants: We interviewed consecutive patients admitted to nine Scottish hospitals over 23 months. Information was obtained, via questionnaire, on age, sex, smoking status, postcode of residence and admission serum cotinine concentration was measured. Follow-up data were obtained from routine hospital admission and death databases. Results: Of the 5815 participants, 1261 were never-smokers. Within 30 days, 50 (4%) had died and 35 (3%) had a non-fatal myocardial infarction. All-cause deaths increased from 10 (2.1%) in those with cotinine ⩽0.1 ng/ml to 22 (7.5%) in those with cotinine >0.9 ng/ml (χ2 test for trend p<0.001). This persisted after adjustment for potential confounders (cotinine >0.9 ng/ml: adjusted OR 4.80, 95% CI 1.95 to 11.83, p = 0.003). The same dose response was observed for cardiovascular deaths and death or myocardial infarction. Conclusions: Secondhand smoke exposure is associated with worse early prognosis following acute coronary syndrome. Non-smokers need to be protected from the harmful effects of secondhand smoke. [ABSTRACT FROM AUTHOR]

The 3-yearly World Congress of Epidemiology is the premier, international, scientific conference organised under the auspices of the International Epidemiological Association (in open competition). This paper explores the justification for seeking to host the Congress and reflects on the structures and processes adopted in making the XIXth Congress in Scotland happen. Preparing the bid was invaluable for forming collaborations, generating scientific ideas, and garnering opinion. After the bid was accepted, we formed a local organising committee, named the Management Executive Committee to signal its decision making authority; and scientific, fundraising, marketing, international and social subcommittees. There was uncertainty about critical matters such as delegate numbers, costs and the total budget. Early decisions had to be made on, for example, the fee and fundraising target (~250,000), despite financial risks. Development of the scientific programme was a critical step that under-pinned fundraising and marketing and permitted involvement of the international committee. Overall the 2011 WCE succeeded. The key ingredients to success were: a large collaboration of institutions and individuals; early pledges of financial support mostly from the UK; the valuable and relevant experience of the professional conference organisers; unstinting support and advice from IEA; and the effectiveness of the committee structure. The educational and professional development benefits of this WCE will reach a worldwide community and not just delegates, because of video, PowerPoint and textual accounts being open access on the Internet. This reach is unprecedented for IEA's World Congresses. We anticipate that the Congress will translate into better public health practice, better future Congresses, advances in epidemiology and improved population health. [ABSTRACT FROM AUTHOR]

Introduction: Physical activity is an important component of military training. Although injuries and musculoskeletal disorders are the most common cause of medical retirement from the Armed Forces, the long-term risk of lower limb osteoarthritis in veterans is unknown. We used data on hip and knee replacement in Scottish military veterans as a proxy measure., Methods: Retrospective cohort study of 78 000 veterans born between 1945 and 1995 and a comparison group of 253 000 non-veterans, matched for age, sex and area of residence, followed up for up to 37 years, using survival analysis to examine the risk of hip and knee replacement., Results: Veterans were significantly less likely to undergo hip replacement than non-veterans, Cox proportional HR 0.87, 95% CI 0.80 to 0.95, p<0.001. There was no significant difference between veterans and non-veterans in respect of knee replacement, HR 1.02, 95% CI 0.94 to 1.11, p=0.643, and there was no difference in the ages at which veterans and non-veterans underwent joint replacement. People who had served for longest in the military had similar risk to those with the shortest service., Conclusions: Based on the likelihood of undergoing joint replacement surgery in later life, we found no evidence of a positive association between military service and an increased risk of lower limb osteoarthritis., Competing Interests: Competing interests: BPB is a military veteran and Honorary Civilian Consultant Advisor (Army) in Veterans’ Health and Epidemiology. No other interests are declared by the authors., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: It has been suggested that ' junior entry ' to the UK Armed Forces (prior to age 17.5 years) increases the risk of adverse mental health outcomes. We used data from a large cohort of veterans to examine long-term mental health outcomes in veterans by age at entry to the UK Armed Forces, compared with non-veterans., Methods: Retrospective cohort study of 78 157 veterans in Scotland, born between 1945 and 1995 and and 252 637 matched non-veterans, with up to 37 years follow-up, using Cox proportional hazard models to examine the association between veteran status and cumulative risk of major mental health disorder, stratified by birth cohort, and age at recruitment for the veterans., Results: The risk of mental health disorder in the veterans increased with age at entry, ranging from HR 1.12, 95% CI 1.06 to 1.18, p<0.001 for junior entrants to HR 1.37, 95% CI 1.27 to 1.80, p<0.001 for those aged 20-25 years at entry. The pattern was most marked for veterans born before 1960, and age at recruitment had little impact in recent birth cohorts. Post-traumatic stress disorder accounted for most of the observed differences. Younger age at recruitment was associated with longer service, median 7.4 years (IQR 3.0-14.7) compared with 5.6 years (IQR 2.1-11.7) for entrants aged 20-25 years., Conclusion: We found no evidence that early recruitment is associated with adverse impact on long-term mental health. Paradoxically, it was veterans who entered service at age 20-25 years who demonstrated increased risk, although this attenuated in more recent birth cohorts., Competing Interests: Competing interests: BPB is a military veteran and Honorary Civilian Consultant Advisor (Army) in Veterans’ Health and Epidemiology. Neither the Army nor the Ministry of Defence had any input to this paper, and the views and opinions expressed are solely those of the authors. NTF is a trustee (unpaid) of The Warrior Programme and an independent advisor to the Independent Group Advising on the Release of Data (IGARD)., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To investigate health, mortality and healthcare inequalities experienced by people with intellectual disabilities, and autistic people, and their determinants; an important step towards identifying and implementing solutions to reduce inequalities. This paper describes the cohorts, record-linkages and variables that will be used., Participants: Scotland's Census, 2011 was used to identify Scotland's citizens with intellectual disabilities, and autistic citizens, and representative general population samples with neither. Using Scotland's community health index, the Census data (demography, household, employment, long-term conditions) were linked with routinely collected health, death and healthcare data: Scotland's register of deaths, Scottish morbidity data 06 (SMR06: cancer incidence, mortality, treatments), Prescribing Information System (identifying asthma/chronic obstructive pulmonary disease; angina/congestive heart failure/hypertension; peptic ulcer/reflux; constipation; diabetes; thyroid disorder; depression; bipolar disorders; anxiety/sleep; psychosis; attention deficit hyperactivity disorder; epilepsy; glaucoma), SMR01 (general/acute hospital admissions and causes, ambulatory care sensitive admissions), SMR04 (mental health admissions and causes), Scottish Care Information-Diabetes Collaboration (diabetic care quality, diabetic outcomes), national bowel screening programme and cervical screening., Findings to Date: Of the whole population, 0.5% had intellectual disabilities, and 0.6% were autistic. Linkage was successful for >92%. The resultant e-cohorts include: (1) 22 538 people with intellectual disabilities (12 837 men and 9701 women), 4509 of whom are children <16 years, (2) 27 741 autistic people (21 390 men and 6351 women), 15 387 of whom are children <16 years and (3) representative general population samples with neither condition. Very good general health was reported for only 3389 (15.0%) people with intellectual disabilities, 10 510 (38.0%) autistic people, compared with 52.4% general population. Mental health conditions were reported for 4755 (21.1%) people with intellectual disabilities, 3998 (14.4%) autistic people, compared with 4.2% general population., Future Plans: Analyses will determine the extent of premature mortality, causes of death, and avoidable deaths, profile of health conditions and cancers, healthcare quality and screening and determinants of mortality and healthcare., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Objectives: Type 2 diabetes is an important public health problem but the risk in UK military veterans is unknown. We used data from the Trends in Scottish Veterans' Health study to investigate the risk in comparison with people with no record of service., Design: Retrospective cohort study of a large national sample in Scotland, with up to 37 years follow-up., Setting: Pseudoanonymised extract of computerised Scottish National Health Service records, including a disease register and national vital records., Participants: 78 000 veterans and 253 000 people with no record of service matched for age, sex and area of residence., Outcome Measures: Cox proportional HRs for first record of type 2 diabetes in veterans compared with non-veterans, overall and by sex and birth cohort. Long-term trend, comorbidity with specific mental health outcomes and risk of limb loss., Results: Overall, 7.2% of veterans were diagnosed with type 2 diabetes, and were at slightly increased risk compared with non-veterans, Cox proportional HR 1.08, 95%CIs 1.04 to 1.11, p<0.001. The increased risk was confined to men, and to veterans born prior to 1960. There has been no change in HR over the last 25 years. Among veterans with post-traumatic stress disorder (PTSD), 12.1% had been diagnosed with type 2 diabetes, compared with 9.4% of non-veterans with PTSD. The difference was statistically significant, OR 1.29, 95% CI 1.04 to 1.59, p=0.021. Risk of limb loss was increased among the oldest veterans., Conclusions: Older veterans in Scotland have an increased risk of type 2 diabetes in comparison with non-veterans, but there is no difference in respect of younger veterans, and the pattern of risk shows no evidence that it is changing. There is a positive association between type 2 diabetes and PTSD, especially in the presence of comorbid mood disorder, an important finding which should be noted by care providers., Competing Interests: Competing interests: BPB is a military veteran and Honorary Civilian Consultant Advisor (Army) in Veterans’ Health and Epidemiology, an unfunded position., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Recent attention has focused on veterans who have lost limbs in conflict, but the number of UK veterans who lose limbs to disease is unknown. We used data from the Trends in Scottish Veterans' Health study to explore postservice lower limb amputation., Methods: We carried out a retrospective cohort study of 78 000 veterans and 253 000 non-veterans born between 1945 and 1995, matched for age, sex and area of residence. We used survival analysis to examine the risk of amputation in veterans compared with non-veterans, and explored associations with antecedent disease., Results: We found no difference between veterans and non-veterans in the risk of lower limb amputation, which was recorded in 145 (0.19%) veterans and 464 (0.18%) non-veterans (Cox proportional hazard ratio (HR) 1.00, 95% CIs 0.82 to 1.20, p=0.961). Peripheral arterial disease was recorded in two-thirds of both veteran and non-veteran amputees, and type 2 diabetes in 41% of veterans and 33% of non-veterans, with a dual diagnosis in 32% of veterans and 26% of non-veterans. Trauma was an infrequent cause of amputation., Conclusions: Although in later life veterans are no more likely to lose a limb to disease than non-veterans, the number so affected greatly outweighs those who have lost limbs in conflict. The high public profile of conflict-related limb loss risks eclipsing the needs of veterans with disease-related loss. Support for ageing veterans who have lost limbs due to disease will require planning with the same care as that afforded to the victims of conflict if inequalities are to be avoided., Competing Interests: Competing interests: BPB is a military veteran and Honorary Civilian Consultant Advisor (Army) in Veterans’ Health and Epidemiology. Neither the Army nor the Ministry of Defence had any input to this paper, and the views and opinions expressed are solely those of the authors., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Oral health may be poorer in adults with intellectual disabilities (IDs) who rely on carer support and medications with increased dental risks., Methods: Record linkage study of dental outcomes, and associations with anticholinergic (e.g. antipsychotics) and sugar-containing liquid medication, in adults with IDs compared with age-sex-neighbourhood deprivation-matched general population controls., Results: A total of 2933/4305 (68.1%) with IDs and 7761/12 915 (60.1%) without IDs attended dental care: odds ratio (OR) = 1.42 [1.32, 1.53]; 1359 (31.6%) with IDs versus 5233 (40.5%) without IDs had restorations: OR = 0.68 [0.63, 0.73]; and 567 (13.2%) with IDs versus 2048 (15.9%) without IDs had dental extractions: OR = 0.80 [0.73, 0.89]. Group differences for attendance were greatest in younger ages, and restoration/extractions differences were greatest in older ages. Adults with IDs were more likely prescribed with anticholinergics (2493 (57.9%) vs. 6235 (48.3%): OR = 1.49 [1.39, 1.59]) and sugar-containing liquids (1641 (38.1%) vs. 2315 (17.9%): OR = 2.89 [2.67, 3.12])., Conclusion: Carers support dental appointments, but dentists may be less likely to restore teeth, possibly extracting multiple teeth at individual appointments instead., (© 2020 The Authors. Journal of Intellectual Disability Research published by MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disibilities and John Wiley & Sons Ltd.)

Objectives: To investigate mortality rates and causes in children and young people with intellectual disabilities., Design: Retrospective cohort; individual record linkage between Scotland's annual pupil census and National Records of Scotland death register., Setting: General community., Participants: Pupils receiving local authority-funded schooling in Scotland, 2008 to 2013, with an Additional Support Need due to intellectual disabilities, compared with other pupils., Main Outcome Measures: Deaths up to 2015: age of death, age-standardised mortality ratios (age-SMRs); causes of death including cause-specific age-SMRs; avoidable deaths as defined by the UK Office of National Statistics., Results: 18 278/947 922 (1.9%) pupils had intellectual disabilities. 106 died over 67 342 person-years (crude mortality rate=157/100 000 person-years), compared with 458 controls over 3 672 224 person-years (crude mortality rate=12/100 000 person-years). Age-SMR was 11.6 (95% CI 9.6 to 14.0); 16.6 (95% CI 12.2 to 22.6) for female pupils and 9.8 (95% CI 7.7 to 12.5) for male pupils. Most common main underlying causes were diseases of the nervous system, followed by congenital anomalies; most common all-contributing causes were diseases of the nervous system, followed by respiratory system; most common specific contributing causes were cerebral palsy, pneumonia, respiratory failure and epilepsy. For all contributing causes, SMR was 98.8 (95% CI 69.9 to 139.7) for congenital anomalies, 76.5 (95% CI 58.9 to 99.4) for nervous system, 63.7 (95% CI 37.0 to 109.7) for digestive system, 55.3 (95% CI 42.5 to 72.1) for respiratory system, 32.1 (95% CI 17.8 to 57.9) for endocrine and 14.8 (95% CI 8.9 to 24.5) for circulatory system. External causes accounted for 46% of control deaths, but the SMR for external-related deaths was still higher (3.6 (95% CI 2.2 to 5.8)) for pupils with intellectual disabilities. Deaths amenable to good care were common., Conclusion: Pupils with intellectual disabilities were much more likely to die than their peers, and had a different pattern of causes, including amenable deaths across a wide range of disease categories. Improvements are needed to reduce amenable deaths, for example, epilepsy-related and dysphagia, and to support families of children with life-limiting conditions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Objective: To investigate current Down syndrome live birth and death rates, and childhood hospitalisations, compared with peers., Setting: General community., Participants: All live births with Down syndrome, 1990-2015, identified via Scottish regional cytogenetic laboratories, each age-sex-neighbourhood deprivation matched with five non-Down syndrome controls. Record linkage to Scotland's hospital admissions and death data., Primary Outcome: HRs comparing risk of first hospitalisation (any and emergency), readmission for children with Down syndrome and matched controls were calculated using stratified Cox proportional hazards (PH) model, and length of hospital stay was calculated using a conditional log-linear regression model., Results: 689/1479 (46.6%) female and 769/1479 (51.9%) male children/young people with Down syndrome were identified (1.0/1000 births, with no reduction over time); 1235 were matched. 92/1235 (7.4%) died during the period, 18.5 times more than controls. More of the Down syndrome group had at least one admission (incidence rate ratio(IRR) 72.89 (68.72-77.32) vs 40.51 (39.15-41.92); adjusted HR=1.84 (1.68, 2.01)) and readmissions (IRR 54.85 (51.46-58.46) vs 15.06 (14.36-15.80); adjusted HR=2.56 (2.08, 3.14)). More of their admissions were emergencies (IRR 56.78 (53.13-60.72) vs 28.88 (27.73-30.07); first emergency admission adjusted HR=2.87 (2.61, 3.15)). Children with Down syndrome had 28% longer first admission after birth. Admission rate increased from 1990-2003 to 2004-2014 for the Down syndrome group (from 90.7% to 92.2%) and decreased for controls (from 63.3% to 44.8%)., Conclusions: We provide contemporaneous statistics on the live birth rate of babies with Down syndrome, and their childhood death rate. They require more hospital admissions, readmissions emergency admissions and longer lengths of stays than their peers, which has received scant research attention in the past. This demonstrates the importance of statutory planning as well as informal support to families to avoid added problems in child development and family bonding over and above that brought by the intellectual disabilities associated with Down syndrome., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: The 'healthy worker effect' predicts that longer employment is positively associated with reduced mortality, but few studies have examined mortality in military veterans irrespective of exposure to conflict., Aims: To examine mortality in a large national cohort of Scottish veterans by length of service., Methods: Retrospective cohort study comparing survival in up to 30-year follow-up among 57 000 veterans and 173 000 people with no record of service, matched for age, sex and area of residence, who were born between 1945 and 1985. We compared antecedent diagnoses in the two groups to provide information on probable risk factors., Results: By the end of follow-up, 3520 (6%) veterans had died, compared with 10 947 (6%) non-veterans. Cox proportional hazard analysis confirmed no significant difference overall unadjusted or after adjusting for deprivation. On subgroup analysis, those who left prematurely (early service leavers) were at significantly increased risk of death (hazard ratio (HR) 1.16, 95% confidence interval (CI) 1.09-1.24, P < 0.001), although the increase became non-significant after adjusting for socioeconomic status (HR 1.05, 95% CI 0.99-1.12). Longer-serving veterans were at significantly lower risk of death than non-veterans; the risk decreased both with length of service and in more recent birth cohorts. Smoking-related disease was the greatest contributor to increased mortality in early leavers., Conclusions: Among longer-serving veterans, there was evidence of a HWE partly attributable to selective attrition of early service leavers, but birth cohort analysis suggests improvements over time which may also reflect a causal effect of improved in-service health promotion., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Drink driving is an important risk factor for road traffic accidents (RTAs), which cause high levels of morbidity and mortality globally. Lowering the permitted blood alcohol concentration (BAC) for drivers is a common public health intervention that is enacted in countries and jurisdictions across the world. In Scotland, on Dec 5, 2014, the BAC limit for drivers was reduced from 0·08 g/dL to 0·05 g/dL. We therefore aimed to evaluate the effects of this change on RTAs and alcohol consumption., Methods: In this natural experiment, we used an observational, comparative interrupted time-series design by use of data on RTAs and alcohol consumption in Scotland (the interventional group) and England and Wales (the control group). We obtained weekly counts of RTAs from police accident records and we estimated weekly off-trade (eg, in supermarkets and convenience stores) and 4-weekly on-trade (eg, in bars and restaurants) alcohol consumption from market research data. We also used data from automated traffic counters as denominators to calculate RTA rates. We estimated the effect of the intervention on RTAs by use of negative binomial panel regression and on alcohol consumption outcomes by use of seasonal autoregressive integrated moving average models. Our primary outcome was weekly rates of RTAs in Scotland, England, and Wales. This study is registered with ISRCTN, number ISRCTN38602189., Findings: We assessed the weekly rate of RTAs and alcohol consumption between Jan 1, 2013, and Dec 31, 2016, before and after the BAC limit came into effect on Dec 5, 2014. After the reduction in BAC limits for drivers in Scotland, we found no significant change in weekly RTA rates after adjustment for seasonality and underlying temporal trend (rate ratio 1·01, 95% CI 0·94-1·08; p=0.77) or after adjustment for seasonality, the underlying temporal trend, and the driver characteristics of age, sex, and socioeconomic deprivation (1·00, 0·96-1·06; p=0·73). Relative to RTAs in England and Wales, where the reduction in BAC limit for drivers did not occur, we found a 7% increase in weekly RTA rates in Scotland after this reduction in BAC limit for drivers (1·07, 1·02-1·13; p=0·007 in the fully-adjusted model). Similar findings were observed for serious or fatal RTAs and single-vehicle night-time RTAs. The change in legislation in Scotland was associated with no change in alcohol consumption, measured by per-capita off-trade sales (-0·3%, -1·7 to 1·1; p=0·71), but a 0·7% decrease in alcohol consumption measured by per-capita on-trade sales (-0·7%, -0·8 to -0·5; p<0·0001)., Interpretation: Lowering the driving BAC limit to 0·05 g/dL from 0·08 g/dL in Scotland was not associated with a reduction in RTAs, but this change was associated with a small reduction in per-capita alcohol consumption from on-trade alcohol sales. One plausible explanation is that the legislative change was not suitably enforced-for example with random breath testing measures. Our findings suggest that changing the legal BAC limit for drivers in isolation does not improve RTA outcomes. These findings have significant policy implications internationally as several countries and jurisdictions consider a similar reduction in the BAC limit for drivers., Funding: National Institute for Health Research Public Health Research Programme., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: There is mounting evidence that associates brain injury and offending behaviour, and there is a need to understand the epidemiology of head injury in prisoners in order to plan interventions to reduce associated disability and risk of reoffending. This is the first study to determine the lifetime prevalence of hospitalised head injury (HHI) in a national population of current prison inmates. In addition characteristics of prisoners with HHI and were compared to prisoners without HHI to discover whether those with HI differed demographically., Methods: Whole life hospital records of everyone aged 35 years or younger and resident in a prison in Scotland on a census date in 2015 were electronically linked via their unique NHS identifier and checked for ICD-9 and 10 codes for head injury. Using a case-control design, these data were compared with a sample from the general population matched 3:1 for age, gender and area-based social deprivation. Comparison of demographic variables was made between prisoners with and without HHI., Results: HHI was found in 24.7% (1,080/4,374) of prisoners and was significantly more prevalent than found in the matched general population sample (18.2%; 2394/13122; OR 2.10; 95%CI 1.87, 2.16). The prevalence of HHI in prisoners and controls was similar with the exception of a higher risk of HHI in prisoners in lower deprivation quintiles. Having three or more HHI was more common in prisoners (OR 3.04; 95%CI 2.33, 3.97) as were HHI with ICD codes for intracranial injuries (OR 1.81; 95% CI 1.54, 2.11), suggesting that more severe HHI is more prevalent in prisoners than the general population. The distributions within demographic variables and the characteristics of HHI admissions in prisoners with and without a history of HHI were similar., Conclusion: Prisoners in Scotland aged 35 years or younger have a higher lifetime prevalence of HHI than the general population and are more likely to have had repeated HI or intracranial injuries. Further work is required to elucidate the correspondence between self-report of HI and hospitalised records and to ascertain persisting effects of HI in prisoners and the need for services to reduce associated disability and risk of reoffending., Competing Interests: The authors have declared that no competing interests exist.

Neuroticism is a personality trait of fundamental importance for psychological well-being and public health. It is strongly associated with major depressive disorder (MDD) and several other psychiatric conditions. Although neuroticism is heritable, attempts to identify the alleles involved in previous studies have been limited by relatively small sample sizes. Here we report a combined meta-analysis of genome-wide association study (GWAS) of neuroticism that includes 91 370 participants from the UK Biobank cohort, 6659 participants from the Generation Scotland: Scottish Family Health Study (GS:SFHS) and 8687 participants from a QIMR (Queensland Institute of Medical Research) Berghofer Medical Research Institute (QIMR) cohort. All participants were assessed using the same neuroticism instrument, the Eysenck Personality Questionnaire-Revised (EPQ-R-S) Short Form's Neuroticism scale. We found a single-nucleotide polymorphism-based heritability estimate for neuroticism of ∼15% (s.e.=0.7%). Meta-analysis identified nine novel loci associated with neuroticism. The strongest evidence for association was at a locus on chromosome 8 (P=1.5 × 10(-15)) spanning 4 Mb and containing at least 36 genes. Other associated loci included interesting candidate genes on chromosome 1 (GRIK3 (glutamate receptor ionotropic kainate 3)), chromosome 4 (KLHL2 (Kelch-like protein 2)), chromosome 17 (CRHR1 (corticotropin-releasing hormone receptor 1) and MAPT (microtubule-associated protein Tau)) and on chromosome 18 (CELF4 (CUGBP elav-like family member 4)). We found no evidence for genetic differences in the common allelic architecture of neuroticism by sex. By comparing our findings with those of the Psychiatric Genetics Consortia, we identified a strong genetic correlation between neuroticism and MDD and a less strong but significant genetic correlation with schizophrenia, although not with bipolar disorder. Polygenic risk scores derived from the primary UK Biobank sample captured ∼1% of the variance in neuroticism in the GS:SFHS and QIMR samples, although most of the genome-wide significant alleles identified within a UK Biobank-only GWAS of neuroticism were not independently replicated within these cohorts. The identification of nine novel neuroticism-associated loci will drive forward future work on the neurobiology of neuroticism and related phenotypes.

Objective: To determine whether caesarean delivery in the first pregnancy is a risk factor for unexplained antepartum stillbirth in a second pregnancy., Design: A population-based retrospective cohort study and meta-analysis., Setting: All maternity units in Scotland., Participants: A cohort of 128 585 second births, 1999-2008., Methods: Time-to-event analysis and random-effects meta-analysis., Main Outcome Measure: Risk of unexplained antepartum stillbirth in a second pregnancy., Results: There were 88 stillbirths among 23 688 women with a previous caesarean delivery (2.34 per 10 000 women per week) and 288 stillbirths in 104 897 women who had previously delivered vaginally (1.67 per 10 000 women per week, P = 0.002). When analysed by cause, women with a previous caesarean delivery had an increased risk of unexplained stillbirth (hazard ratio, HR 1.47; 95% confidence interval, 95% CI 1.12-1.94; P = 0.006) and, as previously observed, the excess risk was apparent from 34 weeks of gestation onwards. The risk did not differ in relation to the indication of the caesarean delivery, and was independent of maternal characteristics and previous obstetric complications. We identified three other comparable studies (two in North America and one in Europe), and meta-analysis of these studies showed a statistically significant association between previous caesarean delivery and the risk of antepartum stillbirth in the second pregnancy (pooled HR 1.40; 95% CI 1.10-1.77; P = 0.006)., Conclusions: Women who have had a previous caesarean delivery are at increased risk of unexplained stillbirth in the second pregnancy., Tweetable Abstract: Caesarean first delivery is associated with an increased risk of unexplained stillbirth in the next pregnancy., (© 2015 Royal College of Obstetricians and Gynaecologists.)

Objective: Both active smoking and exposure to secondhand smoke (SHS) are associated with cardiovascular disease, but sidestream smoke contains higher levels of small particles and toxic gases than mainstream smoke. The relationship between the concentration of cotinine and a number of cardiovascular biomarkers among nonsmokers and active smokers was examined., Methods: A cross-sectional study using the Scottish Health Surveys conducted between 1998 and 2010 was undertaken. Inclusion was restricted to participants aged ≥16 years who had provided saliva and blood samples. Uni- and multivariate regression models were used to examine the relationships between the concentration of cotinine and C-reactive protein (CRP), high-density lipoprotein (HDL) cholesterol, and fibrinogen concentrations, as well as total:HDL cholesterol ratios., Results: Of the 10,018 eligible participants, 7,345 (73.3%) were confirmed to be nonsmokers (cotinine <15.0 ng/mL) and 2,673 (26.7%) were confirmed to be current smokers (cotinine ≥15.0 ng/mL). CRP and total:HDL cholesterol increased, and HDL cholesterol decreased, with increasing cotinine concentration across nonsmokers and smokers (all p < .001). However, there were step changes at the interface, whereby nonsmokers with a high exposure to SHS had lower concentrations of cotinine than light active smokers but comparable concentrations of CRP (p = .709), HDL cholesterol (p = .931), and total:HDL cholesterol (p = .405). Fibrinogen concentrations were significantly raised in moderate and heavy active smokers only (both p < .001)., Conclusion: Exposure to SHS is associated with disproportionately higher biomarkers of cardiovascular risk compared with active smoking. Protection from exposure to SHS should be a public health priority., (Copyright © 2014 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Aims: Current guidelines recommend early referral and initiation of intensive cardiovascular (CV) risk reduction in individuals with a positive family history of coronary heart disease (CHD). We hypothesized that a family history of premature CHD and stroke [CV disease (CVD)] would lead to earlier referral of hypertensive patients to secondary care clinic, leading to better control of risk factors, mitigating the excess risk seen in these individuals., Methods and Results: We studied the association of a positive family history of CVD in 10 787 individuals with longitudinal changes in risk factors and long-term cause-specific mortality in the Glasgow Blood Pressure Clinic using generalized estimating equations and the Cox proportional hazard models, respectively. The total time at risk was 193 756 person-years with a median survival time of 29.2 years. A positive family history of CVD was associated with an earlier presentation to the clinic, a lower burden of traditional CV risk factors, and similar longitudinal blood pressure reduction and drug adherence compared with those without. But despite these positive features, all-cause [hazard ratio (HR) = 1.12, 95% confidence interval 1.01-1.25] and CV (HR = 1.20, 1.04-1.38) mortality independent of baseline risk factors were worse. Consistent results were observed in propensity score-matched analysis. Inclusion of family history of CVD did not improve mortality risk discrimination over and above traditional risk factors., Conclusion: Our study suggests that despite earlier referral and treatment of individuals with a positive family history of premature CVD, excess risk persists, indicating the need for continued and sustained efforts to reduce risk factors and drug adherence in these individuals.

Objective: To determine whether relationships with gestational age and birthweight centile vary between specific causes of special educational need (SEN)., Design: Retrospective cohort study., Setting: Scotland., Population: A cohort of 407,503 schoolchildren., Methods: Polytomous logistic regression was used to examine the risk of each cause of SEN across the spectrum of gestation at delivery and birthweight centile, adjusting for potential confounding factors., Main Outcome Measures: Crude and adjusted odds ratios and confidence intervals., Results: Of the 19,821 children with SEN, 557 (2.8%) had sensory impairments, 812 (4.1%) had physical or motor disabilities, 876 (4.4%) had language impairments, 2823 (14.2%) had social, emotional, or behavioural problems, 7018 (35.4%) had intellectual disabilities, 4404 (22.2%) had specific learning difficulties, and 1684 (8.5%) autistic spectrum disorder (ASD). Extreme preterm delivery (at 24-27 weeks of gestation) was a strong predictor of sensory (adjusted OR 23.64, 95% CI 12.03-46.45), physical or motor (adjusted OR 29.69, 95% CI 17.49-50.40), and intellectual (adjusted OR 11.67, 95% CI 8.46-16.10) impairments, with dose relationships across the range of gestation. Similarly, birthweight below the third centile was associated with sensory (adjusted OR 2.85, 95% CI 2.04-3.99), physical or motor (adjusted OR 2.47, 95% CI 1.82-3.37), and intellectual (adjusted OR 2.67, 95% CI 2.41-2.96) impairments. Together, gestation and birthweight centile accounted for 24.0% of SEN arising from sensory impairment, 34.3% arising from physical or motor disabilities, and 26.6% arising from intellectual disabilities. Obstetric factors were less strongly associated with specific learning difficulties and social or emotional problems, and there were no significant associations with ASD., Conclusions: The association between gestation and birthweight centile and overall risk of SEN is largely driven by very strong associations with sensory, physical or motor impairments, and intellectual impairments., (© 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.)

Objective: To determine whether percutaneous coronary intervention (PCI) hospital volume of throughput is associated with periprocedural and medium-term events, and whether any associations are independent of differences in case mix., Design: Retrospective cohort study of all PCIs undertaken in Scottish National Health Service hospitals over a six-year period., Methods: All PCIs in Scotland during 1997-2003 were examined. Linkage to administrative databases identified events over two years' follow up. The risk of events by hospital volume at 30 days and two years was compared by using logistic regression and Cox proportional hazards models., Results: Of the 17,417 PCIs, 4900 (28%) were in low-volume hospitals and 3242 (19%) in high-volume hospitals. After adjustment for case mix, there were no significant differences in risk of death or myocardial infarction. Patients treated in high-volume hospitals were less likely to require emergency surgery (adjusted odds ratio 0.18, 95% confidence interval (CI) 0.07 to 0.54, p = 0.002). Over two years, patients in high-volume hospitals were less likely to undergo surgery (adjusted hazard ratio 0.52, 95% CI 0.35 to 0.75, p = 0.001), but this was offset by an increased likelihood of further PCI. There was no net difference in coronary revascularisation or in overall events., Conclusion: Death and myocardial infarction were infrequent complications of PCI and did not differ significantly by volume. Emergency surgery was less common in high-volume hospitals. Over two years, patients treated in high-volume centres were as likely to undergo some form of revascularisation but less likely to undergo surgery.

Background: From 26 March 2006, smoking will be prohibited in wholly and substantially enclosed public places in Scotland, and it will be an offence to permit smoking or to smoke in no-smoking premises. We anticipate that implementation of the smoke-free legislation will result in significant health gains associated with reductions in exposure to both environmental tobacco smoke (ETS) and personal tobacco consumption as well as other social and economic impacts., Methods: Health Scotland in conjunction with the Information Services Division (ISD) Scotland and the Scottish Executive have developed a comprehensive evaluation strategy to assess the expected short-term, intermediate and long-term outcomes. Using routine health, behavioural and economic data and commissioned research, we will assess the impact of the smoke-free legislation in eight key outcome areas--knowledge and attitudes, ETS exposure, compliance, culture, smoking prevalence and tobacco consumption, tobacco-related morbidity and mortality, economic impacts on the hospitality sector and health inequalities., Conclusion: The findings from this evaluation will make a significant contribution to the international understanding of the health effects of exposure to ETS and the broader social, cultural and economic impacts of smoke-free legislation.

Objective: To determine whether neonatal respiratory morbidity at term is associated with an increased risk of later asthma and whether this may explain previously described associations between caesarean delivery and asthma., Design: Retrospective cohort study using Scottish Morbidity Record (SMR) data of maternity (SMR02), neonatal (SMR11), and acute hospital (SMR01) discharges., Setting: Scotland., Participants: All singleton births at term between 1992-1995 in 23 Scottish maternity hospitals., Main Outcome Measures: Hospital admission with a diagnosis of asthma in the principal position between 1992 and 2000., Results: Children who had a diagnosis of transient tachypnoea of the newborn or respiratory distress syndrome were at increased risk of being admitted to hospital with a diagnosis of asthma (hazard ratio (HR) 1.7, 95% confidence interval (95% CI) 1.4 to 2.2, p<0.001). This association was observed both among children delivered vaginally (HR 1.5, 95% CI 1.1 to 2.0, p = 0.007) and among those delivered by caesarean section (HR 2.2, 95% CI 1.6 to 3.0, p<0.001). In the absence of neonatal respiratory morbidity, delivery by caesarean section was weakly associated with the risk of asthma in childhood (HR 1.1, 95% CI 1.0 to 1.2, p = 0.004). The strengths of the associations were similar whether the caesarean delivery was planned or emergency and were not significantly altered by adjustment for maternal, obstetric, and other neonatal characteristics., Conclusions: Neonatal respiratory morbidity at term is associated with an increased risk of asthma in childhood which may explain previously described associations between caesarean delivery and later asthma.

Aim: To determine whether mortality following percutaneous coronary intervention vs. coronary bypass grafting varies according to whether or not patients have diabetes., Methods: We used the Scottish Coronary Revascularization Register to identify all patients undergoing revascularization in Scottish NHS hospitals since 1997. We excluded single-vessel disease, left main stem stenosis, and bypass grafting performed at the same time as other operations. We used death certificate data from the Registrar General to identify all subsequent deaths., Results: Of the 6320 eligible procedures, 5042 (80%) were bypass grafts and 1278 (20%) angioplasties. Overall 831 (13%) patients had diabetes with no significant difference by procedure (13% vs. 12%). A total of 382 deaths occurred over a mean follow-up of 2.3 years. Diabetic patients had a poorer prognosis following both surgery (adjusted hazards ratio (HR) 1.43, 95% confidence interval (CI) 1.08, 1.89) and percutaneous intervention (adjusted HR 2.58, 95% CI 1.43, 4.63). Among non-diabetic patients, no significant differences in mortality were detected between the two procedures. Among diabetic patients, no significant difference was detected in those with two-vessel disease. In those with impaired left ventricular function and triple-vessel disease, angioplasty was associated with a significantly higher risk of death (adjusted HR 3.58, 95% CI 1.40, 9.19)., Conclusions: This is the first study to demonstrate statistically significant results that support the BARI trial findings. Our study demonstrated a significant difference for triple-vessel disease but not two-vessel disease. The former may be due to incomplete revascularization using percutaneous intervention. Our results require corroboration from randomized trials.

This study compares 12 month clinical outcomes and procedural costs at two interventional centres with significant differences in crude mortality and revascularization outcomes between 1997 and 1998. Percutaneous coronary intervention (PCI) registry data on 1046 consecutive patients treated contemporaneously at two university centres were linked to hospital discharge and death data to provide 12 month follow-up information on survival and repeat revascularization. Costs were determined by detailed analysis of equipment use, length of stay and staff from 100 contemporary cases at each centre to derive a procedural cost model. This model was then applied retrospectively to estimate cost per procedure. Stents were used more frequently at one centre (56 versus 26 per cent, chi(2) test, p < 0.001) resulting in greater procedural cost [mean (SE), pounds sterling 1970 (34) versus pounds sterling 1521 (39), t-test, p < 0.001). One year repeat target vessel PCI was significantly greater at the centre using more stents (10.3 versus 5.6 per cent, chi(2) test, p = 0.005) and the need for any repeat revascularization (PCI or coronary artery by-pass surgery) was also significantly greater at this centre (18.4 versus 10.8 per cent, chi(2) test, p < 0.001). Cox regression revealed that after correction for case-mix the difference in the need for repeat target vessel PCI between the two centres was no longer significant (p = 0.15). In the two centres studied, crude differences in cost per case, mortality and the need for revascularization were largely accounted for by significant differences in case-mix. Comparison of outcomes and costs between centres should not be published without careful adjustment for differences in case-mix.

Objective: To describe and compare presentation, management, and survival by aetiology of cardiopulmonary arrest., Design, Setting, and Patients: A retrospective cohort study was undertaken of all 21 175 first out of hospital cardiopulmonary arrests in Scotland between May 1991 and March 1998., Main Outcome Measure: Discharge alive from hospital., Results: Presumed cardiac disease accounted for 17 451 cases (82%), other internal aetiologies for 1814 (9%), and external aetiologies for 1910 (9%). Arrests caused by presumed cardiac disease had a better risk profile in terms of presence of a witness, bystander cardiopulmonary resuscitation, call-response interval, and use of defibrillation; 1265 (7%) of those who arrested from presumed cardiac disease were discharged alive, compared with only 77 (2%) of those with non-cardiac disorders (p < 0.001). Among those defibrillated, call-response interval was associated with survival following arrests from both presumed cardiac and non-cardiac causes (p < 0.001)., Conclusions: Out of hospital cardiopulmonary arrests from non-cardiac causes were associated with worse crude survival than arrests from cardiac causes. Improvements in call-response interval and basic life support skills in the community would improve survival irrespective of the aetiology and should therefore be encouraged.

Background: Although atrial fibrillation (AF) is an important cause of cardiovascular morbidity and mortality there is a paucity of data describing hospitalisation rates and case-fatality associated with this common arrhythmia. This study examines recent trends in first-ever hospitalisations for AF in Scotland., Methods: Using the linked Scottish Morbidity Record Scheme, we identified all 22968 patients admitted to Scottish hospitals for the first time with a principal diagnosis of AF between 1986 and 1995. For each calendar year we calculated short (30-day) and medium (31 day to 2 years) case-fatality rates. Adjusting for each patient's age, sex, deprivation status, concurrent diagnoses and prior hospitalisation status, we examined whether case-fatality rates had significantly improved during this 10-year period., Results: Between 1986 and 1995 the number of men hospitalised for the first time with AF increased by 926 (125%) to 1730 per annum and the number of women and by 875 (105%) to 1712 (both P<0.001). Hospitalisation rates increased from 0.31 to 0.70/1000 men and from 0.32 to 0.65/1000 women (both P<0.001). By the end of this period the proportion of men had increased from 48 to 50%. In both sexes, the median age of patients rose--in men from 66 to 68 years and in women from 74 to 75 years (both P<0.01). Despite the increasing age of patients and greater comorbidity, short-term (30-day) case-fatality declined from 4.0 to 3.1% in men (P<0.001) and 4.1 to 3.8% (P<0.01) in women. Similarly, medium-term (31-day to 2-year) case-fatality fell from 25 to 22% in men and 27 to 25% (both P<0.001) in women. Adjusting for the age, sex, extent of deprivation, secondary diagnoses and prior hospitalisation of hospitalised patients, we found that the risk of short-term case-fatality in the 1995 male and female cohort significantly declined by 21% (P<0.05) and 24% (P<0.05), respectively, in comparison to the 1986 cohort. The adjusted risk of case-fatality in the medium term also declined significantly in men by 30% (P<0.05) over this period and by 20% (P<0.05) in women relative to 1986., Conclusion: The number of first-ever hospitalisations for AF has increased twofold during the 10-year period 1986-1995. Although the age of patients has progressively increased during this period, short and medium case-fatality rates have declined, especially in men. This may partly reflect better treatment of AF. However, changing admission thresholds and other factors could also have led to an apparent improvement in prognosis. Nevertheless, medium-term case fatality remains substantial after a first ever admission to hospital with AF.

Background: Most deaths from coronary heart disease occur out of hospital. Hospital patients face social, age, and sex inequalities. Our aim was to examine inequalities and trends in out-of-hospital cardiac deaths., Methods: We used the Scottish record linked database to identify all deaths from acute myocardial infarction that occurred in Scotland (population 5.1 million), in 1986-95. We have compared population-based death rates for men and women across age and social groups., Findings: Between 1986 and 1995, 83365 people died from acute myocardial infarction, out of hospital and without previous hospital admission (44655 men, 38710 women); and 117749 were admitted with a first acute myocardial infarction, of whom 37020 died within 1 year. Thus, out-of-hospital deaths accounted for 69.2% (95% CI 69.0-69.5) of all 120385 deaths. Out-of-hospital deaths, measured as a proportion of all acute myocardial infarction events (deaths plus first hospital admissions), increased with age, from 20.1% (19.2-21.0) in people younger than 55 years, to 62.1% (61.3-62.9) in those older than 85 years. Population-based out-of-hospital mortality rates fell by a third in men and by a quarter in women. Mean yearly falls were larger in people aged 55-64 years (5.6% per year in men, 3.7% in women), than in those older than 85 years (2.5% in men and women). Mortality rates were substantially higher in deprived socioeconomic groups than in affluent groups, especially in people younger than 65 years., Interpretation: These inequalities in age, sex, and socioeconomic class should be actively addressed by prevention strategies for coronary heart disease.

Objectives: We tested the hypotheses that the effect of gender on short-term case fatality following a first admission for acute myocardial infarction (AMI) varies with age, and that this effect is offset by differences in the proportion of men and women who survive to reach hospital., Background: Evidence is conflicting regarding the effect of gender on prognosis after AMI., Methods: All 201,114 first AMIs between 1986 and 1995 were studied. Both 30-day and 1-year case fatality were analyzed for the 117,749 patients hospitalized and for all first AMIs, including deaths before hospitalization. The effect of gender and its interaction with age on survival was examined using multivariate modeling., Results: Gender-based differences in survival varied according to age in hospitalized patients, with younger women having higher 30-day case fatality than men (e.g., <55 years, women 6.5% vs. 4.8% men, p < 0.0001). When deaths from first AMI before hospitalization were included in 30-day case fatality, women were less likely to die (adjusted odds ratio 0.9, confidence interval 0.89 to 0.93). Gender was not an independent predictor of one-year survival (p = 0.16)., Conclusions: Female gender increases the probability of surviving to reach hospital, and this outweighs the excess risk of death occurring in younger women following hospitalization. Overall, men have a higher 30-day case fatality than women. Women do not fare worse than men after AMI when age and other factors are taken into account. However, men are more likely to die before hospitalization.

Background: Individuals who are small at birth are at increased risk of ischaemic heart disease (IHD) in later life. One hypothesis to explain this association is fetal adaptation to a suboptimum intrauterine environment. We investigated whether pregnancy complications associated with low birthweight are related to risk of subsequent IHD in the mother., Methods: Routine discharge data were used to identify all singleton first births in Scotland between 1981 and 1985. Linkage to the mothers' subsequent admissions and deaths provided 15--19 years of follow-up. The mothers' risks of death from any cause or from IHD and admission for or death from IHD were related to adverse obstetric outcomes in the first pregnancy. Hazard ratios were adjusted for socioeconomic deprivation, maternal height and age, and essential hypertension., Findings: Complete data were available on 129,920 (95.6%) eligible deliveries. Maternal risk of IHD admission or death was associated with delivering a baby in the lowest birthweight quintile for gestational age (adjusted hazard ratio 1.9 [95% CI 1.5--2.4]), preterm delivery (1.8 [1.3--2.5]), and pre-eclampsia (2.0 [1.5--2.5]). The associations were additive; women with all three characteristics had a risk of IHD admission or death seven times (95% CI 3.3--14.5) greater than the reference category., Interpretation: Complications of pregnancy linked to low birthweight are associated with an increased risk of subsequent IHD in the mother. Common genetic risk factors might explain the link between birthweight and risk of IHD in both the individual and the mother.

Objectives: To determine the association between ambulance response time and survival from out of hospital cardiopulmonary arrest and to estimate the effect of reducing response times., Design: Cohort study., Setting: Scottish Ambulance Service., Subjects: All out of hospital cardiopulmonary arrests due to cardiac disease attended by the Scottish Ambulance Service during May 1991 to March 1998., Main Outcome Measures: Survival rate to hospital discharge and potential improvement from reducing response times., Results: Of 13 822 arrests not witnessed by ambulance crews but attended by them within 15 minutes, complete data were available for 10 554 (76%). Of these patients, 653 (6%) survived to hospital discharge. After other significant covariates were adjusted for, shorter response time was significantly associated with increased probability of receiving defibrillation and survival to discharge among those defibrillated. Reducing the 90th centile for response time to 8 minutes increased the predicted survival to 8%, and reducing it to 5 minutes increased survival to 10-11% (depending on the model used)., Conclusions: Reducing ambulance response times to 5 minutes could almost double the survival rate for cardiac arrests not witnessed by ambulance crews.

Objective: To determine current outcomes of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG)., Design: The Scottish coronary revascularisation register provided prospectively collected data on case mix and in-hospital complications for all revascularisation procedures between April 1997 and March 1999 (4775 PTCA; 5115 CABG). Linkage to routine hospital discharge and death data provided follow up information on survival and repeat revascularisation., Results: Stents were used in 51% of PTCA procedures. CABG patients were older, had more severe coronary disease, and had greater comorbidity. PTCA was more likely to be undertaken as an urgent or emergency procedure. Perioperative death and urgent surgery followed 0.3% and 0.6% of PTCA procedures, respectively. Case fatality rates were higher following CABG, with 6.7% dead within two years compared with 3.4% following PTCA. PTCA was more often followed by readmission for ischaemic heart disease, repeat angiography, or revascularisation: 22.8% of patients had repeat revascularisation within two years, compared with 1.8% following CABG., Conclusions: The severity of coronary heart disease was greater than in previously published registry studies and randomised trials. Despite this, overall survival figures were comparable and repeat revascularisation rates lower, particularly following PTCA. Perioperative death and urgent surgery following PTCA were also lower. These favourable outcomes may be attributable, in part, to increased use of bail out and elective stenting.

Objectives: To analyse short- and long-term case-fatality trends following admission to hospital with a first acute myocardial infarction, in men and women between 1986 and 1995, after adjusting for risk factors known to influence survival., Design: A Scottish-wide retrospective cohort study., Setting: The Linked Scottish Morbidity Record Database was analysed. This contains accurate data on all hospital admissions since 1981, for the Scottish population of 5.1 million. It is linked to the Registrar General's death certificate data., Subjects: All 117 718 patients admitted to Scottish hospitals with a principal diagnosis of first acute myocardial infarction (ICD-9 code 410) between 1986 and 1995., Main Outcome Measures: The outcome was death, both in and out of hospital, from any cause, at 30 days, 1 year, 5 and 10 years., Results: Overall case-fatality following hospital admission with acute myocardial infarction was 22. 2%, 31.4%, 51.1% and 64.0% at 1 month, 1 year, 5 and 10 years, respectively. Multivariate analyses identified statistically significant independent prognostic factors. Thirty day mortality increased twofold for each decade of increasing age, and increased with any prior admission to hospital. When comparing the most deprived category to that of the most affluent, men had a 10% increased mortality (P<0.01), whilst women had an increased mortality of 4% (not significant). After adjustment for age, sex, deprivation and prior admission to hospital, case-fatality rates fell significantly between 1986 and 1995. Short-term case-fatality fell by 46% in men (27% in women) and long-term by 34% in men (30% in women) (both P<0.001)., Conclusions: Population-based case-fatality rates in Scotland have fallen dramatically since 1986, particularly in men. The increasing survival in patients admitted to hospital suggests that the trial-based efficacy of modern therapies is now translating into population-based effectiveness. However, an individual's life expectancy still halves after a diagnosis of acute myocardial infarction. Of the variables that we could examine, age was the most powerful predictor of prognosis., (Copyright 2000 The European Society of Cardiology.)

Aims: To determine whether men and women suffering cardiopulmonary arrest differ in terms of survival and risk factors for survival., Methods and Results: A prospective cohort study, using the Heartstart (Scotland) database, was undertaken on all 22 161 people suffering community-based cardiopulmonary arrest in Scotland between 1988 and 1997. The outcomes studied were death at the arrest scene, death before admission, death in hospital and death at any point up to discharge. Univariate analysis, using chi-square and Mann-Whitney U tests, was used to compare men and women in terms of patient characteristics, management and outcome. Multivariate logistic regression analysis was used to determine the association between sex and outcome after adjustment for case-mix. Sex differences in outcome varied over time. Women had a poorer risk profile than men. They were older (P<0.0001) and less likely to have shockable rhythms (P<0.0001). Despite this, they were more likely to survive to admission (P<0.0001). However, thereafter, women were more likely to die in hospital (P<0.01). There was no significant difference between the sexes in overall case-fatality rates to discharge., Conclusion: Women have a better early prognosis than men. However, this represents a postponement of death, rather than avoidance., (Copyright 2000 The European Society of Cardiology.)

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

Objective: To determine whether there are seasonal variations in survival following out of hospital cardiopulmonary arrest., Design: Prospective cohort study using the Heartstart (Scotland) database., Setting: All of Scotland., Patients: 10 890 people who suffered out of hospital cardiopulmonary arrest in the summer or winter between December 1988 and August 1997 inclusive., Intervention: Univariate comparisons of 5406 arrests occurring in summer with 5484 in winter, in terms of patient characteristics, management, and survival using chi(2) and Mann-Whitney U tests. Multivariate analysis of the association between season and survival following adjustment for case mix., Main Outcomes Measures: Survival to discharge from hospital, survival pre-admission, in-hospital survival., Results: Only 6% of people who arrested in winter survived to discharge, compared to 8% of those who arrested in summer (odds ratio 0.77, p < 0.001). People who arrested in winter had a poorer risk profile in that they were older, more likely to arrest at home, less likely to have a witness, and less likely to receive defibrillation. However, after adjustment for case mix, people who arrested in winter were still 19% less likely to survive compared to those who arrested in summer. Deaths pre-admission were significantly higher in winter (odds ratio 1.18, p < 0.05) but in-hospital deaths were not., Conclusions: People who suffer cardiopulmonary arrest in winter have a significantly lower likelihood of surviving. This is, in part, caused by the higher frequency of a number of recognised risk factors. However, their prognosis remains poorer even after adjustment for these factors.

Aims: To determine the extent to which increases in the uptake of effective treatments could further reduce coronary heart disease mortality in Scotland., Methods and Results: A cohort-based mortality model combining effectiveness data from published meta-analyses with available information on uptake of all coronary heart disease treatments in all patient categories in Scotland (population 5.1 million). In 1994, medical and surgical coronary disease treatments prevented or postponed an estimated 2722 deaths (minimum estimate 1373, maximum estimate 5986). Increasing treatment uptake to 100% of all eligible patients was considered unrealistic. Increasing uptake to 80% would have prevented or postponed a further 4078 deaths (39% from increases in secondary prevention therapies, 29%, 13%, 10% and 9% from the treatments of heart failure, acute myocardial infarction, hypertension and angina respectively)., Conclusions: Many eligible patients are currently not receiving treatment that is effective in reducing coronary heart disease mortality. Increasing treatment uptake could prevent or postpone a further 4080 deaths each year in Scotland, approximately, more than doubling the present benefit from treatment. By implication, about 30 000 additional deaths could be prevented, annually, in the U.K. Comparable symptom and morbidity benefits might also be expected. Future clinical audit activities should focus particularly on secondary prevention and heart failure treatments.

Background: The number of people residing in nursing homes has increased. General practitioners (GPs) receive an increased capitation fee for elderly patients in recognition of their higher consultation rate. However, there is no distinction between elderly patients residing in nursing homes and those in the community., Aim: To determine whether nursing home residents receive greater general practice input than people residing in the community., Method: Prospective comparative study of all 345 residents of eight nursing homes in Glasgow and a 2:1 age, sex, and GP matched comparison group residing in the community. A comparison of contacts with primary care over three months in terms of frequency, nature, length, and outcome was carried out., Results: Nursing home residents received more total contacts with primary care staff (P < 0.0001) and more face-to-face consultations with GPs (P < 0.0001). They were more likely to be seen as an emergency (P < 0.01) but were no more likely to be referred to hospital, and were less likely to be followed-up by their GP (P < 0.0001). Although individual consultations with nursing home residents were shorter than those with the community group (P < 0.0001), the overall time spent consulting with them was longer (P < 0.001). This equated to an additional 28 minutes of time per patient per annum. Some of this time would have been offset by less time spent travelling, since 61% of nursing home consultations were done during the same visit as other consultations, compared with only 3% of community consultations (P < 0.0001)., Conclusion: Our study suggests that nursing home residents do require a greater input from general practice than people of the same age and sex who are residing in the community. While consideration may be given to greater financial reimbursement of GPs who provide medical care to nursing home residents, consideration should also be given to restructuring the medical cover for nursing home residents. This would result in a greater scope for proactive and preventive interventions and for consulting with several patients during one visit.

Objective: To determine whether age, sex, level of deprivation, and area of residence affect the likelihood of investigation and treatment of patients with coronary heart disease., Design, Patients, and Interventions: Routine discharge data were used to identify patients admitted with acute myocardial infarction (AMI) between 1991 and 1993 inclusive. Record linkage provided the proportion undergoing angiography, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG) over the following two years. Multiple logistic regression analysis was used to determine whether age, sex, deprivation, and area of residence were independently associated with progression to investigation and revascularisation., Setting: Mainland Scotland 1991 to 1995 inclusive., Main Outcome Measures: Two year incidence of angiography, PTCA, and CABG. Results-36 838 patients were admitted with AMI. 4831 (13%) underwent angiography, 587 (2%) PTCA, and 1825 (5%) CABG. Women were significantly less likely to undergo angiography (p < 0.001) and CABG (p < 0.001) but more likely to undergo PTCA (p < 0.05). Older patients were less likely to undergo all three procedures (p < 0.001). Socioeconomic deprivation was associated with a reduced likelihood of both angiography and CABG (p < 0.001). There were significant geographic variations in all three modalities (p < 0.001)., Conclusion: Variations in investigation and management were demonstrated by age, sex, geography, and socioeconomic deprivation. These are unlikely to be accounted for by differences in need; differences in clinical practice are, therefore, likely.