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Aims/hypothesis: The objective of this study was to use Scottish national data to assess the influence of type 2 diabetes on the risk of cancer at 16 different sites, while specifically investigating the role of confounding by socioeconomic status in the diabetes-cancer relationship., Methods: All people in Scotland aged 55-79 years diagnosed with any of the cancers of interest during the period 2001-2007 were identified and classified by the presence/absence of co-morbid type 2 diabetes. The influence of diabetes on cancer risk for each site was assessed via Poisson regression, initially with adjustment for age only, then adjusted for both age and socioeconomic status., Results: There were 4,285 incident cancers in people with type 2 diabetes. RR for any cancers (adjusted for age only) was 1.11 (95% CI 1.05, 1.17) for men and 1.33 (1.28, 1.40) for women. Corresponding values after additional adjustment for socioeconomic status were 1.10 (1.04, 1.15) and 1.31 (1.25, 1.38), respectively. RRs for individual cancer sites varied markedly., Conclusions/interpretation: Socioeconomic status was found to have little influence on the association between type 2 diabetes and cancer.

Aims/hypothesis: The objective of this study was to use Scottish national data to assess the influence of type 2 diabetes on (1) survival (overall and cause-specific) in multiple time intervals after diagnosis of colorectal cancer and (2) cause of death., Methods: Data from the Scottish Cancer Registry were linked to data from a population-based national diabetes register. All people in Scotland diagnosed with non-metastatic cancer of the colon or rectum in 2000-2007 were included. The effect of pre-existing type 2 diabetes on survival over four discrete time intervals (<1, 1-2, 3-5 and >5 years) after cancer diagnosis was assessed by Cox regression. Cumulative incidence functions were calculated representing the respective probabilities of death from the competing causes of colorectal cancer, cardiovascular disease, other cancers and any other cause., Results: Data were available for 19,505 people with colon or rectal cancer (1,957 with pre-existing diabetes). Cause-specific mortality analyses identified a stronger association between diabetes and cardiovascular disease mortality than that between diabetes and cancer mortality. Beyond 5 years after colon cancer diagnosis, diabetes was associated with a detrimental effect on all-cause mortality after adjustment for age, socioeconomic status and cancer stage (HR [95% CI]: 1.57 [1.19, 2.06] in men; 1.84 [1.36, 2.50] in women). For patients with rectal cancer, diabetes was not associated with differential survival in any time interval., Conclusions/interpretation: Poorer survival observed for colon cancer associated with type 2 diabetes in Scotland may be explained by higher mortality from causes other than cancer.

Aims: To describe the proportion of people with Type 2 diabetes living in Scotland who meet eligibility criteria for inclusion in several large randomized controlled trials of glycaemic control to inform physicians and guideline developers about the generalizibility of trial results., Methods: A literature review was performed to identify large trials assessing the impact of glycaemic control on risk of macrovascular disease. Inclusion and exclusion criteria from each trial were applied to data on the population of people with a diagnosis of Type 2 diabetes living in Scotland in 2008 (n = 180,590) in a population-based cross-sectional study and the number and proportion of people eligible for each trial was determined., Results: Seven trials were identified. The proportion of people with Type 2 diabetes who met the eligibility criteria for the trials ranged from 3.5 to 50.7%. Trial participants were younger at age of diagnosis of diabetes and at time of trial recruitment than in the Scottish study population. The application of upper age criteria excluded the largest proportion of patients, with up to 39% of people with Type 2 diabetes ineligible for a trial with the most stringent criteria based on age alone., Conclusions: We found that many of the large trials of glycaemic control among people with Type 2 diabetes have limited external validity when applied to a population-based cohort of people with Type 2 diabetes. In particular, the age distribution of trial participants often does not reflect that of people with Type 2 diabetes in a contemporary British population., (© 2012 The Authors. Diabetic Medicine © 2012 Diabetes UK.)

Aims/hypothesis: The aim of this study was to explore the relationships between type 2 diabetes mellitus, area-based socioeconomic status (SES) and cardiovascular disease mortality in Scotland., Methods: We used an area-based measure of SES, Scottish national diabetes register data linked to mortality records, and general population cause-specific mortality data to investigate the relationships between SES, type 2 diabetes and mortality from ischaemic heart disease (IHD) and cerebrovascular disease (CbVD), for 2001-2007. We used negative binomial regression to obtain age-adjusted RRs of mortality (by sex), comparing people with type 2 diabetes with the non-diabetic population., Results: Among 216,652 people aged 40 years or older with type 2 diabetes (980,687 person-years), there were 10,554 IHD deaths and 4,378 CbVD deaths. Age-standardised mortality increased with increasing deprivation, and was higher among men. IHD mortality RRs were highest among the least deprived quintile and lowest in the most deprived quintile (men: least deprived, RR 1.94 [95% CI 1.61, 2.33]; most deprived, RR 1.46 [95% CI 1.23, 1.74]) and were higher in women than men (women: least deprived, RR 2.84 [95% CI 2.12, 3.80]; most deprived, RR 2.04 [95% CI 1.55, 2.69]). A similar, weaker, pattern was observed for cerebrovascular mortality., Conclusions/interpretation: Absolute risk of cardiovascular mortality is higher in people with diabetes than in the non-diabetic population and increases with increasing deprivation. The relative impact of diabetes on cardiovascular mortality differs by SES, and further efforts to reduce cardiovascular risk both in deprived groups and people with diabetes are required. Prevention of diabetes may reduce socioeconomic health inequalities.

Background: A growing body of research emphasizes the importance of contextual factors on health outcomes. Using postcode sector data for Scotland (UK), this study tests the hypothesis of spatial heterogeneity in the relationship between area-level deprivation and mortality to determine if contextual differences in the West vs. the rest of Scotland influence this relationship. Research into health inequalities frequently fails to recognise spatial heterogeneity in the deprivation-health relationship, assuming that global relationships apply uniformly across geographical areas. In this study, exploratory spatial data analysis methods are used to assess local patterns in deprivation and mortality. Spatial regression models are then implemented to examine the relationship between deprivation and mortality more formally., Results: The initial exploratory spatial data analysis reveals concentrations of high standardized mortality ratios (SMR) and deprivation (hotspots) in the West of Scotland and concentrations of low values (coldspots) for both variables in the rest of the country. The main spatial regression result is that deprivation is the only variable that is highly significantly correlated with all-cause mortality in all models. However, in contrast to the expected spatial heterogeneity in the deprivation-mortality relationship, this relation does not vary between regions in any of the models. This result is robust to a number of specifications, including weighting for population size, controlling for spatial autocorrelation and heteroskedasticity, assuming a non-linear relationship between mortality and socio-economic deprivation, separating the dependent variable into male and female SMRs, and distinguishing between West, North and Southeast regions. The rejection of the hypothesis of spatial heterogeneity in the relationship between socio-economic deprivation and mortality complements prior research on the stability of the deprivation-mortality relationship over time., Conclusions: The homogeneity we found in the deprivation-mortality relationship across the regions of Scotland and the absence of a contextualized effect of region highlights the importance of taking a broader strategic policy that can combat the toxic impacts of socio-economic deprivation on health. Focusing on a few specific places (e.g. 15% of the poorest areas) to concentrate resources might be a good start but the impact of socio-economic deprivation on mortality is not restricted to a few places. A comprehensive strategy that can be sustained over time might be needed to interrupt the linkages between poverty and mortality.

Background: Cutaneous disease is thought to account for 10-15% of patient consultations with general practitioners, but relatively little is known about the demography of dermatological conditions in primary care., Aim: To assess the proportion and diagnostic profile of dermatological conditions seen in primary care in the southeast of Scotland, and to draw comparisons with secondary dermatological care., Methods: General practitioners in 13 general practices were asked to note all skin-related consultations during a 2-week period. The case notes of these patients were reviewed, and diagnosis and treatment was recorded. Patients who had consulted for the same skin disorder on >or= 3 occasions during the previous year were invited for assessment by a consultant dermatologist. Where possible, the case notes from 10% of all consultations during the 2-week study period were examined to assess accuracy of recording., Results: The percentage of consultations relating to cutaneous disorders varied between practices, ranging from 3% to 18.8%, with a mean of 8.4%. Eczema accounted for 22.5%, infections 20.3% and benign tumours for 11.4% of consultations with a dermatological basis. In contrast, in secondary care, benign tumours accounted for 23.8%, malignant tumours for 16.4% and eczema for 16.3% of dermatological consultations., Conclusions: Dermatological disorders make up a significant proportion of general practitioners' workload. The diagnostic profile of primary-care dermatology differs markedly from that of hospital practice. General practitioners may benefit from training specifically tailored to the common primary-care dermatological conditions.

Background: Housing conditions are recognised as an important determinant of health. In the UK, interventions to improve domestic heating are in place with the expectation that they will improve health. As a component of evaluating such policies, this study assesses whether specific health outcomes are significantly associated with the extent and duration of domestic heating use, either directly or via a possible mediating effect of internal environmental conditions., Methods: Baseline data from a prospective controlled study evaluating the health effects of a publicly-funded programme of heating improvements in Scotland were used to assess associations among heating use, internal conditions, and three specific health outcomes., Results: There were significant associations (P < 0.01) between measures of heating use and the presence of environmental problems in the home, such as mould and condensation. The presence of such problems was, in turn, found to be significantly predictive of two health outcomes derived from the SF-36 (P < 0.01) and of adult wheezing (P < 0.05). The direction of significant associations was highly consistent: greater levels of heating were associated with reduced likelihood of environmental problems, and the presence of environmental problems was linked to poorer health status. Heating use was not directly associated with the health outcomes considered., Conclusions: The study findings are consistent with a conceptual model in which health may be influenced by usage patterns of domestic heating, via the mediating effect of poor internal environmental conditions. Since these findings are based on cross-sectional data, interpretation must be carried out cautiously. However, if confirmed by planned future work they have important implications for policy initiatives relating to domestic heating and fuel poverty.

Background: The core values of general practice include holism and patient-centredness. None of the measures of quality of care in general practice presently capture the expression of these values at routine consultations., Objectives: The aim of the present study was to construct a 'consultation quality index' (CQI) which reflects the core values of general practice, using as proxies 'consultation length' and how well patients 'know the doctor' as process measures and 'patient enablement' as an outcome measure., Methods: The CQI was constructed from data collected from 23 799 adult English-speaking patients consulting 221 doctors in four demographically contrasting areas of the UK during 2 weeks of March/April 1998. A total of 171 doctors who entered 50 qualifying consultations were allocated scores for the three component variables, and a total CQI was calculated., Results: CQI scores were in the range 4-18. Validity was examined by looking at high and low scorers in greater detail and by searching for correlates with case mix, patient age and gender, and the deprivation scores of the practices concerned. Particular attention was paid to how registrars and doctors new to their practices scored. The scores of different doctors in the same practice were also noted. The results had strong face validity and were independent of case mix and deprivation. Reliability was gauged by examining similar work from a previous study which had collected information on consultation length and enablement over three time periods. High CQI scores were associated with smaller overall practice list sizes., Conclusions: We have outlined possible uses for the CQI as part of the packages assessing quality of care by doctors and practices. The measure may also have a part to play in recognizing poorly performing doctors. We suggest how CQI scores could contribute to an incentive scheme to reward good consulting practice. Further work is in hand to compare doctors' CQI scores with scores based on performance indicators constructed from routine NHS data on prescribing and preventive medicine.

Objective: I. To identify major trends in the incidence of and mortality from invasive cancer of the cervix uteri in Scotland during the twenty year period 1975-1994; II. to consider the extent to which these trends may have been shaped by the introduction of systematic cervical screening., Design: Analysis of annual age standardised and age specific rates for incidence and mortality, based on data collected by the Scottish Cancer Registry and the General Register Office for Scotland., Setting: Scotland., Subjects: Women registered with the Scottish Cancer Registry as having developed invasive cancer of the cervix during the period of interest., Results: Annual all ages incidence rates of invasive cervical cancer show little overall change over the period 1975-1989, but exhibit a pronounced decline from 1990 onwards. All-ages mortality rates show clear evidence of decline during the period 1975-1994, the rate for 1994 being some 30% lower than that for 1975. Annual age-specific incidence rates show different patterns by age group, with clear evidence of decreasing trends in the age range 50-64 years but different patterns in younger and older age groups. Most age groups show steep declines in incidence from 1990 onwards. Age specific mortality rates for 1975-1994 exhibit the most pronounced decreasing trends in the age range 50-64 years. The trends identified are broadly similar to those experienced in England and Wales over an approximately comparable period., Conclusions: The overall (all ages) incidence of invasive cervical cancer in Scotland changed little during the period 1975-1989, but declined sharply from 1990 onwards. The most pronounced decline in incidence across the period 1975-1994 appears to have taken place in the age range 50-64 years. This decline has been accompanied by a commensurate fall in mortality in the same age range. These reductions in incidence and mortality may be attributable in part to increased coverage of cervical screening programmes during the period of interest. Evidence from other studies suggest that, without the increased coverage of cervical screening achieved during this period incidence rates in Scotland might have been seen to increase.

Objective: To determine changes in the incidence and pattern of eclampsia within the same geographical area over a 60-year period., Design: A retrospective, descriptive study of 1259 consecutive women classified, at the time, as having had an eclamptic convulsion between the years 1931 and 1990., Setting: A large city centre teaching hospital and the surrounding catchment area., Main Outcome Measures: The changes in the incidence and timing of the convulsion and the outcomes for the mother and baby., Results: Over the study period, the incidence of eclampsia fell by more than 90%, from 74.1/10,000 in the 1930s to 7.2/10,000 in the 1980s. Most of the reduction occurred over the first four decades, with little change in the last 20 years. Overall, 44% of the cases of eclampsia occurred in the antenatal period, 33% intrapartum and 23% postpartum. Since the biggest decreases were seen in the incidence of antenatal and particularly intrapartum eclampsia, there has been a relative increase in the proportion of eclampsia occurring postpartum. Maternal death from eclampsia occurred in 15.1% of cases between 1931 and 1940, 13.4% between 1941 and 1950, but fell dramatically to < or = 3.9% after 1950. There has been no maternal death since 1964. Apart from the first decade, postpartum eclampsia was associated with significantly less risk of death to the mother throughout the study period. Perinatal death rate has fallen steadily from 432.6/1000 cases of eclampsia between 1931 and 1940 over the first three decades, to 168.7/1000 between 1961 and 1970. There has been little change since, although a lower proportion of neonatal deaths occurred as stillbirths., Conclusions: We found a significant reduction in both the incidence of eclampsia and associated morbidity in this population over the last 60 years. This has occurred in association with the introduction of the National Health Service, widespread antenatal care for all and a general improvement in health and welfare. Any further reduction in the incidence in the UK may be difficult to achieve. Since the incidence of eclampsia is now low, efforts should perhaps be directed at minimising the morbidity associated with severe pre-eclampsia rather than prevention of convulsions.

Pregnancy-induced hypertension may be regarded as a manifestation of endothelial-cell dysfunction. The role of the eNOS gene in the development of a familial pregnancy-induced hypertension was evaluated by analysis of linkage among affected sisters and in multiplex families (n = 50). Markers from a 4-cM region encoding the eNOS gene showed distortion from the expected allele sharing among affected sisters (P = .001-.05), and the statistic obtained from the multilocus application of the affected-pedigree-member method also showed distortion (T[f(P)=sqrt(P)] = 3.53; P < .001). A LOD score of 3.36 was obtained for D7S505 when a best-fitting model derived from genetic epidemiological data was used, and LOD scores of 2.54-4.03 were obtained when various other genetic models were used. Estimates of recombination rate, rather than maximum LOD-score values, were affected by changes in the genetic parameters. The transmission-disequilibrium test, a model-free estimate of linkage, showed strongest association and linkage with a microsatellite within intron 13 of the eNOS gene (P = .005). These results support the localization of a familial pregnancy-induced hypertension-susceptibility locus in the region of chromosome 7q36 encoding the eNOS gene.