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Biomedical subjects

F Kee

Publications and source records attributed to F Kee.

At least 55 records · Page 3Linked to original sources
PubMed1995

Expanding access to coronary artery bypass surgery: who stands to gain?

OBJECTIVE: To determine the perceptions of general practitioners (GPs) about the benefits of coronary artery bypass surgery, in terms of gains in life expectancy, for different groups of patients. DESIGN: A questionnaire survey of all GPs in Northern Ireland. SETTING: A survey conducted collaboratively by the departments of public health medicine in each of the four health boards in the province, serving a total population of 1.5 million. MAIN OUTCOME MEASURES: The median and mean gain in life expectancy perceived by groups of doctors for smoking and non-smoking male and female 55 year old patients. The percentage of 50 year old and 70 year old non-smoking patients considered likely to have their lives extended with bypass surgery. Differences were assessed using the Mann-Whitney U test for unpaired samples and the Wilcoxon signed rank tests for paired. RESULTS: 541 GPs replied (response rate 56%). The median (and mean) perceived gain in life expectancy after cardiac surgery for non-smoking 55 year old subjects was 120 (104) months for men and 120 (112) months for women (z = 6.42; P < 0.0001; Wilcoxon signed rank test). For male and female smokers of the same age, the perceived gains were 48 (47) and 60 (52) months respectively (z = 6.72; P < 0.0001; Wilcoxon signed ranks test), both figures being significantly different than for non-smokers. The median (and mean) percentage of patients that the doctors considered would have their lives extended by bypass surgery was 70 (64) of every 100 "young" patients and 40 (42) of every 100 "old" patients, (z = 16.2; P < 0.0001). CONCLUSIONS: These results point to a significant overestimation of the benefits of coronary artery bypass surgery by GPs in Northern Ireland and to a need to develop guidelines for referral.

Age Factors↗
PubMed1995

Are the economically active more deserving?

OBJECTIVE: To investigate the possibility of an association between the duration of medical treatment before coronary angiography and demographic and non-clinical factors. DESIGN: A systematic review of a random sample of 500 patients undergoing their first angiographic assessment. SUBJECTS: 500 cases were selected randomly from patients investigated in 1991 at the two catheterisation centres in Northern Ireland. MAIN OUTCOME MEASURES: The duration of medical management before angiography. RESULTS: 346 had elective and 154 urgent catheterisation. The duration of medical management was adjusted for both case mix (age at onset, body mass index, angina grade, history of myocardial infarction, history of hypertension, diabetes or hyperlipidaemia, treatment intensity) and other demographic variables (sex, smoking status, an indicator of "deprivation", and distance of the patient's area of residence from the hospital). After this adjustment the mean duration of medical management before angiography was twice as long for economically inactive patients as for those who were economically active. In a multiple regression, the relevant beta coefficient was 0.44 (95% confidence interval 0.33 to 0.58, P < 0.0001). CONCLUSIONS: These results suggest that, in making discretionary decisions about when to refer patients with angina for revascularisation assessment, doctors may be influenced by non-clinical factors unrelated to disease severity.

Age Factors↗
PubMed1995

Predictors for waiting time for coronary angioplasty in a high risk population.

Objective--To describe the clinical and non-clinical factors which influence the waiting time from initial angiography to angioplasty. Design--Follow up of a random sample of 106 patients undergoing their first coronary angiography for whom a decision to revascularise by percutaneous transluminal angioplasty was made in 1991. The period between the date of angiography and the date of angioplasty and various clinical characteristics of patients were retrieved from medical notes in mid 1993. Patients were sampled from those investigated in the two Northern Ireland catheterisation laboratories in Belfast, which provide services for the whole of the province (population 1.5 million). Main measures--The dependent variable was the period between initial angiography and angioplasty, and the independent variables included age, sex, distance from cardiac catheterisation centre, referral source, characteristics of the clinical history, severity of angina, and anatomical extent of disease. Cox's proportional hazards analysis was used to derive a relative hazard, expressing the relative chances of revascularisation occurring at any time during follow up. Results--Of the 106 patients studied, 93 had had percutaneous transluminal angioplasty at follow up. The most important predictors of waiting time were the presence of severe angina (relative hazards 3.1(95 % confidence interval (95% CI) 1.4-6.8) and 2.7(1.2-6.2) for Canadian Cardiovascular grades III and IV v angina grade I angina), a recent history of myocardial infarction (relative hazard, 2.5(1.3-4.8), and whether or not the patient was economically active (relative hazard 0.6(0.4-1.0) for economically inactive v active patients). Although there was also an association with the relative deprivation of the area of residence of the patient it had no clear linear trend. Conclusions--Although waiting time for percutaneous transluminal angioplasty was predictably related to the patient's clinical presentation, demographic factors may also be important in determining access to intervention. These factors clearly merit further study; ultimately, the evaluation of equity in a waiting time distribution may more properly be a societal rather than a clinical judgment.

Angioplasty, Balloon, Coronary↗
PubMed1995

The effect of diet on lipid, apoprotein and lipoparticle variation in the ECTIM study in Belfast.

The objective of the study was to evaluate the contribution of dietary factors to variation of plasma levels of lipids, apoproteins and lipoparticles in the Northern Ireland population. This study was part of a larger case-control study of the genetic and environmental determinants of myocardial infarction in France and Northern Ireland. A random sample of 175 middle aged men was drawn from the population covered by the Belfast MONICA project register. Habitual diet was assessed by a questionnaire. A blood sample was obtained after an over-night fast for determination of plasma levels of lipids, apoproteins and lipoparticles. All participants had a medical examination and completed a lifestyle questionnaire. In a stepwise regression, after adjusting for co-factors (i) vitamin C and (ii) alcohol consumption were the only nutrients which contributed significantly to the variation in, respectively, (i) Total Cholesterol, LDL Cholesterol and Apolipoprotein B (inverse correlation) and (ii) HDL Cholesterol and LpAI (positive correlation). The amount of variation explained by the final models was modest, ranging from 4% to 15%. In conclusion, in this Northern Ireland population, habitual diet contributes to little of the variation in plasma levels of lipids, apoproteins and lipoparticles.

Adult↗
PubMed1995

Priority for coronary artery surgery: who gets by-passed when demand outstrips capacity?

We investigated the clinical and non-clinical factors which influence the waiting time from initial angiography to bypass surgery, by follow-up of a random sample of 141 patients undergoing their first coronary angiography, for whom a decision to revascularize was made in 1991. The period between the date of angiography and the date of surgery, and a variety of clinical patient characteristics, were retrieved from medical notes in mid-1993. Patients were sampled from those investigated in the two Northern Ireland catheterization laboratories in Belfast, both of which were served by one local surgical centre. Of the 141 patients studied, 86 had had surgery at follow-up. The most important predictors of waiting time were: the presence of severe stenosis of the left main-stem coronary artery [relative hazards, 3.4 (1.6-7.3)], the presence of unstable angina at the time of angiography, [relative hazards, 2.2 (0.97-5.0)], age at angiography, [relative hazards, 2.2 (1.1-4.2) for > 65 years vs. < 50 years], having a positive family history of premature coronary artery disease in a first-degree relative, [relative hazards, 1.8 (1.1-2.9)] and smoking habit at angiography, [relative hazards 0.6 (0.3-1.1), for current vs. never/ex-smokers]. More weight appears to be given to maximizing life extension rather than its quality enhancement in determining who gets priority for surgery. The exception to this may be in regard to smokers, and purchasers might find it useful to set targets for secondary prevention activities with respect to such patients.

Age Factors↗
PubMed1994

Synergistic effects of angiotensin-converting enzyme and angiotensin-II type 1 receptor gene polymorphisms on risk of myocardial infarction.

We reported from our previous multicentre case-control study that the deletion (D) polymorphism of the gene encoding angiotensin-converting enzyme (ACE) was associated with increased risk of myocardial infarction. The main function of ACE is to convert angiotensin I into angiotensin II, which exerts its known cellular actions through the angiotensin II AT1 receptor subtype (AGT1R). We have now investigated the role of a common polymorphism of the AT1 receptor gene (an A-->C transversion at position 1166 of AGT1R) and looked for an interaction between ACE and AGT1R gene polymorphisms on the risk of myocardial infarction. We analysed DNA from 613 patients with myocardial infarction and 723 age-matched population controls. We found a significant interaction between ACE and AGT1R gene polymorphisms; the odds ratio for myocardial infarction associated with the ACE DD genotype was 1.05 (95% CI 0.75-1.49) for subjects without the AGT1R C allele, 1.52 (1.06-2.18) in AC heterozygotes, and 3.95 (1.26-12.4) in CC homozygotes (test for trend, p < 0.02). Among patients defined as low risk by traditional risk factors (serum apolipoprotein B < 1.25 g/L, body-mass index < 26 kg/m2) the interaction was even stronger (odds ratios 1.64 [0.68-3.92], 7.03 [2.61-19.0], and 13.3 [p = 0.05], respectively). These findings, if confirmed, could have clinical implications for the prevention and treatment of coronary heart disease.

Adult↗
PubMed1994

A community outbreak of echovirus infection associated with an outdoor swimming pool.

Forty-six people became ill with vomiting, diarrhoea and headache within days of an outdoor swimming pool opening for the summer season in a small seaside village. During the weekend of the outbreak, 185 tickets to the pool had been sold. It was found that 34 bathers were ill, and one subject had vomited into the pool. All other cases arose after this incident. The risk of infection was greatest among those who swallowed pool water (24/28 versus 10/17, p = 0.07). Echovirus 30 was isolated from the case who vomited into the pool and from six other cases. Normal chlorine levels had not been adequate to contain the infection risk from vomitus, and, in future, pool attendants witnessing such incidents should consider closing the pool to the public and seeking advice on superchlorination.

Adolescent↗
PubMed1994

Is choice of general practitioner important for patients having coronary artery investigations?

OBJECTIVE: To determine whether particular sociodemographic characteristics of patients with stable angina affected their general practitioners' (GPs') decisions to refer them for revascularisation assessment. DESIGN: Postal questionnaire survey. SETTING: Collaborative survey by the departments of public health medicine in each of the four health boards in Northern Ireland, serving a total population of 1.5 million. SUBJECTS: All (962) GPs. MAIN MEASURES: The relation between GPs' referral decisions and patients' age, sex, employment status, home circumstances, smoking habits, and obesity. RESULTS: 541 GPs replied (response rate 56%). Most were "neutral" towards a patient's sex (428, 79%), weight (331, 61%), smoking habit (302, 56%), employment status (431, 80%), and home circumstances (408, 75%) in making decisions about referral. In assigning priority for surgery most were neutral towards the patient's sex (459, 85%), employment status (378, 70%), and home circumstances (295, 55%). However, most GPs (518, 95%) said that younger patients were more likely to be referred, and a significant minority were less likely to refer patients who smoked (202, 37%) and obese patients (175, 32%) and more likely to refer employed patients (97, 18%) and those with dependents (117, 22%) (compared with patients with otherwise comparable clinical characteristics); these views paralleled the priority which GPs assigned these groups. The stated likelihood of referral of young patients was independent of the GPs' belief in ability to benefit from revascularisation, but propensity to refer and perception of benefit were significantly associated for all other patient characteristics. CONCLUSION: GPs' weighting of certain characteristics in reaching decisions about referral for angiography is not uniform and may contribute to unequal access to revascularisation services for certain patient groups.

Age Factors↗
PubMed1994

Polymorphisms of the angiotensin-converting-enzyme gene in subjects who die from coronary heart disease.

It has been shown that myocardial infarction survivors are more likely to carry an insertion/deletion polymorphism (I/D) of the angiotensin-converting-enzyme (ACE) gene than age-matched population controls. To test whether the association with coronary risk had been under-estimated, the frequency of the ACE I/D was studied in 213 fatal cases of definite and possible myocardial infarction which came to autopsy in the Belfast MONICA Project area. In comparison to controls from the same population, the autopsy cases had an increased frequency of the ACE D allele (p < 0.02). The overall odds ratios were 2.2 for DD vs. II, and 1.8 for ID vs II (test for trend p = 0.01). The findings bear out the hypothesis that the ACE I/D polymorphism is a risk factor for fatal myocardial infarction and sudden cardiac death.

Adult↗
PubMed1994

The role of the general practitioner hospital in inpatient care.

The rationale of the general practitioner hospital continues to be questioned. A study of the services and case-mix of two of the four remaining general practitioner hospitals in Northern Ireland was undertaken to determine whether the nature and cost of inpatient care in these hospitals was comparable to the available alternatives. The case-notes of all non-maternity admissions (n = 509) were reviewed. The two hospitals provide acute medical care for a wide range of patients. The majority of patients appeared to require hospitalisation. It is likely that the beds at the two hospitals were mainly a substitute for district general hospital care. The general practitioner hospitals were estimated to be less costly than alternative forms of care, although it was doubtful whether they fulfilled all the structural criteria of quality generally regarded as important for hospitals of this type.

Family Practice↗
PubMed1993

Reliability of reported family history of myocardial infarction.

OBJECTIVE: To assess the reliability of reported family histories of myocardial infarction. DESIGN: A case-control study in which reported histories of first degree relatives were validated from death certificates, general practitioners' records, and hospital notes. SETTING: Participants enrolled in the Belfast centre of the World Health Organisation's study monitoring trends and determinants in cardiovascular disease (MONICA). SUBJECTS: 200 men who survived myocardial infarction and 200 age matched controls drawn randomly from the population. MAIN OUTCOME MEASURES: The sensitivity, specificity, positive predictive value, and proportion of overall agreement with validated records of reported family histories of myocardial infarction in first degree relatives; odds ratios for myocardial infarction, given at least one reported relative or at least one verified relative being affected. RESULTS: 349 of the 400 probands provided detailed family histories, reporting on 2812 first degree relatives. The overall sensitivity, specificity, and positive predictive value of reported histories were 67.3%, 96.5%, and 70.5% for cases and 68.5%, 97.7%, and 73.8% for controls. The kappa coefficients were modest: 0.65 for cases and 0.68 for controls. The odds ratios for myocardial infarction, given at least one affected relative, were not substantially inflated by recall bias. Some recall bias was evident for the probands' reports of their siblings' histories of myocardial infarction, the odds ratio for a reported history being 1.67 (95% confidence interval 1.09 to 2.57) and for the validated history 1.54 (1.01 to 2.37). CONCLUSIONS: Although the relative risk of disease is correctly estimated, the predictive accuracy of a casual family history of myocardial infarction may limit the effectiveness of targeted screening programmes. They may, however, complement other strategies based on genetic testing.

Case-Control Studies↗
PubMed1993

Access to coronary catheterisation: fair shares for all?

OBJECTIVE: To determine the effects of patient's sex and area's material deprivation on utilisation rates of coronary catheterisation and angiography in the investigation of ischaemic heart disease. DESIGN: Retrospective analysis of routinely collected hospital statistics. SETTING: Acute hospitals throughout Northern Ireland. SUBJECTS: 24,179 episodes of patients discharged from hospital with a primary diagnosis of ischaemic heart disease and 1270 episodes relating to patients with an underlying diagnosis of ischaemic heart disease who had either coronary catheterisation or angiography. MAIN OUTCOME MEASURES: Age standardised admission rates for heart disease and age standardised utilisation rates for catheterisation or angiography, or both, for 566 electoral wards ranked by Townsend "deprivation" scores. RESULTS: Catheterisation-angiography rates in men were over fivefold those of women, ranging from 85.5/100,000 v 16/100,000 in patients from "well off" areas to 123/100,000 v 22/100,000 for patients from deprived areas. After admission rates for heart disease were controlled for, the overall rate ratio for women was 0.48 (95% confidence interval 0.38 to 0.60). After differential admission rates for heart disease and other potential clinical confounders were controlled for, the investigation rates of patients from the least and most "deprived" areas were not significantly different (rate ratio 1.04 (0.87 to 1.25)). CONCLUSION: Although investigation rates were significantly lower in women than in men, further clinical data would be required before labelling this underutilisation as evidence of bias. There was no significant difference in invasive investigation rates for heart disease in areas of varying deprivation or affluence.

Adult↗
PubMed1993

Deletion polymorphism in angiotensin-converting enzyme gene associated with parental history of myocardial infarction.

In a European study an insertion (I)/deletion (D) polymorphism in the angiotensin converting enzyme (ACE) gene has been shown to be associated with the risk of myocardial infarction (MI). In the same study, we investigated the association of the polymorphism with a parental history of fatal MI. There was an excess of both DD (odds ratio 2.6, p = 0.02) and ID (odds ratio = 1.9, p = 0.08) genotypes among those having a parental history of MI, confirming that genetic variation in the ACE locus could be involved in the risk of MI.

Adult↗
PubMed1993

Referrals for coronary angiography in a high risk population.

OBJECTIVES: To examine variations in referral for coronary angiography within Northern Ireland and relate these to local death rates from coronary artery disease (ICD rubrics 410-414). DESIGN: A descriptive retrospective analysis of aggregate hospital activity data for 1979-88 and corresponding mortality rates in the local population. SETTING: Two regional referral hospitals and 26 local district council areas. PATIENTS: 5173 patients aged 35-74 years with an underlying diagnosis of ischaemic heart disease, whose records contained complete information on their age, sex, and home address. MAIN MEASURES: Age-standardised angiography rates and corresponding standardised death rates derived from the registrar general's reports. RESULTS: Among the 26 constituent district council areas there was significant heterogeneity in the angiography rates, ranging from 62 to 335/100,000 in men and from 7 to 62/100,000 in women (likelihood ratio statistic 856 and 359 respectively). There was no significant association between these angiography rates and the local death rates from ischaemic heart disease. CONCLUSION: The results suggest a non-uniform threshold for referral for angiography. IMPLICATIONS: Clinicians need to examine the appropriate indications for referral for invasive investigation.

Adult↗
PubMed1993

Enhancing mammography uptake: who do women listen to?

Previous work has established that women who attend for mammography differ from non-attenders in a number of socio-demographic and attitudinal characteristics. The present study was conducted to determine whether women who attended for mammography differed from non-attenders in a number of key areas: (1) in how they obtained information about screening; (2) in their understanding of the disease and basic screening precepts; and (3) in the extent to which they perceived their general practitioners (GPs) and other members of the primary case team, such as practice nurses, had actively promoted the programme. Three hundred attenders and 300 non-attenders were interviewed in their own homes using a structured questionnaire. Only 5% of women interviewed had ever asked their GP for any advice about breast screening, and only 18% recalled their family doctor every discussing or raising the subject with them. Although attenders and non-attenders differed significantly in their understanding of the scope and purpose of screening, both groups obtained information more often from friends and relatives and broadcast media than from official sources. Attenders were more likely to cite material in the GP's surgery as an important source of information (chi 2 = 5.1, p = 0.02). Attenders were marginally more likely than non-attenders to have previously attended a well-woman clinic in primary care (chi 2 = 3.1, p = 0.08) and were more likely to say that such clinics were being offered by their family doctor (chi 2 = 9.8, p = 0.008).(ABSTRACT TRUNCATED AT 250 WORDS)

Attitude to Health↗
PubMed1993

Evaluating the breast screening programme: the need for surgical audit.

It is to be anticipated that a reduction in population mortality attributable to mammographic screening would be heralded by an increasing proportion of breast cancer cases diagnosed at earlier stages and by an improvement in case fatality. Few cancer registers routinely produce incidence or survival data by stage at diagnosis and thus improvement in these will be the harder to assess. By thorough casenote review and follow up, this study has determined the usual presentation and survival of breast cancer in Northern Ireland in 1986 before the introduction of screening. Overall, 85% of cases were Manchester stage I or II, figures which accord with other British studies. Five-year survival ranged from 77.8% for stage I (95% confidence limits 71.7%, 82.7%) to 35.7% for stage IV (95% confidence limits 13.0%, 59.4%). Forty-three per cent of cases treated in non-teaching hospitals could not be pathologically staged, more than twice the figure for teaching hospitals (Chi-squared = 15.7, df = 1, P < 0.001). Since many tumours not detected by screening will be treated outside teaching centres, this difference will reduce the statistical power to detect the true shift in stage distribution and improvement in survival from screening. Comprehensive surgical audit would help to resolve the inadequacies in existing data collection and improve the ability to evaluate the outcome of the screening programme.

Adult↗