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Background: Hospital discharge data have been used to study trends in Lower Extremity Amputation (LEA) rates in people with and without diabetes. The aim of this study was to assess the reliability of routine hospital discharge data in the Republic of Ireland (RoI) for this purpose by determining the level of agreement between hospital discharge data and medical records for both the occurrence of LEA and diagnosis of diabetes., Methods: Two concordance studies between hospital discharge data (HIPE) and medical records were performed. To determine the level of agreement for LEA occurrence, HIPE records were compared to theatre logbooks in 9 hospitals utilising HIPE over a two-year period in a defined study area. To determine the level of agreement for diabetes diagnosis, HIPE records were compared to laboratory records in each of the 4 largest hospitals utilising HIPE over a one week period in the same study area. The proportions of positive and negative agreement and Cohen's kappa statistic of agreement were calculated., Results: During a two-year study period in 9 hospitals, 216 LEAs were recorded in both data sources. Sixteen LEAs were recorded in medical records alone and 25 LEAs were recorded in hospital discharge records alone. The proportion of positive agreement was 0.91 (95% CI 0.88-0.94), the proportion of negative agreement was 0.99 (95% CI 0.98-0.99) and the kappa statistic was 0.91 (95% CI 0.88-0.94). During a one-week study period in 4 hospitals, 49 patients with diabetes and 716 patients without diabetes were recorded in both data sources. Eighteen patients had diabetes in medical records alone and 2 patients had diabetes in hospital discharge records alone. The proportion of positive agreement was 0.83 (95% CI 0.76-0.9), the proportion of negative agreement was 0.99 (95% CI 0.98-0.99) and the kappa statistic was 0.82 (95% CI 0.75-0.89)., Conclusions: This study detected high levels of agreement between hospital discharge data and medical records for LEA and diabetes in a defined study area. Based on these findings, we suggest that HIPE is sufficiently reliable to monitor trends in LEAs in people with and without diabetes in the RoI.

Objective: To compare the risk of stillbirth and miscarriage in a subsequent pregnancy in women with a previous caesarean or vaginal delivery., Design: Systematic review of the published literature including seven databases: CINAHL; the Cochrane library; Embase; Medline; PubMed; SCOPUS and Web of Knowledge from 1945 until November 11(th) 2011, using a detailed search-strategy and cross-checking of reference lists., Study Selection: Cohort, case-control and cross-sectional studies examining the association between previous caesarean section and subsequent stillbirth or miscarriage risk. Two assessors screened titles to identify eligible studies, using a standardised data abstraction form and assessed study quality., Data Synthesis: 11 articles were included for stillbirth, totalling 1,961,829 pregnancies and 7,308 events. Eight eligible articles were included for miscarriage, totalling 147,017 pregnancies and 12,682 events. Pooled estimates across the stillbirth studies were obtained using random-effect models. Among women with a previous caesarean an increase in odds of 1.23 [95% CI 1.08, 1.40] for stillbirth was yielded. Subgroup analyses including unexplained stillbirths yielded an OR of 1.47 [95% CI 1.20, 1.80], an OR of 2.11 [95% CI 1.16, 3.84] for explained stillbirths and an OR of 1.27 [95% CI 0.95, 1.70] for antepartum stillbirths. Only one study reported adjusted estimates in the miscarriage review, therefore results are presented individually., Conclusions: Given the recent revision of the National Institute for Health and Clinical Excellence guidelines (NICE), providing women the right to request a caesarean, it is essential to establish whether mode of delivery has an association with subsequent risk of stillbirth or miscarriage. Overall, compared to vaginal delivery, the pooled estimates suggest that caesarean delivery may increase the risk of stillbirth by 23%. Results for the miscarriage review were inconsistent and lack of adjustment for confounding was a major limitation. Higher methodological quality research is required to reliably assess the risk of miscarriage in subsequent pregnancies.

Objectives: To characterize longitudinal patterns of musculoskeletal pain in a community sample of older adults over a 6-year period and to identify factors associated with persistence of pain., Design: Secondary analysis of the Cardiovascular Health Study., Setting: Community-based cohort drawn from four U.S. counties., Participants: Five thousand ninety-three men and women aged 65 and older., Measurements: Over a 6-year period, pain was assessed each year using a single question about the presence of pain in any bones or joints during the last year. If affirmative, participants were queried about pain in seven locations (hands, shoulders, neck, back, hips, knees, feet). Participants were categorized according to the percentage of time that pain was present and according to the intermittent or chronic pattern of pain. Factors associated with persistent pain during five remaining years of the study were identified., Results: Over 6 years, 32% of participants reported pain for three or more consecutive years, and 32% reported pain intermittently. Of those who reported pain the first year, 54% were pain free at least once during the follow-up period. Most of the pain at specific body locations was intermittent. Factors associated with remission of pain over 5 years included older age, male sex, better self-rated health, not being obese, taking fewer medications, and having fewer depressive symptoms. Approximately half of those with pain reported fewer pain locations the following year., Conclusion: Musculoskeletal pain in older adults, despite high prevalence, is often intermittent. The findings refute the notion that pain is an inevitable, unremitting, or progressive consequence of aging., (© 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.)

Background: A ban on smoking in the workplace was introduced in Ireland on March 29, 2004. As exposure to secondhand smoke has been implicated in the development of coronary disease, this might impact the incidence of acute coronary syndromes (ACS)., Hypothesis: The smoking ban was associated with a decreased rate of hospital admissions for ACS., Methods: We analyzed data collected in a registry of all patients admitted to hospital with ACS in the southwest of Ireland, catchment population 620 525, from March 2003 until March 2007., Results: In the year following implementation of the ban, there was a significant 12% reduction in ACS admissions (177.9 vs 205.9/100,000; 95% confidence interval [CI]: 164.0-185.1, P = 0.002). This reduction was due to fewer events occurring among men (281.5 vs 233.5, P = 0.0011) and current smokers (408 vs 302 admissions, P < 0.0001). There was no change in the rate of admissions for ACS in the following year (174.3/100,000; 95% CI: 164.0-185.1, P > 0.1). However, a further 13% reduction was observed between March 2006 and March 2007 (149.2; 95% CI: 139.7-159.2). Variation in admissions with time as a continuous variable also demonstrated a reduction on implementation of the smoking ban., Conclusions: A national ban on smoking in public places was associated with an early significant decrease in hospital admissions for ACS, suggesting a rapid effect of banning smoking in public places on ACS. A further reduction of similar magnitude 2 years after implementation of the ban is consistent with a longer-term effect that should be further examined in long-term studies., (© 2012 Wiley Periodicals, Inc.)

Background: Statin therapy reduces the risk of occlusive vascular events, but uncertainty remains about potential effects on cancer. We sought to provide a detailed assessment of any effects on cancer of lowering LDL cholesterol (LDL-C) with a statin using individual patient records from 175,000 patients in 27 large-scale statin trials., Methods and Findings: Individual records of 134,537 participants in 22 randomised trials of statin versus control (median duration 4.8 years) and 39,612 participants in 5 trials of more intensive versus less intensive statin therapy (median duration 5.1 years) were obtained. Reducing LDL-C with a statin for about 5 years had no effect on newly diagnosed cancer or on death from such cancers in either the trials of statin versus control (cancer incidence: 3755 [1.4% per year [py]] versus 3738 [1.4% py], RR 1.00 [95% CI 0.96-1.05]; cancer mortality: 1365 [0.5% py] versus 1358 [0.5% py], RR 1.00 [95% CI 0.93-1.08]) or in the trials of more versus less statin (cancer incidence: 1466 [1.6% py] vs 1472 [1.6% py], RR 1.00 [95% CI 0.93-1.07]; cancer mortality: 447 [0.5% py] versus 481 [0.5% py], RR 0.93 [95% CI 0.82-1.06]). Moreover, there was no evidence of any effect of reducing LDL-C with statin therapy on cancer incidence or mortality at any of 23 individual categories of sites, with increasing years of treatment, for any individual statin, or in any given subgroup. In particular, among individuals with low baseline LDL-C (<2 mmol/L), there was no evidence that further LDL-C reduction (from about 1.7 to 1.3 mmol/L) increased cancer risk (381 [1.6% py] versus 408 [1.7% py]; RR 0.92 [99% CI 0.76-1.10])., Conclusions: In 27 randomised trials, a median of five years of statin therapy had no effect on the incidence of, or mortality from, any type of cancer (or the aggregate of all cancer).

Background: Parental obesity is a predominant risk factor for childhood obesity. Family factors including socio-economic status (SES) play a role in determining parent weight. It is essential to unpick how shared family factors impact on child weight. This study aims to investigate the association between measured parent weight status, familial socio-economic factors and the risk of childhood obesity at age 9., Methodology/principal Findings: Cross sectional analysis of the first wave (2008) of the Growing Up in Ireland (GUI) study. GUI is a nationally representative study of 9-year-old children (N = 8,568). Schools were selected from the national total (response rate 82%) and age eligible children (response rate 57%) were invited to participate. Children and their parents had height and weight measurements taken using standard methods. Data were reweighted to account for the sampling design. Childhood overweight and obesity prevalence were calculated using International Obesity Taskforce definitions. Multinomial logistic regression examined the association between parent weight status, indicators of SES and child weight. Overall, 25% of children were either overweight (19.3%) or obese (6.6%). Parental obesity was a significant predictor of child obesity. Of children with normal weight parents, 14.4% were overweight or obese whereas 46.2% of children with obese parents were overweight or obese. Maternal education and household class were more consistently associated with a child being in a higher body mass index category than household income. Adjusted regression indicated that female gender, one parent family type, lower maternal education, lower household class and a heavier parent weight status significantly increased the odds of childhood obesity., Conclusions/significance: Parental weight appears to be the most influential factor driving the childhood obesity epidemic in Ireland and is an independent predictor of child obesity across SES groups. Due to the high prevalence of obesity in parents and children, population based interventions are required.

Background: Most cardiovascular disease (CVD) occurs in the presence of traditional risk factors, including hypertension and dyslipidemia, and these in turn are influenced by behavioural factors such as diet and lifestyle. Previous research has identified a group at low risk of CVD based on a cluster of inter-related factors: body mass index (BMI) < 25 Kg/m2, moderate exercise, alcohol intake, non-smoking and a favourable dietary pattern. The objective of this study was to determine whether these factors are associated with a reduced prevalence of hypertension and dyslipidemia in an Irish adult population., Methods: The study was a cross-sectional survey of 1018 men and women sampled from 17 general practices. Participants completed health, lifestyle and food frequency questionnaires and provided fasting blood samples for analysis of glucose and insulin. We defined a low risk group based on the following protective factors: BMI <25 kg/m2; waist-hip ratio (WHR) <0.85 for women and <0.90 for men; never smoking status; participants with medium to high levels of physical activity; light alcohol consumption (3.5-7 units of alcohol/week) and a "prudent" diet. Dietary patterns were assessed by cluster analysis., Results: We found strong significant inverse associations between the number of protective factors and systolic blood pressure, diastolic blood pressure and dyslipidemia. The prevalence odds ratio of hypertension in persons with 1, 2, 3, > or = 4 protective factors relative to those with none, were 1.0, 0.76, 0.68 and 0.34 (trend p < 0.01). The prevalence odds ratio of dyslipidemia in persons with 1, 2, 3, > or = 4 protective factors relative to those with none were 0.83, 0.98, 0.49 and 0.24 (trend p = 0.001)., Conclusion: Our findings of a strong inverse association between low risk behaviours and two of the traditional risk factors for CVD highlight the importance of 'the causes of the causes' and the potential for behaviour modification in CVD prevention at a population level.

Purpose of Review: To summarize recent and ongoing randomized trials of statin therapy for the prevention of major vascular events., Recent Findings: Four large-scale randomized trials have compared high-dose vs. standard doses of statin therapy among patients with coronary heart disease, and their results suggest that higher doses are more effective for preventing major vascular events, albeit with evidence of increased toxicity. There is now clear evidence that statin therapy is effective among most patients with type 2 diabetes, although uncertainty remains about the benefits in those with advanced nephropathy. Ongoing trials will assess whether statin therapy is beneficial among patients with noncoronary vascular disease (such as congestive heart failure, cerebrovascular disease, or aortic stenosis), and among people with comorbid conditions or risk factors that increase the risk of vascular disease (including chronic kidney disease and raised C-reactive protein with below average low-density lipoprotein cholesterol)., Summary: Statin therapy safely reduces the risk of vascular events in a wide range of patients. Uncertainties persist about the effects of higher statin doses and the role of statins among patients with specific conditions or risk factors.

Objective: To assess the effects of selective cyclo-oxygenase-2 (COX 2) inhibitors and traditional non-steroidal anti-inflammatory drugs (NSAIDs) on the risk of vascular events., Design: Meta-analysis of published and unpublished tabular data from randomised trials, with indirect estimation of the effects of traditional NSAIDs., Data Sources: Medline and Embase (January 1966 to April 2005); Food and Drug Administration records; and data on file from Novartis, Pfizer, and Merck., Review Methods: Eligible studies were randomised trials that included a comparison of a selective COX 2 inhibitor versus placebo or a selective COX 2 inhibitor versus a traditional NSAID, of at least four weeks' duration, with information on serious vascular events (defined as myocardial infarction, stroke, or vascular death). Individual investigators and manufacturers provided information on the number of patients randomised, numbers of vascular events, and the person time of follow-up for each randomised group., Results: In placebo comparisons, allocation to a selective COX 2 inhibitor was associated with a 42% relative increase in the incidence of serious vascular events (1.2%/year v 0.9%/year; rate ratio 1.42, 95% confidence interval 1.13 to 1.78; P = 0.003), with no significant heterogeneity among the different selective COX 2 inhibitors. This was chiefly attributable to an increased risk of myocardial infarction (0.6%/year v 0.3%/year; 1.86, 1.33 to 2.59; P = 0.0003), with little apparent difference in other vascular outcomes. Among trials of at least one year's duration (mean 2.7 years), the rate ratio for vascular events was 1.45 (1.12 to 1.89; P = 0.005). Overall, the incidence of serious vascular events was similar between a selective COX 2 inhibitor and any traditional NSAID (1.0%/year v 0.9%/year; 1.16, 0.97 to 1.38; P = 0.1). However, statistical heterogeneity (P = 0.001) was found between trials of a selective COX 2 inhibitor versus naproxen (1.57, 1.21 to 2.03) and of a selective COX 2 inhibitor versus non-naproxen NSAIDs (0.88, 0.69 to 1.12). The summary rate ratio for vascular events, compared with placebo, was 0.92 (0.67 to 1.26) for naproxen, 1.51 (0.96 to 2.37) for ibuprofen, and 1.63 (1.12 to 2.37) for diclofenac., Conclusions: Selective COX 2 inhibitors are associated with a moderate increase in the risk of vascular events, as are high dose regimens of ibuprofen and diclofenac, but high dose naproxen is not associated with such an excess.

Background: Results of previous randomised trials have shown that interventions that lower LDL cholesterol concentrations can significantly reduce the incidence of coronary heart disease (CHD) and other major vascular events in a wide range of individuals. But each separate trial has limited power to assess particular outcomes or particular categories of participant., Methods: A prospective meta-analysis of data from 90,056 individuals in 14 randomised trials of statins was done. Weighted estimates were obtained of effects on different clinical outcomes per 1.0 mmol/L reduction in LDL cholesterol., Findings: During a mean of 5 years, there were 8186 deaths, 14,348 individuals had major vascular events, and 5103 developed cancer. Mean LDL cholesterol differences at 1 year ranged from 0.35 mmol/L to 1.77 mmol/L (mean 1.09) in these trials. There was a 12% proportional reduction in all-cause mortality per mmol/L reduction in LDL cholesterol (rate ratio [RR] 0.88, 95% CI 0.84-0.91; p<0.0001). This reflected a 19% reduction in coronary mortality (0.81, 0.76-0.85; p<0.0001), and non-significant reductions in non-coronary vascular mortality (0.93, 0.83-1.03; p=0.2) and non-vascular mortality (0.95, 0.90-1.01; p=0.1). There were corresponding reductions in myocardial infarction or coronary death (0.77, 0.74-0.80; p<0.0001), in the need for coronary revascularisation (0.76, 0.73-0.80; p<0.0001), in fatal or non-fatal stroke (0.83, 0.78-0.88; p<0.0001), and, combining these, of 21% in any such major vascular event (0.79, 0.77-0.81; p<0.0001). The proportional reduction in major vascular events differed significantly (p<0.0001) according to the absolute reduction in LDL cholesterol achieved, but not otherwise. These benefits were significant within the first year, but were greater in subsequent years. Taking all years together, the overall reduction of about one fifth per mmol/L LDL cholesterol reduction translated into 48 (95% CI 39-57) fewer participants having major vascular events per 1000 among those with pre-existing CHD at baseline, compared with 25 (19-31) per 1000 among participants with no such history. There was no evidence that statins increased the incidence of cancer overall (1.00, 0.95-1.06; p=0.9) or at any particular site., Interpretation: Statin therapy can safely reduce the 5-year incidence of major coronary events, coronary revascularisation, and stroke by about one fifth per mmol/L reduction in LDL cholesterol, largely irrespective of the initial lipid profile or other presenting characteristics. The absolute benefit relates chiefly to an individual's absolute risk of such events and to the absolute reduction in LDL cholesterol achieved. These findings reinforce the need to consider prolonged statin treatment with substantial LDL cholesterol reductions in all patients at high risk of any type of major vascular event.

Objective: To examine the association between chronic infection and cumulative burden of infection and acute coronary syndrome., Design: The 5C (Cork coronary care case-control) study was a community based case-control study. Patients and controls underwent a standard physical examination and had blood samples taken for serological analysis for Helicobacter pylori (IgG), Chlamydia pneumoniae (IgA, IgM, and IgG), cytomegalovirus (IgG), and herpes simplex virus types 1 and 2 (IgG)., Setting: Patients were recruited from four hospitals in Cork City and Mallow Town. Controls, individually matched on age and sex, were selected by incident density sampling from the same general practices as the referent case., Main Outcome Measures: Age and sex adjusted and fully adjusted odds ratios for acute coronary syndrome by seropositivity and by increasing number of infections., Results: Cases and controls did not differ significantly in seropositivity to C pneumoniae, cytomegalovirus, herpes simplex viruses, and H pylori. In unconditional logistic regression analysis adjusted for age, sex, waist to hip ratio, smoking, physical activity, alcohol consumption, and social class there was no evidence of an increasing risk for acute coronary syndrome with increasing burden of infection., Conclusions: The findings do not support an association between specific infectious agents and acute coronary syndrome and do not provide evidence of a burden of infection effect.

Purpose: To examine the prevalence and the level of awareness, treatment and control of hypertension in different world regions., Study Selection: A literature search of the MEDLINE database, using the Medical Subject Headings prevalence, hypertension, blood pressure and cross-sectional studies, was conducted. Published studies, which reported the prevalence of hypertension and were conducted in representative population samples, were included in the review. The search was restricted to studies published from January 1980 through July 2003., Data Extraction: All data were extracted independently by two investigators using a standardized protocol and data collection form., Results: The reported prevalence of hypertension varied around the world, with the lowest prevalence in rural India (3.4% in men and 6.8% in women) and the highest prevalence in Poland (68.9% in men and 72.5% in women). Awareness of hypertension was reported for 46% of the studies and varied from 25.2% in Korea to 75% in Barbados; treatment varied from 10.7% in Mexico to 66% in Barbados and control (blood pressure < 140/90 mmHg while on antihypertensive medication) varied from 5.4% in Korea to 58% in Barbados., Conclusion: Hypertension is an important public health challenge in both economically developing and developed countries. Significant numbers of individuals with hypertension are unaware of their condition and, among those with diagnosed hypertension, treatment is frequently inadequate. Measures are required at a population level to prevent the development of hypertension and to improve awareness, treatment and control of hypertension in the community.

Aim: The aim of this study was to introduce a protocol for the use of antimicrobials in surgical prophylaxis for the described procedures in Antrim Area Hospital., Method: Historical data of antimicrobial use were obtained from retrospective analysis of patients' charts, for those patients identified as having one of the following 'clean/contaminated' surgical procedures over the previous six months; cholecystectomy or abdominal hysterectomy. These data were analysed, and a protocol was introduced providing guidelines for the choice of antimicrobial agent, its administration time, route, dose, duration and frequency of treatment., Main Outcome Measure: The main outcome measure was the success of the uptake of the protocol following its implementation., Results: There was a total of 285 patients identified, 105 prior to and 180 post implementation. Overall, 68% of patients received some form of prophylaxis in the first cycle, and 72% in the second., Conclusion: Although the introduction of the protocol led to slight improvements in compliance with standard prescribing procedures, with an increase in single-dose prophylaxis, and a reduction in prolonged prophylactic treatment, the improvements did not reach expectations. This paper attempts to identify the possible barriers to protocol implementation.

This study compared the prevalence of asthma in travelling schoolboys and settled controls to determine whether the travelling lifestyle may be a protective factor in the development of asthma. Information was collected by parental responses to the ISAAC (International Study of Asthma and Allergies in Childhood) questionnaire. The design was a cross-sectional study with descriptive and analytical components. The subjects were six to twelve year old schoolboys from all male travelling children in Cork and from a selection of settled schoolboys. In addition the study collected information on the predictor variables--age, passive smoking and number of siblings. The questionnaire was administered to 54 travelling boys and 129 controls. The parent reported prevalence of wheeze and related symptoms were all more common in controls compared with the travelling boys. The values were significant for wheeze in the last year (31.3% v 14.8%; OR-5.6, p = 0.025), and for doctor diagnosed asthma (25.6% v 11.1%; OR = 5.1, p = 0.04). Schoolboys from travelling families have less wheeze and doctor diagnosed asthma than controls. The experience of the travelling lifestyle maybe a protective factor in the development of asthma.