Core competencies in applied infectious disease epidemiology: a framework for countries in Europe

In 2009, the European Centre for Disease Prevention and Control (ECDC) developed a competency framework to support European Union countries and the European Commission in ensuring a competent public health workforce for Europe. The coronavirus disease (COVID-19) pandemic emphasised the importance of harmonised public health strategies and competencies across international boundaries, specifically for infectious diseases. This perspective presents the process to update the competency framework for applied infectious disease epidemiology, highlighting ECDC's efforts to support countries with using the framework. ECDC commissioned the Association of Schools of Public Health in the European Region (ASPHER) to update the framework through publication and dissemination of a technical report and a self-assessment tool linked to training resources. A mixed methods approach to gather input from experts in relevant specialities included qualitative interviews with 42 experts, workshops with ECDC Technical Advisory Group and an online survey of 212 public health professionals across Europe and beyond. Modifications resulted in 157 core competencies in 23 domains, each mapping to one of six subject areas of importance in applied infectious disease epidemiology. The framework serves as a basis to update the curriculum of the ECDC Fellowship programme with two alternative paths: intervention epidemiology or public health microbiology.

Physical activity and emotional-behavioural difficulties in young people: a longitudinal population-based cohort study

BACKGROUND

There is growing concern around youth mental health. A population health approach to improve mental health must address, among other issues, economic insecurity, access to housing and education, harm reduction from substance use. As a universal public health intervention, increasing physical activity at a population level may have an important role in our approach. The aim of this study was to examine the longitudinal association between physical activity patterns between childhood and early adolescence and emotional-behavioural difficulties in later adolescence.

METHODS

This study was based on data from the '98 Child cohort of the Growing Up in Ireland Study. Participants were categorized according to physical activity levels at ages 9 and 13. Emotional-behavioural difficulties at age 17 were measured using the parent-reported Strengths and Difficulties Questionnaire. Logistic regression was used to examine the association between physical activity and emotional-behavioural outcomes.

RESULTS

Among 4618 participants included in the regression model, those categorized as Inactive (n=1607) or Reducer (n=1662) were more than twice as likely to have emotional-behavioural difficulties at age 17 compared with those who were Active [adjusted odds ratio (AOR) 2.1, 95% CI 1.46-3.01, P<0.001; AOR 1.93, 95% CI 1.34-2.76, P<0.001, respectively]. Among those with emotional-behavioural difficulties at baseline (n=525), those categorized as Active had 2.3-fold reduced odds for emotional-behavioural problems at age 17 compared with those who were Inactive (AOR 0.43, 95% CI 0.23-0.78, P=0.006).

CONCLUSIONS

Increasing physical activity among adolescents is a safe and sustainable public health intervention associated with improved mental health.

Management of type 1 diabetes in primary schools in Ireland: a cross-sectional survey

BACKGROUND

Parents reported experiences of support for diabetes management in schools are variable. Recent data from European countries are sparse and experiences in the Irish primary school setting have not been described previously.

AIM

To describe parents' experiences of support for diabetes management in primary schools in Ireland.

METHODS

Questionnaires were distributed through nine regional and tertiary paediatric diabetes services to parents of children aged 4-13 years with type 1 diabetes attending primary school. Data sought included patient demographics, treatment regimens, diabetes education of school staff, assistances received, and interactions between the school and family.

RESULTS

Responses were received from 418 parents of primary school children with type 1 diabetes. Twenty-six percent of children were not on intensive insulin therapy. Children on a multiple daily injection regime who were unable to self-administer insulin had administration facilitated by attendance of a parent in 95% of cases. Seventy-eight percent of parents were phoned by the school regarding diabetes management, particularly those of younger children (p < 0.001). More than half of parents attended the school at least once per month to assist with diabetes management, particularly those of younger children (p < 0.001). Younger children were also more likely to have a special needs assistant (p < 0.001) and have a written management plan (p = 0.001).

CONCLUSIONS

Our research has demonstrated deficits in care with respect to access to intensive insulin therapy, individualised care plans and a high burden on families which should be addressed through the National Clinical Programme for Paediatrics and Neonatology and relevant government departments.

Physical activity and mental health in an Irish population

BACKGROUND

Physical activity represents a modifiable behaviour which may be associated with increased likelihood of experiencing positive mental health.

AIMS

The aim of this study was to examine the association between self-rated physical activity and subjective indicators of both positive and negative mental health in an Irish adult population.

METHODS

Based on data from a population-based, observational, cross-sectional study, participants were categorised using the International Physical Activity Questionnaire (IPAQ) into those who reported that they did and did not meet recommended physical activity requirements. Self-reported positive and negative mental health indicators were assessed using the Energy and Vitality Index (EVI) and the Mental Health Index-5 (MHI-5) from the SF-36 Health Survey Instrument, respectively. Binary logistic regression was used to identify variables independently associated with self-reported positive and negative mental health.

RESULTS

A total of 7539 respondents were included in analysis. Overall, 32% reported that they met recommended minimal physical activity requirements. Self-reported positive and negative mental health were reported by 16 and 9% of respondents, respectively. Compared with those who reported meeting-recommended physical activity requirements, those performing no physical activity were three times less likely to report positive mental health (adjusted odds ratio (OR) 0.39, 95% confidence interval (CI) 0.28-0.55) and three times more likely to report negative mental health (OR 3.27, 95% CI 2.38-4.50).

CONCLUSION

Compared with those who do not, those who report meeting-recommended physical activity requirements are more and less likely to report experiencing positive and negative mental health, respectively. Future policy development around physical activity should take cognisance of the impact of this activity on both physical and mental health outcomes.

Health-related quality of life and associated factors in people with HIV: an Irish cohort study

Background

Considering the chronic and debilitating nature of HIV infection, health-related quality of life (HRQoL) is an important patient-reported clinical outcome to better understand the effects of this infection and its treatment on patients’ lives. The purpose of this study was to assess the HRQoL and its association with sociodemographic, behavioural, clinical, nutrition-related factors and social support in an Irish HIV cohort.

Methods

A cross-sectional, prospective study using the Medical Outcomes Study HIV Health survey assessed the 10 dimensions of HRQoL and summarised as Physical Health Summary (PHS) and Mental Health Summary (MHS) scores. Participants were categorised as having good or poor PHS and MHS using the standardised mean score of 50. The variables independently associated with PHS and MHS were identified using multivariable logistic regression models.

Results

Overall, 521 participants completed the HRQoL questionnaire. The median (IQR) PHS and MHS scores were 56 (47–60) and 51 (41–58) respectively. All the covariate groups had lower MHS than PHS. Participants with symptoms of HIV reported the lowest median (IQR) PHS score 44.7 (32.–54.5) and MHS score 36.1 (28.6–48.4). Of the 10 dimensions of HRQoL, the lowest scores were for the energy level and general health. Symptoms of HIV, co-morbidities, social support, employment and ethnicity had independent association with both PHS and MHS. Gender, education, alcohol intake and HIV-complications were associated with PHS. Age, illicit drugs, BMI and malnutrition were associated with MHS. However, CD4 count and viral load were not independently associated with PHS and MHS in multivariable regression models.

Conclusion

Overall, HIV-infected people in this cohort had an average level of HRQoL. However, it is impaired in people with symptoms and co-morbidities, and not independently associated with CD4 and viral load. Alleviating HIV symptoms and preventing co-morbidities are important in managing HIV. Providing psychosocial supports for behaviour modification and return to work or exploring new opportunities will help to improve HRQoL. Healthcare providers and policy makers need to plan and implement programs to routinely assess the HRQoL in a systematic method to facilitate a holistic management of HIV.

Educational influences on early retirement through disability in Ireland

BACKGROUND

Studies suggest a higher prevalence of early retirement through disability among older people with lower educational attainment. There have been no national studies in Ireland on the factors that affect early withdrawal from the labour force through disability or long-term illness.

AIMS

To identify and analyse potential impacts of education on early retirement through disability in the over 50 age cohort of the Irish Labour force.

METHODS

We analysed the educational attainment of participants using The Irish Longitudinal Study of Ageing (TILDA). The group of interest were those aged 50-75 who had retired early. The sample was dichotomized on disability. Examination of interviewer-recorded information on background influences determining early retirement decisions included the following factors: age, gender, education, family and socio-economic circumstances, including parental education.

RESULTS

A total of 334 of 1179 study subjects (28%) retired early through disability. Comparison of those retired early with and without disability showed a significantly higher frequency of lower educational attainment both personally and for parents. Men with lower educational attainment and from a non-professional background were more likely to retire early through disability. Non-professional disabled respondents with less well-educated parents had lower educational attainment than non-disabled respondents.

CONCLUSIONS

Among TILDA participants, educational attainment appears to influence early retirement through disability. The sector of previous employment was also a significant factor. Behaviour, lifestyle and employment choice are influenced by educational level, which may affect cognitive ability to process health information. Factors affecting the education-disability relationship could include parental education, employment status and socio-economic characteristics.

Hepatitis B virus infection among HIV-infected pregnant women in Malawi and transmission to infants

BACKGROUND & AIMS

The extent of HBV infection to infants of HBV/HIV-coinfected pregnant women in sub-Saharan Africa is unknown. The aim of this study was to assess prevalence of HBV infection among antiretroviral-naïve, HIV-infected pregnant women in Malawi and examine HBV transmission to their infants.

METHODS

Plasma from 2048 HIV-infected, Malawian women and their infants were tested for markers of HBV infection. Study participants were provided standard-of-care health services, which included administration of pentavalent vaccine to infants at 6, 10, and 14 weeks of age.

RESULTS

One-hundred and three women (5%) were HBsAg-positive; 70 of these HBsAg-positive women were also HBV-DNA-positive. Sixteen women (0.8%) were HBV-DNA-positive but HBsAg-negative. Five of 51 infants (9.8%) born to HBsAg-positive and/or HBV-DNA-positive women were HBV-DNA-positive by 48 weeks of age.HBV DNA concentrations of two infants of mothers who received extended lamivudine-containing anti-HIV prophylaxis were <4 log10 IU/ml compared to ⩾ 8 log10 IU/ml in three infants of mothers who did not.

CONCLUSIONS

HBV DNA was detected in nearly 10% of infants born to HBV/HIV-coinfected women. Antenatal testing for HIV and HBV, if instituted, can facilitate implementation of prophylactic measures against infant infection by both viruses.

Gastrointestinal diseases: projected burden of care on acute public hospitals

The burden of care on acute public hospitals pertaining to Diseases of the digestive system and Procedures on the digestive system in Ireland was estimated using hospital discharge data for 2006 and population projections for 2021 and 2031. Age-specific rates derived from 2006 acute hospital discharge data and census figures for the same year were applied to population projections for 2021 and 2031 to estimates the case numbers. In 2031, the number of discharges for Diseases of the digestive system is estimated to increase by 69,978 (60%) while the number of procedures is estimated to increase by 86,228 (65%). For people aged 65+ years, episodes of discharges for diseases of the digestive system are estimated to increase by 38,535 (128%) in 2031 while the number of procedures is estimated to increase by 47,324 (125%). These will significantly increase the burden of care on acute hospitals and the cost of providing care.

Classical Galactosaemia in Ireland: incidence, complications and outcomes of treatment

Newborn screening for the inborn error of metabolism, classical galactosaemia prevents life-threatening complications in the neonatal period. It does not however influence the development of long-term complications and the complex pathophysiology of this rare disease remains poorly understood. The objective of this study was to report the development of a healthcare database (using Distiller Version 2.1) to review the epidemiology of classical galactosaemia in Ireland since initiation of newborn screening in 1972 and the long-term clinical outcomes of all patients attending the National Centre for Inherited Metabolic Disorders (NCIMD). Since 1982, the average live birth incidence rate of classical galactosaemia in the total Irish population was approximately 1:16,476 births. This reflects a high incidence in the Irish 'Traveller' population, with an estimated birth incidence of 1:33,917 in the non-Traveller Irish population. Despite early initiation of treatment (dietary galactose restriction), the long-term outcomes of classical galactosaemia in the Irish patient population are poor; 30.6 % of patients ≥ 6 yrs have IQs <70, 49.6 % of patients ≥ 2.5 yrs have speech or language impairments and 91.2 % of females ≥ 13 yrs suffer from hypergonadotrophic hypogonadism (HH) possibly leading to decreased fertility. These findings are consistent with the international experience. This emphasizes the requirement for continued clinical research in this complex disorder.

Comparison of interferon {gamma} release assays and conventional screening tests before tumour necrosis factor {alpha} blockade in patients with inflammatory arthritis

OBJECTIVE

To compare the performance of two interferon gamma release assays (IGRAs) and conventional screening tests in patients with inflammatory arthritis undergoing screening for latent tuberculosis infection (LTBI) before treatment with anti-tumour necrosis factor alpha (anti-TNFalpha) compounds.

METHODS

Successive patients were subjected to conventional LTBI screening, including a tuberculin skin test (TST). The T-SPOT.TB test was performed on all patients and the QuantiFERON-TB Gold test was performed on a large subset. The results of the IGRAs were compared with the results of conventional screening tests.

RESULTS

A total 150 patients were evaluated. The majority (57.9%) had rheumatoid arthritis. Previous vaccination with Bacille Calmette-Guerin was confirmed in 82% of patients. No patient had received prior anti-TB treatment. A total of 57 patients (38.0%) had at least one positive conventional risk factor. In contrast, an unequivocally positive T-SPOT.TB test was seen in only 14/143 (9.8%). There was 98.2% agreement between the two IGRAs. Statistically significant associations were found between each of the IGRAs and both TST and risk history, but not chest x-ray (CXR). A positive IGRA result was significantly associated with increased age. TB was not reactivated in any patient during the follow-up period.

INTERPRETATION

This study suggests that IGRAs may be useful when screening for LTBI before anti-TNFalpha therapy in patients with immune-mediated inflammatory diseases. The observations reported here also highlight the inadequate performance of CXR as a marker of LTBI.

Incidence of hip fracture in the Republic of Ireland and future projections: a population-based study

SUMMARY

There are no previously published data for hip fracture incidence rates in the Republic of Ireland. The rates of fracture for the total population aged 50 years and over were 407 and 140 per 100,000 for females and males, respectively. Assuming a stable incidence rate, the absolute number of hip fractures occurring on an annual basis is expected to increase by 100% by the year 2026. Health care providers should accommodate these increases into future strategies.

INTRODUCTION

Hip fractures are an important cause of morbidity in the elderly and represent an increasing burden on health service providers. Significant regional and international variation in incidence rates of hip fracture exists. In order for health service providers to be able to commit adequate resources to the care of hip fracture patients, accurate estimates of hip fracture numbers are required now and for the future. To date, there have been no reported incidence rates for hip fracture in the Republic of Ireland.

METHODS

We performed a search of the national hospital in-patient enquiry database for all hip fractures occurring in the Republic of Ireland between 2000 and 2004. Population data was obtained from the 2002 national census data. Population projections were made for the years 2016 and 2026 to allow determination of expected hip fracture numbers for those years.

RESULTS

The rates of hip fracture in the Irish population aged 50 years and over were 407 and 140 per 100,000 for females and males, respectively. Annual hip fracture numbers are expected to increase by 100% by the year 2026, assuming a stable incidence rate.

CONCLUSION

Health service providers should take into account the expected increase in hip fracture numbers when allocating resources for the care of these patients in the mid-term future.

Incidence of hip fractures in Dublin's north inner city

Hip fractures are an important cause of morbidity and mortality in the elderly and represent an increasing burden on health service providers. There is significant regional and international variation in the incidence rates of such injuries, depending on age, sex and ethnic variations in populations. To date, there are no reported incidence rates for hip fractures in Ireland. Over a five year period, 717 low energy hip fractures were treated in the orthopaedic trauma unit of the Mater Misericordiae hospital. For this population, the female to male ratio was 3.3:1 (549 females and 166 males), the gender specific incidences were 470 per 100,000 and 179 per 100,000 for females and males, respectively. The overall age standardized rate was 341 per 100,000. This study quantifies the burden of hip fracture on a local population. With this knowledge, health service providers should be able to allocate appropriate resources for these patients in terms of acute and step-down care facilities.

Irish National Joint Registry: a concept

Despite the well-documented benefits, some countries have yet to agree on the establishment of a national joint register. A questionnaire study was undertaken to ascertain the opinions of the consultant orthopaedic surgeons and specialist registrars, regarding establishment of an Irish National Joint Register. The aim was to find out the possible reasons why a national joint register has not been established in Ireland. A 69% first response rate was recorded. Ninety-seven percent believe it is time to set up a registry and 81% say it should be made compulsory for unwilling surgeons and hospitals to participate. Despite the overwhelming support, privacy and liability issues were major concerns. Fifty-eight percent agree that access to registry report by general public can expose surgeons and hospitals to medico-legal implications. Legislation may be required to protect the integrity of a national joint replacement registry to ensure that the data are used as intended.

Clinical features of amyotrophic lateral sclerosis according to the El Escorial and Airlie House diagnostic criteria: A population-based study

BACKGROUND

The El Escorial and the revised Airlie House diagnostic criteria for amyotrophic lateral sclerosis (ALS) classify patients into categories reflecting different levels of diagnostic certainty. We conducted a prospective, population-based study of the natural course of ALS in the Republic of Ireland during a 6-year period to examine the utility of these ALS diagnostic criteria.

METHODS

Using data from the Irish ALS Register, we studied the clinical features of all patients diagnosed as having ALS in Ireland throughout their illness.

RESULTS

Between 1993 and 1998, 388 patients were diagnosed as having ALS. Forty percent of patients reported bulbar-onset symptoms. Disease progression occurred over time: at last follow-up, 75% of all patients had bulbar signs, compared with 59% at diagnosis. When the El Escorial criteria were applied, more than half of patients (218 [56%]) had definite or probable ALS at diagnosis. Of the 165 possible and suspected ALS cases at diagnosis (trial ineligible), 110 (67%) were trial eligible at last follow-up. Of the 254 patients who had died, 229 (90%) had definite or probable ALS, whereas 25 patients (10%) remained trial ineligible at death. El Escorial category at diagnosis was not a significant prognostic indicator. Use of the Airlie House criteria had no effect on the median time from symptom onset to trial eligibility (12.9 vs 12.8 months).

CONCLUSIONS

The El Escorial and Airlie House diagnostic criteria are excessively restrictive. Furthermore, levels of diagnostic certainty cannot be used as prognostic indicators. Arch Neurol. 2000;57:1171-1176

The Short Form 36 (SF-36) Health Survey: normative data for the Irish population

BACKGROUND

Generic measures of quality of life have a wide application in health research. They measure disease impact by comparing scores in patient groups with a healthy population. They also facilitate comparative studies between different patient groups. The SF-36 Health Survey quantifies respondents' perceptions of their functioning in eight dimensions of daily life.

AIM

The aim of this study was to set normative values for the SF-36 in the Irish population aged 18 years and over.

METHOD

A random sample of 800 subjects was drawn from the electoral register using the RANSAM method of sampling.

RESULTS

Two hundred and ninety five (37%) valid questionnaires were returned for analysis. The SF-36 was found to have acceptable internal consistency and validity. Normative values for the total population are presented, in addition to results for males and females across seven age groups. Ageing was associated with a decline in the physical dimensions of health.

CONCLUSIONS

There was no evidence to suggest that there were significant differences in health status between males and females, or between this Irish sample and the published norms for the US population.

Prevalence of hysterectomy in Ireland

OBJECTIVES

To assess factors influencing the prevalence of hysterectomy in Ireland.

METHODS

Analysis of results of a questionnaire completed by a population-based cohort of 17735 women aged 50-65 years attending for breast screening.

RESULTS

Prevalence of hysterectomy was 22.2%, was increased in proportion to parity and was higher in younger women, those who had previously used oral contraception and those who had private health insurance; peak age at operation was 45-49 years.

CONCLUSION

The relatively high prevalence parity reflects contraceptive practices and utilization of health service resources.

Gender differences in the management and outcome of acute myocardial infarction in unselected patients in the thrombolytic era

This study compares the clinical features, management, and outcome in men and women from a consecutive, unselected series of patients with acute myocardial infarction (AMI) who were admitted to a university cardiac center over a 3-year period. It is a retrospective observational study of 1,059 admissions with AMI identified through the Hospital In-Patient Enquiry (HIPE) registry, validated according to Minnesota Manual criteria, and followed for a period of up to 5 years (median 36 months). Women comprised 40% of all admissions, had a higher hospital mortality (24% vs. 16%, p<0.001), and were less likely to receive thrombolysis (23% vs. 33%, p<0.01), admission to coronary care (65% vs. 77%, p<0.001), or subsequent invasive or noninvasive investigations (55% vs. 63%, p<0.01). However, women with AMI were older than men with AMI (71 vs. 65 years, p<0.001). After adjusting for age, differences that remained significant were prevalence of hypertension (odds ratio [OR] 2.12, 95% confidence intervals [CI] 1.56 to 2.88) and cigarette smoking (OR 0.47, 95% CI 0.35 to 0.65), management in coronary care (OR 0.66, 95% CI 0.49 to 0.88), and hospital mortality (OR 1.48, 95% CI 1.07 to 2.04). Excess mortality occurred predominantly in women <65 years old (18% vs. 8%, OR [multivariate] 2.35, 95% CI 1.19 to 4.56), among whom multivariate analysis demonstrated a significantly lower thrombolysis rate (OR 0.48, 95% CI 0.27 to 0.86). In this group, lack of thrombolysis independently predicted hospital mortality (OR 5.37, 95% CI 1.45 to 19.82). Female gender was not an independent predictor of mortality following AMI (OR 1.42, 95% CI 0.90 to 2.26). Thus, among unselected patients, female gender is associated with, but not an independent predictor of, reduced survival after AMI. Gender differences in mortality are greatest in younger patients, who are less likely to receive thrombolysis and in whom lack of thrombolysis is independently associated with mortality after AMI.

Physical function, employment and quality of life in end-stage renal disease

INTRODUCTION

The impact of end-stage renal disease (ESRD) on quality of life (QoL) can be measured in terms of physical, psychological and social consequences, including the ability to work.

SUBJECTS AND METHODS

This multi-center, cross-sectional study explored relationships between QoL, employment status and physical function in ESRD patients aged 18-65 years, via a customised interviewer-administered questionnaire, which included the SF-36 health survey. The International Labour Office method was applied to describe employment rate.

RESULTS

144 patients (85 male, 49 female), comprising 49 haemodialysis (HD), 35 peritoneal dialysis (PD) and 60 renal transplant (TX) patients were studied. Mean age was 44 +/- 12 years. 32 were voluntarily not working, leaving 112 in the labour force. Of the latter, 49% were unemployed, in contrast with the concurrent national rate of 10%. QoL in the ESRD group was reduced in the SF-36 physical and social dimensions compared to population norms. Unemployed ESRD patients scored significantly lower than those employed in physical function, role physical, bodily pain, general health, vitality and role emotional scales. Logistic regression demonstrated that multiple comorbidities (p<0.005), a premorbid physical occupation (p<0.05) and poor physical function (p<0.05) predicted unemployment in ESRD independent of all other variables. Multiple regression showed that age (p<0.05), female sex (p<0.05) and a diagnosis of musculoskeletal disease (p<0.005) were independent predictors of poor physical function.

CONCLUSIONS

These findings suggest that vocational rehabilitation of ESRD patients must consider physical function and occupational demands as well as co-morbidity and that musculoskeletal disease is key factor in impaired physical function.

Characteristics and outcomes in patients with acute myocardial infarction with ST-segment depression on initial electrocardiogram

BACKGROUND

Acute myocardial infarction (AMI) with nonreciprocal ST-segment depression is said to have a poor prognosis, and early diagnosis and treatment are problematic. The aim of this study was to determine the proportion of unselected consecutive patients admitted to a university center with AMI with nonreciprocal ST-segment depression and to characterize these patients in terms of clinical features, treatment, and short- and long-term prognoses.

METHODS AND RESULTS

Admission electrocardiographic data on 852 consecutive admissions with AMI were analyzed. Nonreciprocal ST-depression was an admitting feature in 95 (11%) patients, the majority of whom had ST depression >3 mm. These were older (70.3 vs 66.8 years, P <.05), more likely to have had myocardial infarction (40% vs 25%, P <.01), and to have left ventricular failure (56% vs 42%, P <.5), cardiogenic shock (15% vs 9% P =.06), and atrial fibrillation (34% vs 19%, P <.01). Hospital mortality rate was significantly higher (31% vs 17%, P <.01). Patients were less likely to undergo thrombolysis (17% vs 31%, P <.01), angiography (22% vs 35%, P <.05), or percutaneous revascularization (5% vs 9%, P <.01). Patients with ST depression undergoing coronary angiography were more likely to have 3-vessel disease (71% vs 47%, P <.05). Mortality rate at follow-up (median 36 months) was significantly higher in patients with ST depression (56% vs 32%, P <.001). Analysis by individual electrocardiography demonstrated ST-segment depression to be the third most frequent presentation after ST elevation (n = 327) and T-wave changes (n = 258), in whom hospital mortality rates were 24% and 9%, respectively. In multivariate analysis, previous myocardial infarction was an independent predictor of nonreciprocal ST depression at initial examination (odds ratio 2.04 [1.25 to 3.34], P <.005). No electrocardiographic presentation was an independent predictor of death in the hospital after AMI.

CONCLUSIONS

In unselected cases of AMI, patients with ST-segment depression make up a significant minority (11%), who are likely to be older with a high prevalence of previous myocardial infarction and multivessel disease, and who have a poor prognosis.

Gender differences in the results of the final medical examination at University College Dublin

OBJECTIVES

In 1984 females made up 45% of medical undergraduates in Ireland. By 1996 this proportion had increased to 57%. This study examines gender differences in performance at final medical examinations, with a view to ascertaining the impact of the change in proportion of females attending medical school.

DESIGN

Final year examination results of medical students over a 5-year period (1992-96) were obtained from the broadsheets of University College Dublin (UCD) examinations office. The results of 557 students (females n=277; males=280) were analysed for all final year examinations (n=5).

SETTING

University College Dublin.

SUBJECTS

Final year medical students.

RESULTS

Overall females were found to have performed better than their male counterparts. They were more likely to achieve an honours grade and had a similar or lower likelihood of passing or failing. Gender differences in performance were most marked in paediatrics (P < 0.01), psychiatry (P < 0.01) and obstetrics and gynaecology (P=0.01), females being more successful in each case.

CONCLUSIONS

The success of females and their increased numbers at undergraduate level are not reflected at senior registrar and consultant level. As medical manpower becomes more of an issue the lack of women, particularly in certain specialties, and the possible reasons for this need to be addressed.

Amyotrophic lateral sclerosis mimic syndromes: a population-based study

BACKGROUND

The Irish ALS Register is a population-based register of the epidemiological characteristics of amyotrophic lateral sclerosis (ALS) in the republic of Ireland.

OBJECTIVE

To describe the clinical and demographic details of those patients included in the Irish ALS Register who were incorrectly diagnosed as having ALS (patients who were ultimately rediagnosed as having an "ALS mimic syndrome").

METHODS

The medical records of each patient referred to the register are routinely reviewed and, where possible, patients are examined by our group during their illness.

RESULTS

Between January 1, 1993, and December 31, 1997, 32 patients (representing 7.3% of 437 referrals) were rediagnosed as having a condition other than ALS. The median age at onset for these 32 patients was 56.0 years (range, 19.5-85.8 years) for men and 53.5 years (range, 39.5-70.4 years) for women. Twenty-nine patients (91%) presented with symptoms referable to the limbs, and the remainder presented with symptoms involving the bulbar musculature. Multifocal motor neuropathy was the most common condition mistaken for ALS, accounting for 7 cases (22%), followed closely by Kennedy disease (4 cases [13%]). Factors leading to diagnostic revision included evolution of atypical symptoms, results of specific investigations, and failure of symptoms to progress. Twenty-seven (84%) of the patients with an ALS mimic syndrome fulfilled the El Escorial criteria for either "suspected" or "possible" ALS, 4 (13%) met the criteria for probable ALS, and 1 (3%) had definite ALS.

CONCLUSIONS

The application of the El Escorial diagnostic criteria may facilitate early recognition of non-ALS cases. Misdiagnosis of ALS remains a common clinical problem despite the increased availability of investigations and a greater awareness among neurologists of potential diagnostic pitfalls.

Hospital mortality of acute myocardial infarction in the thrombolytic era

OBJECTIVE

To examine the management and outcome of an unselected consecutive series of patients admitted with acute myocardial infarction to a tertiary referral centre.

DESIGN

A historical cohort study over a three year period (1992-94) of consecutive unselected admissions with acute myocardial infarction identified using the HIPE (hospital inpatient enquiry) database and validated according to MONICA criteria for definite or probable acute myocardial infarction.

SETTING

University teaching hospital and cardiac tertiary referral centre.

RESULTS

1059 patients were included. Mean age was 67 years; 60% were male and 40% female. Rates of coronary care unit (CCU) admission, thrombolysis, and predischarge angiography were 70%, 28%, and 32%, respectively. Overall in-hospital mortality was 18%. Independent predictors of hospital mortality by multivariate analysis were age, left ventricular failure, ventricular arrhythmias, cardiogenic shock, management outside CCU, and reinfarction. Hospital mortality in a small cohort from a non-tertiary referral centre was 14%, a difference largely explained by the lower mean age of these patients (64 years). Five year survival in the cohort was 50%. Only age and left ventricular failure were independent predictors of mortality at follow up.

CONCLUSIONS

In unselected consecutive patients the hospital mortality of acute myocardial infarction remains high (18%). Age and the occurrence of left ventricular failure are major determinants of short and long term mortality after acute myocardial infarction.

Mortality from breast cancer in Ireland prior to the introduction of population-based mammographic screening

Mammographic screening has been shown in international randomised controlled trials and case-control studies to be effective in reducing mortality from breast cancer. Ireland has a high mortality rate from breast cancer when compared with rates from other countries. Organised population-based mammographic screening for breast cancer is about to begin in Ireland. The purpose of this study was to examine current mortality from breast cancer, as well as trends in breast cancer mortality in Ireland since 1975, as a baseline against which future evaluations of the impact of screening can be carried out. Over the 23-yr period of review, mortality from breast cancer appears to have remained quite stable. Within the period, however, there is some variation in adjusted rates, most notably an increase to a peak in 1989, followed by a decrease between 1989 and 1997. Continued monitoring of recent trends is required, with in-depth analysis of possible explanations, such as changing breast cancer incidence rates, biological characteristics, therapeutic regimes and coding practices.

Management and outcome of acute myocardial infarction in older patients in the thrombolytic era

OBJECTIVE

Acute myocardial infarction (AMI) is an important cause of mortality and morbidity in older patients. The aim of this study was to determine the proportion of unselected admissions with AMI that is older than 75 years and to examine management and outcomes in this group.

DESIGN

An historical cohort study of consecutive unselected admissions with AMI identified using the Hospital In Patient Enquiry (HIPE) database and validated according to MONICA criteria for definite or probable AMI.

SETTING

An acute cardiac unit in a university teaching hospital/cardiac tertiary referral center.

RESULTS

Of 1059 patients, 606 (57%) were older than 65 years and 309 (29.2%) were older than 75 years. Mean age in this group was 80.5 years. Hospital mortality was almost twice as high as in patients younger than 75 years (28% vs 15%, P < .001), and age was an independent predictor of short- and long-term mortality following AMI. Women constituted a significantly higher proportion of older patients. Family history of AMI and cigarette smoking were less prevalent in older patients. Mean cholesterol was lower and comorbidities were higher. Other baseline characteristics, including previous AMI, did not differ. However older patients were less likely to receive thrombolysis (13% vs 36%, P < .001), aspirin (76% vs 86%, P < .01), or beta-blockers (25% vs 51%, P < .001) and were less likely to undergo cardiac catheterization or revascularization. Only 53% were admitted to coronary care.

CONCLUSION

Patients more than age 75 comprise almost one-third of patients with AMI and have a poor prognosis. Although age is an independent predictor of mortality following AMI, suboptimal management may contribute to the high mortality in these patients.

Incidence and prevalence of ALS in Ireland, 1995-1997: a population-based study

BACKGROUND

We conducted a prospective, population-based study of ALS in the Republic of Ireland for the 3-year period 1995 to 1997.

METHODS

To ensure complete case ascertainment, multiple sources of information were used, including consultant neurologists, neurophysiologists, primary care physicians, and the Irish Motor Neuron Disease Association. The El Escorial diagnostic criteria for ALS were applied to all cases enrolled on the register and each patient was regularly followed up during his or her illness.

RESULTS

Between January 1, 1995, and December 31, 1997, 231 patients were diagnosed with possible, probable, or definite ALS, including 133 men (57.6%) and 98 women (42.4%). The average annual incidence rate was 2.1 per 100,000 person-years (95% CI, 1.8 to 2.4), and 2.8 per 100,000 person-years for the population older than 15 years (95% CI, 2.4 to 3.1). The incidence rate was higher for men, being 2.5 per 100,000 person-years (95% CI, 2.0 to 2.9), than for women, at 1.8 per 100,000 person-years (95% CI, 1.5 to 2.2), and increased with age for both sexes. The median age at onset was 64.2 years for men and 67.8 years for women. On December 31, 1996, the crude prevalence was 4.7 per 100,000 of the total population (95% CI, 4.0 to 5.5), and 6.2 per 100,000 for the population older than 15 years (95% CI, 5.3 to 7.1). Adjusting to the 1996 Irish population as standard, the incidence of ALS in Ireland during the 3-year study period is the third highest reported to date.

CONCLUSIONS

There was a trend toward a higher incidence of ALS in the northwestern region of Ireland, although the numbers of cases involved were small and further study is required.

Detection of coronary artery disease using dobutamine stress echocardiography in patients with an abnormal resting electrocardiograph

PURPOSE

We assessed the value of dobutamine stress echocardiography for the detection of coronary artery disease in patients with chest pain and an abnormal resting electrocardiograph (ECG).

METHODS

Dobutamine stress echocardiography was performed in a standard fashion. Significant coronary artery disease was defined as a >50% luminal diameter stenosis on coronary angiography.

RESULTS

The sensitivity, specificity, positive and negative predictive value of dobutamine stress echocardiography for the detection of coronary artery disease in 218 patients were 89, 50, 95 and 32%, respectively. The sensitivity for detection of multi-, double- and single vessel disease were 97, 82 and 81%, respectively. The sensitivity for the detection of coronary artery disease in a subgroup of 69 patients by treadmill exercise testing was 37%.

CONCLUSION

Dobutamine stress echocardiography is better than exercise ECG for the detection of significant coronary artery disease. The negative predictive value of dobutamine stress echocardiography in this patient group is low.

Alcohol consumption and idiopathic dilated cardiomyopathy: a case control study

BACKGROUND

Alcohol has been implicated as a risk factor for idiopathic dilated cardiomyopathy (DCM), but a causal relation has not been established. The objective of this study was to determine the association between alcohol consumption and DCM.

METHODS

Questionnaires detailing average weekly intake of alcohol, total lifetime consumption, and alcohol abuse were administered in a cohort of well-defined patients with DCM and a randomly selected, population-based control group.

RESULTS

Significantly more of the 100 patients with DCM than the 211 members of the control group drank greater than the recommended weekly intake of alcohol (40% vs 24%; p < 0.01) and were alcohol abusers according to the CAGE questionnaire (27% vs 16%; p < 0.05). The average total lifetime consumption measured in units of alcohol was also significantly greater in cases than in the control group (31,200 vs 7,904; p < 0.01). Patients with familial DCM were not significantly more likely to consume alcohol above recommended limits or to be alcohol abusers compared with nonfamilial cases.

CONCLUSIONS

This study confirms previous suspicion of a causal association between alcohol and DCM, with significantly more patients than members of the control group either abusing alcohol or drinking it in excess of recommended limits.

Long-term clinical outcome following coronary artery bypass grafting for isolated stenosis of the left anterior descending coronary artery

AIMS

To detail the clinical and angiographic profile, and long-term outcome in consecutive patients with isolated stenosis of the left anterior descending coronary artery undergoing bypass surgery.

METHODS

A retrospective study of all patients (n = 301) (January 1984-December 1990) and undergoing coronary artery bypass grafting for isolated left anterior descending disease, in the Irish Republic, was performed. Survival was compared with that of an exact age- and gender-matched cohort.

RESULTS

Mean age was 53 (+/- 9.3) years. There were 238 (79%) males. In 241 (80%) patients an internal thoracic arterial bypass graft was used. Operative mortality was 1.3%. Of the 280 (93%) patients alive (16 cardiac deaths) at 7.1 (+/- 1.9) years, 105 (35%) had angina, 26 (9%) suffered an interval myocardial infarction, and repeat revascularization was required on 29 (10%). Female gender (P = 0.002), pre-operative myocardial infarction (P = 0.02), significant diagonal disease (P = 0.04) and postoperative myocardial infarction (P = 0.0001) were independently associated with survival. Females were more likely to develop congestive cardiac failure (P = 0.01) or postoperative angina (P = 0.03) than their male counterparts.

CONCLUSIONS

Survivorship (97%) and event-free survival (96%) at 5 years following coronary artery bypass grafting for isolated left anterior descending coronary artery disease is excellent and equivalent to an age-matched and gender-matched cohort.

Comparison of dobutamine stress echocardiography and treadmill exercise electrocardiography for detection of coronary artery disease

BACKGROUND

Critical analysis of treadmill exercise testing (TMET) for the detection of coronary artery disease has revealed many shortcomings. Excellent diagnostic accuracy has been reported for dobutamine stress echocardiography (DSE).

METHODS

A prospective comparison of DSE and TMET for the detection of coronary artery disease in routine clinical practice was performed using contrast cineangiography (significant stenosis > or = 50%) as a gold standard.

RESULTS

A total of 116 patients (82 men, 34 women) were studied. Significant stenosis was detected by coronary angiography in 92 patients (79%). Single vessel disease occurred in 28, double-vessel disease in 32, and multivessel disease in 32 patients. Although sensitivity of DSE was better than that of TMET (82 versus 40%), specificity was worse (63 versus 79%). Positive predictive values for both DSE and TMET were good at 89 and 87%, respectively, whereas negative predictive values were poor for both (47% for DSE, 26% for TMET).

CONCLUSIONS

Overall, DSE performs better than TMET in terms of sensitivity and positive and negative predictive value. Its lower specificity than that of TMET may lead to more patients being referred for diagnostic coronary angiography. The poor negative predictive value of DSE and TMET means that one should not be falsely reassured by normal results.

Dobutamine stress echocardiography in the detection of coronary artery disease in a clinical practice setting

In this prospective study, patients referred for coronary angiography for detection of disease underwent dobutamine stress echocardiography to define its value in a clinical practice setting.

RESULTS

Of 219 patients studied, 170 (78%) had significant coronary artery disease. The overall sensitivity and specificity of dobutamine stress echocardiography for coronary artery disease were 82 and 65%, respectively. The sensitivity was 88% for detection of triple-vessel disease, 83% for double-vessel disease, and 74% for single-vessel disease. Positive and negative predictive values for coronary artery disease were 89 and 51%, respectively. Dobutamine stress echocardiography correctly identified only 72 of 138 patients with significant stenosis of the left anterior descending coronary artery. In 219 patients, 345 of 657 major epicardial vessels had significant disease. Dobutamine stress echocardiography could only correctly identify the vessel involved in 188. Triple-vessel disease was present in 65 patients. Dobutamine stress echocardiography correctly categorised 18% (n = 12) of these. The remainder were incorrectly classified as having double-vessel disease or single-vessel disease (n = 45), or no disease at all (n = 8).

CONCLUSION

Dobutamine stress echocardiography performs well. However, lower specificity may lead to unwarranted referrals for coronary angiography, and the low NPV give false reassurance as to the absence of disease.

Dobutamine stress echocardiography in the detection of coronary artery disease: importance of the pretest likelihood of disease

Although the accuracy of dobutamine stress echocardiography for the detection of coronary artery disease in a high-risk population is known, it has not been well defined for lower risk groups. Two probability groups, high (>75%; n = 199) and intermediate (>10% but < or =75%; n = 118), were studied. Dobutamine stress echocardiography was performed in a standard fashion. Significant coronary artery disease was defined as a >50% luminal diameter stenosis on coronary angiography. The positive predictive accuracy of dobutamine stress echocardiography for the detection of coronary artery disease was greater in the high-probability group (96% vs 86%), as was the sensitivity (89% vs 78%), whereas the negative predictive value was greater in the intermediate-probability group (50% vs 23%), as was the specificity (63% vs 50%). Dobutamine stress echocardiography does have a diagnostic role in the evaluation of patients with an intermediate probability of coronary artery disease.

Idiopathic dilated cardiomyopathy: familial prevalence and HLA distribution

OBJECTIVES

To compare HLA distribution in familial and non-familial dilated cardiomyopathy, because a serum marker that could identify families at risk of developing dilated cardiomyopathy should be of use in screening for the disease.

PATIENTS

100 patients with dilated cardiomyopathy.

METHODS

200 first degree relatives from 56 of the proband families were screened for dilated cardiomyopathy by echocardiography. The HLA profile of the patients with dilated cardiomyopathy, as well as of the familial and non-familial subgroups, was compared with that of 9000 normal controls.

RESULTS

The familial prevalence of dilated cardiomyopathy in this patient group was "definite" in 14 of 56 (25%) and "possible" in 25 of 56 (45%). The HLA-DR4 frequency in the 100 patients with dilated cardiomyopathy was similar to that in the 9000 controls (39% v 32%). However, the DR4 subtype was significantly more common in the 25 probands with a familial tendency to dilated cardiomyopathy than in the 31 probands with non-familial dilated cardiomyopathy (68% v 32%; P < 0.05).

CONCLUSIONS

The present finding supports an HLA linked predisposition to familial dilated cardiomyopathy. The HLA type DR4 was significantly more common in familial than in non-familial cases. The DR4 halotype was associated with two thirds of the families at risk for dilated cardiomyopathy.

Skin type distribution and skin disease in Ireland

The Irish are generally considered to have a fair complexion. We surveyed the distribution of skin type in an Irish city population (n = 1000). Skin type prevalence was as follows: type 1: 26%, type 2: 49.6%, type 3: 19.7%, type 4: 4.3%, type 5: 0.3%, type 6: 0.1%. Sunbeds were used by 16% of the population. Malignant melanoma occurred in 1.4% of patients, non-melanoma skin cancer in 6%. The high frequency of sunbed use in a fair skinned population and the high incidence of skin cancer is disturbing and highlights the need for ongoing public health education regarding ultraviolet radiation risks.

Evaluation of patients with diabetes mellitus for coronary artery disease using dobutamine stress echocardiography

BACKGROUND

There is a high prevalence of coronary artery disease (CAD) in patients with diabetes mellitus. Detection of inducible ischaemia using treadmill exercise testing may be limited by the relatively poor inherent predictive accuracy of the test. The purpose of this study was to determine the value of dobutamine stress echocardiography (DSE) for the detection of CAD in patients with diabetes mellitus.

METHODS

Patients with diabetes mellitus referred for cardiac assessment were considered eligible for study. DSE was performed in a standard fashion. Significant CAD was defined as a > 50% luminal diameter stenosis on coronary angiography.

RESULTS

A total of 52 patients (mean age 59 years) with diabetes mellitus were studied prospectively using DSE. Risk factors for CAD included hypertension in 19, family history in 21, hypercholesterolaemia in 14, history of smoking in 38. The sensitivity, specificity, positive and negative predictive values of DSE for detection of CAD were 82, 54, 84 and 50% respectively.

CONCLUSION

The specificity of DSE for CAD in patients with diabetes mellitus is low. Whether this reflects an underdetection of small vessel disease by contrast coronary angiography or whether it relates to test performance is unclear.

Safety of dobutamine stress echocardiography in 474 consecutive studies

BACKGROUND

With expanding applications and increasingly aggressive stress protocols, concerns about the safety of dobutamine stress echocardiography (DSE) have arisen. The purpose of this study was to analyse prospectively the safety, adverse event profile and complication rate of DSE.

METHODS

Prospective data were recorded in a consecutive series of 474 patients undergoing DSE. Dobutamine was administered intravenously in graded infusion, each stage over 3 min, at 10, 20, 40 and, if required, 50 micrograms/kg/min. Atropine (1 mg) was administered thereafter if the response remained suboptimal.

RESULTS

The mean dose of dobutamine was 42 micrograms/kg/min, with 111 patients (23%) receiving 50 micrograms/kg/min. Atropine was required for 27 patients (6%). No patient died or suffered a myocardial infarction. Sustained ventricular tachycardia occurred in one patient, angina pectoris in 127 (27%), non-sustained ventricular tachycardia in eight (2%) and supraventricular tachycardia in 19 (4%). Profound bradycardia requiring cessation of the test occurred in one patient. Pulmonary oedema developed in one patient. A hypotensive response requiring cessation of the test was seen in one patient. Test termination because the patient complained of nausea, tremor or headache was not required.

CONCLUSION

DSE is safe. Side effects are rare and when they occur, are usually minor. Ischaemic pain is effectively treated by termination of the test and sublingual administration of nitrates.

Women's dietary fat and sugar intakes: implications for food based guidelines

OBJECTIVE

To examine how women's dietary data can be used to formulate food based dietary guidelines for fat.

DESIGN

Dietary intake data was assessed cross-sectionally using the 7 d diet history method. Subjects were divided into quartiles on the basis of their intakes of total fat and saturated fatty acids (% energy) and the diets of those in the lowest and highest quartiles were compared.

SUBJECTS AND SETTING

Subjects studied were socially advantaged and disadvantaged women (n = 83, mean age 35 years) recruited from their workplaces.

RESULTS

The inverse relationship between intakes of sugar and total fat (P < 0.0001) found in this study also extended to saturated fatty acids (P = 0.0007). Women in the lowest quartile of total fat, in common with those in the lowest quartile of saturated fatty acids, were found to have higher intakes of fibre (P < 0.005), vitamin C (P < 0.01), folate (P < 0.005) and vitamin B6 (P < 0.05) while their intakes of vitamin A were lower (P = 0.01). Most (76%) of the differences in sugars intake between women of low and high total fat consumption were accounted for by added sugars, particularly non-fat containing confectionery/drink food sources where median daily intake values were 15 g vs 7 g sugars (P = 0.05) respectively. The finding that at best only 62% of the women had total fat and saturated fatty acids intake in similar quartiles, together with the differences that emerged in their food intake patterns, indicate that the goals for these nutrients may be separately achieved.

CONCLUSION

Existing dietary data can be useful for the formulation of specific food based dietary guidelines and diets higher in sugar are not necessarily more dilute in micronutrients.

Cholesterol levels in normal Irish adults: the Mater Hospital Cholesterol Screening Survey

Serum samples from 954 Irish adults (604 males, 350 females) aged 18 to 65 years were analyzed within 24 hours of receipt for non-fasting total serum cholesterol levels. The subjects were volunteer blood donors (Blood Transfusion Service Board, Pelican House, Dublin) presenting from June 1990 to February 1991. Serum cholesterol increased significantly with age in both males and females. Mean serum cholesterol in males increased from 4.5 (+/- 0.9) mmol/l in those < 25 years, to 5.7 (+/- 1.0) mmol/l at age 55-64 years. In females, mean serum cholesterol increased from 4.3 (+/- 0.9) mmol/l less than 25 years to 6.2 (+/- 0.8) mmol/l at age 55-64 years. Options for reporting cholesterol ranges are discussed. The overall mean cholesterol concentration of 5.1 mmol/l seen in this study is lower than that reported for comparable studies of U.K. and American subjects, but higher than observed in Japanese individuals. Almost 48% of the studied population had a serum cholesterol value less than 5 mmol/l and over 56% had levels less than 5.2 mmol/l.

International trials and national practice: a questionnaire survey of current physician practice in the treatment of acute myocardial infarction

To establish current national clinical practice in the care of patients with acute myocardial infarction (AMI), a questionnaire survey of 50 consultant physicians currently working in the Republic of Ireland was carried out. There were 45 (90%) respondents. 32/45 (71%) give thrombolysis in CCU only; 13/45 (29%) give thrombolysis in casualty also. Streptokinase (Stk) is the first choice thrombolytic agent for the majority. 14/45 (31%) use tPA for anterior AMI in patients under 60 years. Angiotensin converting enzyme (ACE) inhibitors are given by 34/45 (76%) to patients with evidence of left ventricular dysfunction. ACE inhibitors are neither used routinely nor are they prescribed in the first three days after the AMI by the majority of the physicians surveyed. Serum magnesium is checked routinely by 5/45 (11%) and intravenous magnesium is given routinely by 5/45 (11%). The percentage of AMI patients considered for angiography varied from 10-50%. Despite reports from randomised, controlled trials showing reduced mortality in patients given tPA (versus Stk), routine early ACE inhibition and intravenous magnesium post-AMI, most clinicians in Ireland use streptokinase, selective late ACE inhibition and no magnesium. The reasons for the dichotomy between the favourable results of randomised clinical trials and routine practice are speculative.

Trends in the incidence of polycythemia vera among Olmsted County, Minnesota residents, 1935-1989

To investigate the suggestion that the incidence of polycythemia vera has increased in recent decades, we ascertained secular trends in the incidence of polycythemia vera in Olmsted County, Minnesota, over the 55-year period, 1935-1989. The inpatient and outpatient medical records of all potential cases of polycythemia vera in Olmsted County residents were reviewed and the diagnostic criteria of the Polycythemia Vera Study Group were applied. We found no indication of an increase in the age- and sex-adjusted incidence of polycythemia vera, which averaged 1.9 per 100,000 person-years (95% C.I., 1.4-2.5) over the study period. Incidence rates increased with age, and age-adjusted incidence rates were greater for men (2.8 per 100,000 person-years; 95% C.I., 1.8-3.9) than for women (1.3 per 100,000 person-years; 95% C.I., 0.7-1.9), with the highest incidence rate (23.5 per 100,000 person-years) among men aged 70-79 years. Survival was reduced in this inception cohort of 50 cases, compared to that expected for individuals of like age and sex (P < 0.0001); median survival following diagnosis was 7.2 years.

Screening for breast cancer in Ireland: the Eccles Breast Screening Programme

The Eccles Breast Screening Programme is a population-based screening programme for breast cancer, based at the Mater Misericordiae Hospital, Dublin. It began in 1989 simultaneously with similar programmes in Belgium, France, Greece, Portugal and Spain. The objectives of the Eccles Programme are: (i) to evaluate the impact of mammographic screening on morbidity and mortality from breast cancer in Irish women; and (ii) to address the feasibility and potential value of a national breast cancer screening programme. The specific group targeted for screening is women born in 1925 to 1940 inclusive, in a defined geographical area comprising north Dublin City and County, and Counties Cavan and Monaghan. The areas combined comprise 16% of the country's population; just over 29,000 women were invited for screening. An analysis of the demographic and socioeconomic features of the target population reveals that it represents the total population remarkably well. Participants were invited from a population register to attend one of two screening units. Follow-up treatment for those with abnormalities takes place predominantly at the Mater Hospital where the facilities of the Departments of Pathology, Surgery and Oncology have been made available to the programme. Almost 18,000 women had a mammogram in the first round of screening, an overall response rate of 62%. A total of 129 cancers were detected, a prevalence of breast cancer of 7.2 per 1,000. Of those, 15 (11.6%) were entirely intraduct, and an additional 7 (5.4%) had minimal invasion. This is considerably higher than the proportion of intraduct cancers seen in referral practice populations.

Indices of obesity and body fat distribution in arteriographically defined coronary artery disease in men

Anthropometric measurements descriptive of obesity, body fat distribution and body build were made in 186 males undergoing diagnostic coronary arteriography. Using stepwise multiple logistic regression analysis, two indices of body fat distribution were independently associated with coronary disease, while the widely used indices of obesity, namely body mass index and percentage body fat, were not. A significant association with disease was found for the ratio of waist to thigh circumferences (waist/thigh ratio), which emerged in the first step of the multivariate model (p < 0.005). The ratio of waist to hip circumferences (waist/hip ratio), a widely used index of body fat distribution, was found to have a negative association with disease (p < 0.05). This study suggests that use of body fat distribution indices may assist in the assessment of the risk factor profile of cardiac patients.

HLA typing in Irish psoriatics

Histocompatibility antigens were determined in 93 unrelated Irish psoriatic patients. The results were compared with the HLA profiles of 253 healthy unrelated Irish controls. There was a statistically significant increase in HLA B17 (P < 0.0001), B13 (P = 0.02), and B27 (P = 0.015) among the psoriatic patients. The frequency of HLAB8 (P = 0.002) and HLA B12 (P = 0.001) was lower than expected. When the subgroup of patients with psoriatic arthritis was evaluated separately, it was noted that the increase in HLAB27 was highly statistically significant (P < 0.0001). The relative risks of an Irish patient carrying the major psoriasis associated alleles of developing psoriasis are documented;-possession of the HLA B17 and B13 antigens conferring a risk of developing psoriasis vulgaris of 6.08 and 2.9 respectively. Further values for psoriatic subsets are presented. This is the first report of HLA typing in an Irish psoriatic population. The findings are discussed and compared with other population groups.

The clinical course of idiopathic dilated cardiomyopathy. A population-based study

OBJECTIVE

To describe the prognosis of individuals with idiopathic dilated cardiomyopathy in a population-based sample and to compare this with the prognosis of patients in a previous referral center case series of idiopathic dilated cardiomyopathy.

DESIGN

Cohort study.

SETTING

Population-based in Olmsted County, Minnesota.

PATIENTS

Forty residents of Olmsted County, Minnesota with idiopathic dilated cardiomyopathy initially diagnosed between 1975 and 1984 who were followed through 1 July 1989 and 104 patients from a Mayo Clinic referral case series from 1960 to 1973.

MEASUREMENTS

Survival for the population-based cohort at 1 year and 5 years.

RESULTS

Survival at 1 year differed dramatically between the population-based cohort and the referral case series at 1 year (95% compared with 69%, respectively) and at 5 years (80% compared with 36%, respectively) (P less than 0.001). Long-term survival for the population-based cohort was nonetheless impaired when compared with an age- and sex-matched cohort, that is, the 1980 Minnesota white population (8-year survival: observed, 58% compared with expected, 83%; P less than 0.001). Among community patients, older age (adjusted Cox model hazard ratio for 10-year increase in age, 1.59; 95% CI, 1.08 to 2.35) and lower left ventricular ejection fraction (adjusted hazard ratio for 10% decrease, 1.90; CI, 1.04 to 3.50) were independently associated with impaired survival.

CONCLUSIONS

These population-based data challenge the clinical perception of the clinical course of idiopathic dilated cardiomyopathy based on referral practice prognostic studies and suggest that the clinical course of this condition may be more favorable than previously recognized.

Prognostic significance of c-erbB-2 and estrogen receptor status in human breast cancer

Using the 21N polyclonal antibody, we immunohistochemically stained 314 primary breast carcinomas to identify those tumors overexpressing the c-erbB-2 oncoprotein and to ascertain the prognostic significance of this expression on disease-free and overall survival. Positive membrane staining was present in 52 (17%) of these carcinomas of which 7 (13%) were ductal carcinomas in situ. There was no significant relationship between c-erbB-2 positivity and (a) age at diagnosis, (b) menopausal status, (c) tumor size, (d) lymph node status, (e) estrogen receptor status, or (f) whether or not the patient had disseminated disease outside the axillary fields. However, c-erbB-2-positive tumors were significantly associated with poorer grade (P = 0.02). Patients who were positive for this oncoprotein had a shorter disease-free survival (P = 0.002) and reduced overall survival (P = 0.0001). Overexpression of this oncoprotein was predictive of a worse prognosis in lymph node-positive disease (P = 0.003) and in patients presenting with grade II tumors (P = 0.001). Stratifying the patients on the basis of estrogen receptor status suggested that c-erbB-2+/estrogen receptor-negative status was predictive of a poorer prognosis when compared with the other subgroups (P less than 0.001). Primary and recurrent tumor tissues were available from 42 of the 314 patients. Identical patterns of c-erbB-2 expression occurred in 95% of cases, arguing against a direct role for c-erbB-2 expression in the process of tumor dissemination. The high incidence of staining in ductal carcinomas in situ suggests that expression of this oncoprotein is an early event in tumorigenesis. Finally, multivariate analysis indicated that the c-erbB-2 oncoprotein was an independent prognostic indicator for overall survival in breast carcinoma patients.

Late effects of paralytic poliomyelitis in Olmsted County, Minnesota

We identified a cohort of 300 individuals who had paralytic polio between 1935 and 1955. All lived in Olmsted County, Minnesota. From the 247 survivors, we selected 50 subjects for detailed historical, functional, psychological, clinical, and electrophysiologic evaluation. Sixty-four percent of these 50 survivors complained of new symptoms of muscle pain, fatigue, and weakness after a period of prolonged stability. This led to changes in lifestyle or activity in only 18%. The likelihood of expressing new complaints was not related to present age or interval since polio, and electrophysiologic testing did not distinguish between those with or without new problems. The development of new difficulties in a limb was most strongly predicted by significant paralysis of that limb at the time of the acute illness. Patients with leg weakness were twice as likely to complain of new problems compared to those with arm weakness. Elevated creatine kinase levels were present only in those with new complaints.

In vivo phosphorus-31 magnetic resonance spectroscopy of normal and pathological breast tissues

In vivo phosphorus-31 magnetic resonance spectroscopy, at 1.5 T, in addition to magnetic resonance imaging and mammography, was performed on the breast tissue of 59 subjects, using a 40 mm or 80 mm surface coil for spectral localization. The patients were divided into three groups: Group 1, 46 control subjects; Group 2, nine patients with breast carcinoma; Group 3, four patients with benign breast disease. The relationship of age, menopausal status, breast size and pattern, use of contraceptive pill and history of breast disease to spectral characteristics of breast tissue was examined for the control group. In multivariate analysis, only menopausal status and age were found to be significantly related to tissue biochemistry. Pre-menopausal women had reduced phosphocreatine (PCr) (%) (p = 0.02), and increased phosphomonoesters (PMEs) and beta-nucleotide triphosphate (beta-NTP) (%) (p = 0.05), while the fat-to-water ratio was higher in older women (p = 0.02). No significant differences were identified between the control subjects and the patients with benign breast disease. When spectra from patients with breast carcinoma were compared with an age-matched volunteer group, alpha- and gamma-NTP (%) were found to be higher in the cancer tissue (p less than 0.01 and p = 0.01, respectively), while PCr (%) was reduced (p less than 0.01). The ratio beta-NTP:PCr was higher in the carcinoma group of patients (p less than 0.05). In vivo phosphorus-31 magnetic resonance spectroscopy is a non-invasive examination which may prove useful in the early differentiation of malignant breast disease from normal and benign conditions.

Prognosis of ovarian cancer

Fifty-three patients were treated in the gynaecological unit of the Mater Hospital for ovarian cancer between 1980-86. The demographic features of the patients reviewed were similar to those of the Southern Tumour Registry (1981-85), and in the absence of a national tumour registry are presumed to be representative of the country as a whole. Data from the STR indicates that the annual incidence of ovarian cancer is 20/100,000; extrapolating from these figures to the national would suggest that approximately 280 women develop ovarian cancer each year. The majority of Mater patients (72%) had either stage I or stage II ovarian cancer which is at variance with other studies and may reflect an under-staging at initial laparotomy. Their survival rates were better than those of the STR, probably because they had presented earlier and had a lower portion of undifferented tumours. Ovarian cancer is the main cause of death from genital cancer in Ireland. While the stage of disease at diagnosis is critical to survival, chemotherapy did not influence survival.