Mortality among oral contraceptive users: 20 year follow up of women in a cohort study.

OBJECTIVE--To see whether the use of oral contraceptives influences mortality. DESIGN--Non-randomised cohort study of 17,032 women followed up on an annual basis for an average of nearly 16 years. SETTING--17 Family planning clinics in England and Scotland. SUBJECTS--Women recruited during 1968-74. At the time of recruitment each woman was aged 25-39, married, a white British subject, willing to participate, and either a current user of oral contraceptives or a current user of a diaphragm or intrauterine device (without previous exposure to the pill). MAIN OUTCOME MEASURES--Overall mortality and cause specific mortality. RESULTS--238 Deaths occurred during the follow up period. The main analyses concerned women entering the study while using either oral contraceptives or a diaphragm or intrauterine device. The overall relative risk of death in the oral contraceptive users was 0.9 (95% confidence interval 0.7 to 1.2). Though the numbers of deaths were small in most individual disease categories, the trends observed were generally consistent with findings in other reports. Thus the relative risk of death in the oral contraceptive users was 4.9 (95% confidence interval 0.7 to 230) for cancer of the cervix, 3.3 (95% confidence interval 0.9 to 17.9) for ischaemic heart disease, and 0.4 (95% confidence interval 0.1 to 1.2) for ovarian cancer. There was a linear trend in the death rates from cervical cancer and ovarian cancer (in opposite directions) with total duration of oral contraceptive use. Death rates from breast cancer (relative risk 0.9; 95% confidence interval 0.5 to 1.4) and suicide and probable suicide (relative risk 1.1; 95% confidence interval 0.3 to 3.6) were much the same in the two contraceptive groups. In 1981 the relative risk of death in oral contraceptive users from circulatory diseases as a group was reported to be 4.2 (95% confidence interval 2.3 to 7.7) in the Royal College of General Practitioners oral contraception study. The corresponding relative risk in this study was only 1.5 (95% confidence interval 0.7 to 3.0). CONCLUSIONS--These findings contain no significant evidence of any overall effect of oral contraceptive use on mortality. None the less, only small numbers of deaths occurred during the study period and a significant adverse (or beneficial) overall effect might emerge in the future. Interestingly, the mortality from circulatory disease associated with oral contraceptive use was substantially less than that found in the Royal College of General Practitioners study.     

Live measles vaccine: a 21 year follow up.

21 years after receiving Schwartz strain live measles vaccine 4500 trial participants showed a continuing high level of protection compared with those who were unvaccinated. Over the last seven years of the follow up no cases of measles were reported in vaccinated participants who had had close contact with the disease. Immunity induced by the vaccine seems to survive the challenge of close contact with measles in young children, even after 21 years.     

Radiological progression and lung function in silicosis: a ten year follow up study.

Chest radiographs and spirometric tests were performed on 81 patients who had silicosis from two granite quarries in 1975, 73 of whom were followed up for two to 10 (mean 7.2) years. Each patient''s initial and most recent chest radiographs were assessed independently by three experienced readers, and the yearly declines in forced expiratory volume in one second and forced vital capacity were estimated from two to four (mean 3.45) serial spirometric readings. Estimates of individual dust exposure were based on extensive historical data on hygiene. All but 11 patients were no longer exposed to dust by the start of follow up, but 24 (45%) of 53 patients who had simple silicosis and 11 (55%) of 20 who had the complicated disease showed radiological evidence of disease progression. In patients who had simple silicosis and showed no radiological progression the yearly declines in forced expiratory volume in one second and forced vital capacity were modest (64 ml/year and 59 ml/year, respectively), whereas significantly greater declines in lung function were seen in those who showed radiological evidence of progression (97 ml/year and 95 ml/year, respectively). In addition to radiological progression the previous average dust concentration to which patients had been exposed also influenced declines in both forced expiratory volume in one second and forced vital capacity after allowing for the effects of age, smoking, duration of exposure, history of tuberculosis, initial state of disease, and baseline lung function. The probability of radiological progression was most strongly influenced by the average dust concentration previously exposed to. The progression of simple silicosis is thus accompanied by appreciable declines in lung function and is strongly affected by previous levels of exposure to dust.     

Three year follow up of patients with raised blood pressure identified at health checks in general practice.

OBJECTIVE--To assess the extent of three year follow up of blood pressure, weight, and smoking habit in patients with raised blood pressure identified at health checks. DESIGN--Retrospective audit of medical and nursing records. SETTING--Three general practices in Oxfordshire. PATIENTS--386 of 448 patients with raised blood pressure (diastolic greater than or equal to 90 or systolic greater than or equal to 160 mm Hg) identified from 2935 patients aged 35-64 attending health checks in 1982-4. MEASUREMENTS and MAIN RESULTS--All records of blood pressure, weight, and smoking habit in the medical record were abstracted for three years after the initial health check. All 42 patients with an initial diastolic blood pressure greater than or equal to 105 mm Hg and 316 of 344 patients with an initial pressure of 90-104 mm Hg had at least one further measurement of their blood pressure. Follow up of smoking habit and of weight was less complete with only half of the 100 smokers and 67 of the 87 obese patients (body mass index greater than or equal to 30) having any documented follow up of these risk factors. Annual follow up in the second and third years occurred in 228/297 (76.8%) and 232/320 (72.5%) in patients with blood pressure greater than 95 mm Hg at the beginning of each year. For patients who smoked annual follow up in these years occurred in fewer than a third and for those who were obese in just over half. On the assumption that those not followed up had not changed, at the end of three years the proportion of patients with diastolic blood pressure greater than or equal to 100 mm Hg had fallen from 61 patients (15.8%) to 31 (8.1%); the proportion of smokers had fallen from 103 (26.7%) to 94 (24.4%); and the proportion of obese patients had fallen from 87 (22.5%) to 79 (20.5%). CONCLUSIONS--These changes were modest and in the absence of a control group cannot be attributed necessarily to health checks. Although the standard of follow up was better than in previously reported studies of the management of hypertension, the results emphasise the need to develop formal protocols for dietary and antismoking interventions and to evaluate formally the effectiveness (and cost effectiveness) of health checks.     

Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms

Objective: To investigate psychiatric and neurological morbidity, diagnostic stability, and indicators of prognosis in patients previously identified as having medically unexplained motor symptoms. Design: Follow up study. Setting: National Hospital for Neurology and Neurosurgery, London—a secondary and tertiary referral hospital for neurological disorders. Subjects: 73 patients with medically unexplained motor symptoms admitted consecutively in 1989-91. 35 (48%) patients had absence of motor function (for example, hemiplegia) and 38 (52%) had abnormal motor activity (for example, tremor, dystonia, or ataxia). Main outcome measures: Neurological clinical diagnosis at face to face reassessment by a neurologist and a psychiatric diagnosis after a standardised assessment interview—the schedule for affective disorders and schizophrenia—conducted by a psychiatrist. Results: Good follow up data were available for 64 subjects (88%). Only three subjects had new organic neurological disorders at follow up that fully or partly explained their previous symptoms. 44/59 (75%) subjects had had psychiatric disorders; in 33 (75%) patients, the psychiatric diagnosis coincided with their unexplained motor symptoms. 31/59 (45%) patients had a personality disorder. Three subjects had developed new psychiatric illnesses at follow up, but in only one did the diagnosis account for the previous motor symptoms. Resolution of physical symptoms was associated with short length of symptoms, comorbid psychiatric disorder, and a change in marital status during follow up. Conclusions: Unlike Slater’s study of 1965, a low incidence of physical or psychiatric diagnoses which explained these patients’ symptoms or disability was found. However, a high level of psychiatric comorbidity existed.

Key messages

• Motor symptoms that remain unexplained medically despite thorough investigation are a common clinical problem, but the emergence of a subsequent organic explanation for these symptoms is rare
• The prevalence of coexistent affective and anxiety disorders is high and many patients also have a personality disorder
• Patients with a shorter duration of symptoms and coexistent anxiety or depression are likely to do better at follow up
• Reinvestigation of these patients is both expensive and potentially dangerous and should be avoided where no clear clinical indication exists

     

High mortality by natural and unnatural causes: a 10 year follow up study of patients admitted to a poisoning treatment centre after suicide attempts.

OBJECTIVE--To describe mortality by suicide and other causes of death in a group of patients who attempted suicide, and to identify predictive factors. DESIGN--10 year follow up study based on records of suicide attempters in 1980. SETTING--Poisoning treatment centre at a general hospital. SUBJECTS--974 patients aged 15 and over referred to the poisoning treatment centre after deliberate self poisoning. MAIN OUTCOME MEASURES--Death by different causes registered in the Danish death cause register. RESULTS--In 10 years of follow up 306 patients died: 103 by suicide, 131 from natural causes, and 31 by accident; five were murdered, and in 36 cases the cause of death was uncertain. The standard mortality ratio was 550. Cause specific standardised mortality rates were 2960 for suicide, 236 for natural causes, 1256 for accidents, and 5459 for uncertain causes. In a Cox regression analysis, high risk factors for subsequent suicide were: more than one previous suicide attempt (relative risk 2.25), living alone (2.28), and age (1.03 per year). Predictors of death by natural causes were receiving a pension (1.69), drug misuse (2.72), more than one previous suicide attempt (2.25), age (1.06 per year), and male sex (2.49). The group of patients fulfilling at least one high risk criterion for later suicide differed significantly from the rest of the patient group in incidence of suicide, but both sensitivity and specificity were low. CONCLUSIONS--Most patients who attempted suicide were at high risk of succeeding because the risk factors, though significant, are not very specific. A strategy to prevent suicide must be directed toward the majority of those who attempt suicide.     

Social effects of wheeze in childhood: a 25 year follow up.

OBJECTIVES--To determine the outcome of childhood wheeze in terms of education, employment, housing, and social class. DESIGN--25 year follow up study. SETTING--Community study based at the department of thoracic medicine, Aberdeen Royal Infirmary. PARTICIPANTS--Three groups of subjects who had been identified in a random community survey in 1964: those who had had asthma in childhood (n = 97), those who had wheezed only in the presence of upper respiratory tract infections (n = 132), and a comparison group who had had no respiratory symptoms as children (n = 131). Subjects were aged 34 to 40 years at the time of the current study. MAIN OUTCOME MEASURES--Interview and questionnaire data on education, employment, housing and social class, ventilatory function, and peak flow rate. RESULTS--Pulmonary function testing showed that only the "asthmatic" group had airways obstruction; this group showed greater peak flow variation than the "wheezy" group, which did not differ from the comparison group. The asthmatic subjects were more likely to have experienced respiratory problems during their school years and associated with their work. Despite these problems, educational attainment, employment, housing, and eventual social class were similar for all three groups. CONCLUSION--Childhood wheeze did not adversely affect education, employment, housing, or social class in this population.     

Predictors of mortality of patients newly diagnosed with clinical type 2 diabetes: a 5-year follow up study

Background

At diabetes diagnosis major decisions about life-style changes and treatments are made based on characteristics measured shortly after diagnosis. The predictive value for mortality of these early characteristics is widely unknown. We examined the predictive value of patient characteristics measured shortly after diabetes diagnosis for 5-year all-cause and cardiovascular mortality with special reference to self-rated general health.

Methods

Data were from a population-based sample of 1,323 persons newly diagnosed with clinical diabetes and aged 40 years or over. Possible predictors of mortality were investigated in Cox regression models.

Results

Multivariately patients who rated their health less than excellent experienced increased all-cause and cardiovascular mortality. These end-points also increased with sedentary life-style, relatively young age at diagnosis and presence of cardiovascular disease (CVD) at diagnosis. Further predictors of all-cause mortality were male sex, low body mass index and cancer, while cardiovascular mortality increased with urinary albumin concentration.

Conclusions

We found that patients who rated their health as less than excellent had increased 5-year mortality, similar to that of patients with prevalent CVD, even when biochemical, clinical and life-style variables were controlled for. This finding could motivate doctors to discuss perceptions of health with newly diagnosed diabetic patients and be attentive to patients with suboptimal health ratings. Our findings also confirm that life-style changes and optimizing treatment are particularly relevant for relatively young and inactive patients and those who already have CVD or (micro)albuminuria at the time of diabetes diagnosis.     

Predictors of mortality in insulin dependent diabetes: 10 year observational follow up study.

OBJECTIVE: To evaluate the prognostic significance of microalbuminuria and overt diabetic nephropathy and other putative risk factors for cardiovascular and all cause mortality in insulin dependent diabetes. DESIGN: Ten year observational follow up study. SETTING: Outpatient diabetic clinic in a tertiary referral centre. SUBJECTS: All 939 adults with insulin dependent diabetes (duration of diabetes five years or more) attending the clinic in 1984; 593 had normal urinary albumin excretion (< or = 30 mg/24 h), 181 persistent microalbuminuria (31-299 mg/24 h), and 165 overt nephropathy (> or = 300 mg/24 h). MAIN OUTCOME MEASURE: All cause and cardiovascular mortality. RESULTS: Fifteen per cent of patients (90/593) with normoalbuminuria, 25% (45/181) with microalbuminuria, and 44% (72/165) with overt nephropathy at baseline died during follow up. Cox multiple regression analysis identified the following significant predictors of all cause mortality: male sex (relative risk 2.03; 95% confidence interval 1.37 to 3.02), age (1.07; 1.06 to 1.08), height (0.96; 0.94 to 0.98), smoking (1.51; 1.09 to 2.08), social class V versus social class IV (1.70; 1.25 to 2.31), log10 urinary albumin excretion (1.45; 1.18 to 1.77), hypertension (1.63; 1.18 to 2.25), log10 serum creatinine concentration (8.96; 3.34 to 24.08), and haemoglobin A1c concentration (1.11; 1.03 to 1.20). Age, smoking, microalbuminuria, overt nephropathy, and hypertension were significant predictors of cardiovascular mortality. Mortality in patients with microalbuminuria was only slightly increased compared with that in patients with normoalbuminuria. Median survival time after the onset of overt diabetic nephropathy was 13.9 years (95% confidence interval 11.8 to 17.2 years). CONCLUSIONS: Abnormally increased urinary albumin excretion and other potentially modifiable risk factors such as hypertension, smoking, poor glycaemic control, and social class predict increased mortality in insulin dependent diabetes. Microalbuminuria by itself confers only a small increase in mortality. The prognosis of patients with overt diabetic nephropathy has improved, probably owing to effective antihypertensive treatment.     

Contribution of a general practitioner hospital: a further study.

OBJECTIVE--To audit the workload of a general practitioner hospital and to compare the results with an earlier study. DESIGN--Prospective recording of discharges from the general practitioner hospital plus outpatient and casualty attendances and of all outpatient referrals and discharges from other hospitals of patients from Brecon Medical Group Practice during one year (1 June 1986-31 May 1987). SETTING--A large rural general group practice which staffs a general practitioner hospital in Brecon, mid-Wales. PATIENTS--20,000 Patients living in the Brecon area. RESULTS--1540 Patients were discharged from the general practitioner hospital during the study period. The hospital accounted for 78% (1242 out of 1594) of all hospital admissions of patients of the practice. There were 5835 new attendances at the casualty department and 1896 new outpatient attendances at consultant clinics at the hospital. Of all new outpatient attendances by patients of the practice, 71% (1358 out of 1896) were at clinics held at the general practitioner hospital. Since the previous study in 1971 discharges from the hospital have increased 37% (from 1125 to 1540) and new attendances at consultant clinics 30% (from 1450 to 1896). The average cost per inpatient day is lower at this hospital than at the local district general hospital (pounds 71.07 v pounds 88.06 respectively). CONCLUSIONS--The general practitioner hospital deals with a considerably larger proportion of admissions and outpatient attendances of patients in the practice than in 1971 and eases the burden on the local district general hospital at a reasonable cost. IMPLICATIONS--General practitioner hospitals should have a future role in the NHS.     

Partial splenic embolisation for hypersplenism of thalassaemia major: five year follow up.

Six patients with thalassaemia major were treated by partial splenic embolisation as an alternative to splenectomy and followed up for five years. Results were compared with those in a matched control group of seven patients treated by splenectomy. All patients treated by partial splenic embolisation showed a reduction in blood transfusion requirements comparable with those in the controls and which remained unchanged over the five years. Serious infections that commonly occur in patients splenectomised for thalassaemia did not occur after embolisation, presumably owing to preservation of some immune function by the splenic remnant. By contrast with the change in platelet counts seen after splenectomy, platelet counts remained normal after partial splenic embolisation, so reducing the risk of thromboses. On the other hand, pre-existing leucopenia and thrombocytopenia were corrected after embolisation. It is concluded that partial splenic embolisation provides an alternative to splenectomy for thalassaemia major and is equally effective and much safer.     

Course of HIV-I infection in a cohort of homosexual and bisexual men: an 11 year follow up study.

OBJECTIVE--To characterise the natural history of sexually transmitted HIV-I infection in homosexual and bisexual men. DESIGN--Cohort study. SETTING--San Francisco municipal sexually transmitted disease clinic. PATIENTS--Cohort included 6705 homosexual and bisexual men originally recruited from 1978 to 1980 for studies of sexually transmitted hepatitis B. This analysis is of 489 cohort members who were either HIV-I seropositive on entry into the cohort (n = 312) or seroconverted during the study period and had less than or equal to 24 months between the dates of their last seronegative and first seropositive specimens (n = 177). A subset of 442 of these men was examined in 1988 or 1989 or had been reported to have developed AIDS. MAIN OUTCOME MEASURES--Development of clinical signs and symptoms of HIV-I infection, including AIDS, AIDS related complex, asymptomatic generalised lymphadenopathy, and no signs or symptoms of infection. MEASUREMENTS AND MAIN RESULTS--Of the 422 men examined in 1988 or 1989 or reported as having AIDS, 341 had been infected from 1977 to 1980; 49% (167) of these men had died of AIDS, 10% (34) were alive with AIDS, 19% (65) had AIDS related complex, 3% (10) had asymptomatic generalised lymphadenopathy, and 19% (34) had no clinical signs or symptoms of HIV-I infection. Cumulative risk of AIDS by duration of HIV-I infection was analysed for all 489 men by the Kaplan-Meier method. Of these 489 men, 226 (46%) had been diagnosed as having AIDS. We estimated that 13% of cohort members will have developed AIDS within five years of seroconversion, 51% within 10 years, and 54% within 11.1 years. CONCLUSION--Our analysis confirming the importance of duration of infection to clinical state and the high risk of AIDS after infection underscores the importance of continuing efforts both to prevent transmission of HIV-I and to develop further treatments to slow or stall the progression of HIV-I infection to AIDS.     

Operations for portal hypertension due to extrahepatic obstruction: results and 10 year follow up.

Between 1976 and 1984, 136 patients with portal hypertension due to extrahepatic obstruction were operated on. Twenty two patients had emergency and 114 elective operations. The operative mortality was 9% and 1%, respectively. Altogether 117 patients (86%) were followed up for from two to 10 years: 17 rebled, none developed encephalopathy or sepsis after splenectomy, and 90% and 75% were alive at five and 10 years respectively. Unlike endoscopic sclerotherapy and treatment with propranolol, operative treatment of variceal bleeding can usually be completed during one admission and carries a low mortality and a fairly low morbidity. Operation seems to be the best form of treatment for poor patients living far from medical facilities in developing countries and may be the treatment of choice in developed countries as well.     

Risk factors for developing non-insulin dependent diabetes: a 10 year follow up of men in Uppsala.

OBJECTIVE--To analyse anthropometric and metabolic characteristics as risk factors for development of non-insulin dependent diabetes mellitus in middle aged normoglycaemic men. DESIGN--Prospective population study based on data collected in a health survey and follow up 10 years later. SETTING--Uppsala, a middle sized city in Sweden. SUBJECTS--2322 men aged 47-53, of whom 1860 attended the follow up 7-14 years later, at which time they were aged 56-64. MAIN OUTCOME MEASURES--Incidence of non-insulin dependent diabetes. RESULTS--In a multivariate logistic regression analysis, variations of 1 SD from the mean of the group that remained euglycaemic were used to calculate odds ratios and 95% confidence intervals. Blood glucose concentration 60 minutes after the start of an intravenous glucose tolerance test (odds ratio = 5.93, 95% confidence interval 3.05 to 11.5), fasting serum insulin concentration (2.12, 1.54 to 2.93), acute insulin increment at an intravenous glucose tolerance test (1.71, 1.21 to 2.43), body mass index (1.41, 1.01 to 1.97), and systolic blood pressure (1.23, 0.97 to 1.56) were independent predictors of diabetes. In addition, the use of antihypertensive drugs at follow up (selective or unselective beta blocking agents, thiazides, or hydralazine) was an independent risk factor (1.70, 1.11 to 2.60). CONCLUSIONS--Metabolic and anthropometric characteristics associated with or reflecting insulin resistance as well as a poor acute insulin response to glucose challenge were important predictors of future diabetes in middle aged men. Antihypertensive drugs were found to constitute a further, iatrogenic risk factor.     

Use of psychiatric services by patients in a general hospital.

OBJECTIVE--To identify physical disorders associated with increased rate of use of psychiatric services. DESIGN--Retrospective analysis of routine abstracts of general hospital inpatient records linked with those of psychiatric care, for inpatients with physical disorders with possible psychiatric associations and for controls. SETTING--Oxfordshire health district. SUBJECTS--Inpatients aged 15-64 years discharged from general hospitals during 1975-85 with a diagnosis among 14 selected diagnostic groups (including potentially life threatening conditions, chronic disabling diseases, and non-specific symptomatic conditions) and control inpatients with acute conditions. MAIN OUTCOME MEASURES--Observed and expected numbers of patients receiving psychiatric care. RESULTS--Observed use of psychiatric services before and after index admission was close to that expected for controls. For most other diagnoses the observed use was significantly increased in the year preceding and that subsequent to the admission. For four diagnostic groups it was significantly greater in the year after admission than in that before (acute myocardial infarction (ratio before to after 2.17, 95% confidence interval 1.5 to 3.3), cancer (2.05, 1.7 to 2.5), diabetes mellitus (1.89, 1.4 to 2.9), and chest pain (1.78, 1.3 to 2.4)). During four years after the admission the use of psychiatric services was significantly higher than in the general population for nonspecific symptomatic conditions (observed/expected: abdominal pain 1.7, chest pain 2.0, and headache 4.2), cirrhosis of the liver (10.4), and fractures in road accidents and other fractures (1.3, 1.6). CONCLUSIONS--More patients with certain physical conditions used psychiatric services. Alternative methods of service delivery may be needed, especially for disabling chronic physical illness, alcohol related disorders, and non-specific symptomatic conditions.     

Ablative radioiodine therapy for hyperthyroidism: long term follow up study.

A total of 225 patients were treated for hyperthyroidism with 555 MBq (15 mCi) radioiodine to ablate the thyroid and induce early hypothyroidism. The efficacy of this treatment in eradicating hyperthyroidism and problems of follow up were assessed one to six years later from case records and questionnaires. Information was received from 197 out of 219 live patients (90%) and from 160 doctors concerning 207 patients (92%). Only three patients were not traced and six had died since treatment. The modal time to hypothyroidism was three months, and 64% of patients were hypothyroid at one year; 5.6% had failed to become euthyroid within one year. Ninety five per cent of patients had been seen by the doctor and 82% had had a thyroid test done within the past two years. Most doctors preferred patients to be returned to their care once thyroxine treatment was stabilised. An ablative dose of 131I is recommended as an effective means of treatment which has clear advantages over conventional methods. Good communications and effective follow up should ensure success.