AJ Lee

University of Aberdeen, Aberdeen, Scotland, United Kingdom

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Publications (95)669.35 Total impact

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    ABSTRACT: Objective/background Chronic venous disease (CVD) is common, but the incidence of venous reflux, a precursor to this condition, is unknown. This study measured the incidence of venous reflux and associated risk factors, and examined the association between venous reflux and the incidence of CVD. Methods In the Edinburgh Vein Study, a random sample of 1566 men and women aged 18–64 years were examined at baseline. Eight hundred and eighty of these patients were followed up 13 years and underwent an examination comprising clinical classification of CVD and duplex scanning of the deep and superficial systems to measure venous reflux ≥0.5 s. Results The 13-year incidence of reflux was 12.7% (95% confidence interval [CI] 9.2–17.2), equivalent to an annual incidence of 0.9% (95% CI 0.7–1.3). The 13-year incidence of isolated superficial, isolated deep, and combined deep and superficial reflux was 8.8% (95% CI 5.6–12.0), 2.6% (95% CI 1.2–5.0), and 1.3% (95% CI 0.4–3.2), respectively. The highest incidence was in the great saphenous vein in the lower thigh (8.1%, 95% CI 5.4–11.8). There were no age or sex differences (p > .050). The risk of developing reflux was associated with being overweight (odds ratio [OR] 2.1, 95% CI 1.0–4.4) and with history of deep vein thrombosis (OR 11.3, 95% CI 1.0–132.3). Venous reflux at baseline was associated with new varicose veins at follow up (p < .001): the age- and sex-adjusted OR was 4.4 (95% CI 1.8–10.8) in those with isolated superficial reflux and 7.3 (95% CI 2.6–22.5) in those with combined deep and superficial reflux. Conclusion For every year of follow-up, around 1% of this adult population developed venous reflux. In two thirds of cases, the superficial system was affected. Venous reflux increased the risk of developing varicose veins, especially when combined deep and superficial reflux was present.
    Journal of Vascular Surgery 08/2014; 48(2). DOI:10.1016/j.ejvs.2014.05.017 · 2.98 Impact Factor
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    ABSTRACT: Individual participant time-to-event data from multiple prospective epidemiologic studies enable detailed investigation into the predictive ability of risk models. Here we address the challenges in appropriately combining such information across studies. Methods are exemplified by analyses of log C-reactive protein and conventional risk factors for coronary heart disease in the Emerging Risk Factors Collaboration, a collation of individual data from multiple prospective studies with an average follow-up duration of 9.8 years (dates varied). We derive risk prediction models using Cox proportional hazards regression analysis stratified by study and obtain estimates of risk discrimination, Harrell's concordance index, and Royston's discrimination measure within each study; we then combine the estimates across studies using a weighted meta-analysis. Various weighting approaches are compared and lead us to recommend using the number of events in each study. We also discuss the calculation of measures of reclassification for multiple studies. We further show that comparison of differences in predictive ability across subgroups should be based only on within-study information and that combining measures of risk discrimination from case-control studies and prospective studies is problematic. The concordance index and discrimination measure gave qualitatively similar results throughout. While the concordance index was very heterogeneous between studies, principally because of differing age ranges, the increments in the concordance index from adding log C-reactive protein to conventional risk factors were more homogeneous.
    American Journal of Epidemiology 03/2014; 179(5):621-632. DOI:10.1093/aje/kwt298 · 4.98 Impact Factor
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    International Journal of Epidemiology 10/2012; 41(5):1419-1433. DOI:10.1093/ije/dys086 · 9.20 Impact Factor
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    ABSTRACT: OBJECTIVE: The purpose of this study was to correlate the clinical findings in the Edinburgh Vein Study with the results of duplex scanning of the deep and superficial venous systems. METHODS: An age-stratified random sample of 1566 people (699 men and 867 women) aged 16-64 were selected from computerized age-sex registers of participating practices (twelve general practices with catchment areas geographically and socioeconomically distributed throughout Edinburgh). Screening included clinical examination, photography and duplex ultrasonography of the superficial veins and the deep veins down to popliteal level. Telangiectasia and varicose veins were graded 1-3 according to severity. RESULTS: Since there was good agreement between the duplex findings of the right versus left legs, the current analyses are based on 1092 subjects (486 men and 606 women) with complete duplex scan data in their left legs. There was no significant trend of increasing incompetence in either the deep veins only (P = 0.214) or in the combined deep and superficial veins (P = 0.111) with increasing severity of the telangiectasia. There was a statistically significant trend for increasing incompetence in (a) the superficial veins (P = 0.006) and (b) either the superficial or deep veins (P < 0.001) to be associated with advancing grade of telangiectasia. When stratified by gender, significant trends were maintained for male superficial vein incompetence and for either superficial or deep incompetence in both genders. Examination of incompetence in individual venous segments showed that increasing severity of telangiectasia was significantly associated with an increasing proportion of reflux in the upper and lower great saphenous and femoral vein segments. There was no significant association between small saphenous incompetence and increasing grade of telangiectasia. CONCLUSION: There is a significant, but not wholly consistent, association between grade of telangiectasia and reflux in both the deep and superficial systems. This association does not apply to the small saphenous system.
    Phlebology 11/2011; 27(6). DOI:10.1258/phleb.2011.011007 · 1.92 Impact Factor
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    ABSTRACT: To compare ultrasound gradings of steatosis with fat fraction (FF) on magnetic resonance spectroscopy (MRS; the non-invasive reference standard for quantification of hepatic steatosis), and evaluate inter- and intraobserver variability in the ultrasound gradings. Triple grading of hepatic ultrasound examination was performed by three independent graders on 131 people with type 2 diabetes. The stored images of 60 of these individuals were assessed twice by each grader on separate occasions. Fifty-eight patients were pre-selected on the basis of ultrasound grading (normal, indeterminate/mild steatosis, or severe steatosis) to undergo (1)H-MRS. The sensitivity and specificity of the ultrasound gradings were determined with reference to MRS data, using two cut-offs of FF to define steatosis, ≥9% and ≥6.1%. Median (intraquartile range) MRS FF (%) in the participants graded on ultrasound as normal, indeterminate/mild steatosis, and severe steatosis were 4.2 (1.2-5.7), 4.1 (3.1-8.5) and 19.4 (12.9-27.5), respectively. Using a liver FF of ≥6.1% on MRS to denote hepatic steatosis, the unadjusted sensitivity and specificity of ultrasound gradings (severe versus other grades of steatosis) were 71 and 100%, respectively. Interobserver agreement within one grade was observed in 79% of cases. Exact intraobserver agreement ranged from 62 to 87%. Hepatic ultrasound provided a good measure of the presence of significant hepatic steatosis with good intra- and interobserver agreement. The grading of a mildly steatotic liver was less secure and, in particular, there was considerable overlap in hepatic FF with those who had a normal liver on ultrasound.
    Clinical Radiology 02/2011; 66(5):434-9. DOI:10.1016/j.crad.2010.09.021 · 1.66 Impact Factor
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    Journal of Vascular Surgery 01/2011; 53(1):254-254. DOI:10.1016/j.jvs.2010.11.011 · 2.98 Impact Factor
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    ABSTRACT: Whether triglyceride-mediated pathways are causally relevant to coronary heart disease is uncertain. We studied a genetic variant that regulates triglyceride concentration to help judge likelihood of causality. We assessed the -1131T>C (rs662799) promoter polymorphism of the apolipoprotein A5 (APOA5) gene in relation to triglyceride concentration, several other risk factors, and risk of coronary heart disease. We compared disease risk for genetically-raised triglyceride concentration (20,842 patients with coronary heart disease, 35,206 controls) with that recorded for equivalent differences in circulating triglyceride concentration in prospective studies (302 430 participants with no history of cardiovascular disease; 12,785 incident cases of coronary heart disease during 2.79 million person-years at risk). We analysed -1131T>C in 1795 people without a history of cardiovascular disease who had information about lipoprotein concentration and diameter obtained by nuclear magnetic resonance spectroscopy. The minor allele frequency of -1131T>C was 8% (95% CI 7-9). -1131T>C was not significantly associated with several non-lipid risk factors or LDL cholesterol, and it was modestly associated with lower HDL cholesterol (mean difference per C allele 3.5% [95% CI 2.6-4.6]; 0.053 mmol/L [0.039-0.068]), lower apolipoprotein AI (1.3% [0.3-2.3]; 0.023 g/L [0.005-0.041]), and higher apolipoprotein B (3.2% [1.3-5.1]; 0.027 g/L [0.011-0.043]). By contrast, for every C allele inherited, mean triglyceride concentration was 16.0% (95% CI 12.9-18.7), or 0.25 mmol/L (0.20-0.29), higher (p=4.4x10(-24)). The odds ratio for coronary heart disease was 1.18 (95% CI 1.11-1.26; p=2.6x10(-7)) per C allele, which was concordant with the hazard ratio of 1.10 (95% CI 1.08-1.12) per 16% higher triglyceride concentration recorded in prospective studies. -1131T>C was significantly associated with higher VLDL particle concentration (mean difference per C allele 12.2 nmol/L [95% CI 7.7-16.7]; p=9.3x10(-8)) and smaller HDL particle size (0.14 nm [0.08-0.20]; p=7.0x10(-5)), factors that could mediate the effects of triglyceride. These data are consistent with a causal association between triglyceride-mediated pathways and coronary heart disease. British Heart Foundation, UK Medical Research Council, Novartis.
    The Lancet 05/2010; 375(9726):1634-9. DOI:10.1016/S0140-6736(10)60545-4 · 45.22 Impact Factor
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    ABSTRACT: Aims/hypothesisThe aim of the study was to identify risk factors for depression and anxiety in a well-characterised cohort of individuals with type 2 diabetes mellitus. MethodsWe used baseline data from participants (n = 1,066, 48.7% women, aged 67.9 ± 4.2years) from the Edinburgh Type 2 Diabetes Study. Symptoms of anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS). Obesity was characterised according to both overall (body mass index, fat mass) and abdominal (waist circumference) measurements. Cardiovascular disease was assessed by questionnaire, physical examination and review of medical records. Stepwise multiple linear regression was performed to identify explanatory variables related to either anxiety or depression HADS scores. ResultsAbdominal obesity (waist circumference) and cardiovascular disease (ischaemic heart disease and ankle–brachial pressure index) were related to depression but not anxiety. Lifetime history of severe hypoglycaemia was associated with anxiety. Other cardiovascular risk factors or microvascular complications were not related to either anxiety or depressive symptoms. Conclusions/interpretationDepression but not anxiety is associated with abdominal obesity and cardiovascular disease in people with type 2 diabetes mellitus. This knowledge may help to identify depressive symptoms among patients with type 2 diabetes who are at greatest risk.
    Diabetologia 03/2010; 53(3):467-471. DOI:10.1007/s00125-009-1628-9 · 6.88 Impact Factor
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    ABSTRACT: Aims: This study compares the outcome of three different techniques of antireflux surgery, carried out at three regional specialist units.Methods: Patients undergoing open Nissen fundoplication (Newcastle (ON), n = 76), laparoscopic Nissen fundoplication (Edinburgh (LN), n = 119), and laparoscopic Watson fundoplication (Aberdeen (LW), n = 254) between December 1993 and February 2001 were identified from prospectively compiled databases. Patients were sent a questionnaire, including two gastrointestinal symptom scores (DeMeester and Gastrointestinal Symptom Rating Scale (GSRS)).Results: A total of 357 (80.6 per cent) patients completed questionnaires; no differences in response rate were observed among centres. Median time since surgery was 3.8 years for LW group, 2.4 years for LN group and 3.5 years for ON group (P < 0.001). Only a mean of 6.5 per cent patients reported a poor outcome. DeMeester score (GORD symptoms) was highest following LW and lowest following LN (P = 0.009), and increased with time from operation. However, logistic regression revealed no difference among the procedures after allowing for the effect of time, suggesting that time since operation is important, not procedure type. Overall, LN patients reported greater inability to belch (P = 0.007), however, this symptom also improved over time (r = −0.14, P = 0.009), and there was no difference among groups after taking time since operation into account. In addition there was no significant difference in the GSRS scores, painful bloating or inability to vomit between groups.Conclusion: This study has confirmed that the long-term outcome following all three procedures is similar with gradual reduction in inability to belch with time and some recurrence of other GORD symptoms.
    British Journal of Surgery 01/2009; 89(S1):26 - 26. · 5.21 Impact Factor
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    ABSTRACT: Context Associations of major lipids and apolipoproteins with the risk of vascular disease have not been reliably quantified.Objective To assess major lipids and apolipoproteins in vascular risk.Design, Setting, and Participants Individual records were supplied on 302 430 people without initial vascular disease from 68 long-term prospective studies, mostly in Europe and North America. During 2.79 million person-years of follow-up, there were 8857 nonfatal myocardial infarctions, 3928 coronary heart disease [CHD] deaths, 2534 ischemic strokes, 513 hemorrhagic strokes, and 2536 unclassified strokes.Main Outcome Measures Hazard ratios (HRs), adjusted for several conventional factors, were calculated for 1-SD higher values: 0.52 loge triglyceride, 15 mg/dL high-density lipoprotein cholesterol (HDL-C), 43 mg/dL non–HDL-C, 29 mg/dL apolipoprotein AI, 29 mg/dL apolipoprotein B, and 33 mg/dL directly measured low-density lipoprotein cholesterol (LDL-C). Within-study regression analyses were adjusted for within-person variation and combined using meta-analysis.Results The rates of CHD per 1000 person-years in the bottom and top thirds of baseline lipid distributions, respectively, were 2.6 and 6.2 with triglyceride, 6.4 and 2.4 with HDL-C, and 2.3 and 6.7 with non–HDL-C. Adjusted HRs for CHD were 0.99 (95% CI, 0.94-1.05) with triglyceride, 0.78 (95% CI, 0.74-0.82) with HDL-C, and 1.50 (95% CI, 1.39-1.61) with non–HDL-C. Hazard ratios were at least as strong in participants who did not fast as in those who did. The HR for CHD was 0.35 (95% CI, 0.30-0.42) with a combination of 80 mg/dL lower non–HDL-C and 15 mg/dL higher HDL-C. For the subset with apolipoproteins or directly measured LDL-C, HRs were 1.50 (95% CI, 1.38-1.62) with the ratio non–HDL-C/HDL-C, 1.49 (95% CI, 1.39-1.60) with the ratio apo B/apo AI, 1.42 (95% CI, 1.06-1.91) with non–HDL-C, and 1.38 (95% CI, 1.09-1.73) with directly measured LDL-C. Hazard ratios for ischemic stroke were 1.02 (95% CI, 0.94-1.11) with triglyceride, 0.93 (95% CI, 0.84-1.02) with HDL-C, and 1.12 (95% CI, 1.04-1.20) with non–HDL-C.Conclusion Lipid assessment in vascular disease can be simplified by measurement of either total and HDL cholesterol levels or apolipoproteins without the need to fast and without regard to triglyceride. Figures in this Article Reliable assessment of the separate and joint associations of major blood lipids and apolipoproteins with the risk of vascular disease is important for the development of screening and therapeutic strategies.1- 2 Expert opinion is divided about whether assessment of apolipoprotein AI (apo AI) and apolipoprotein B (apo B) should replace assessment of high-density lipoprotein cholesterol (HDL-C) and total cholesterol levels in assessment of vascular risk.3- 5 Although there is agreement about the value of reducing low-density lipoprotein cholesterol (LDL-C or, approximately analogously, non–high-density lipoprotein cholesterol [non–HDL-C]), uncertainty persists about the merits of modification or measurement of triglycerides or HDL-C.3 There are strongly positive epidemiological associations of triglyceride concentration with risk of vascular disease,6- 7 but it is not clear to what extent these relationships depend on cholesterol levels or vary with fasting state. Similarly, although previous analyses have generally reported inverse associations of HDL-C with risk of vascular disease, many studies have not investigated the extent to which they depend on triglyceride concentration.8 The failure of torcetrapib has raised questions about the value of raising HDL-C and highlighted the need to characterize more reliably the relationship between HDL-C and vascular risk, particularly at high HDL-C levels.9 Different uncertainties apply in relation to the risk of ischemic stroke and the cholesterol content of proatherogenic lipoproteins. The reduction in ischemic stroke in randomized trials of statins (which principally lower LDL-C) is remarkable in light of the weak epidemiological association reported between circulating LDL-C concentration and ischemic stroke,10- 11 suggesting the need for more powerful and detailed prospective analyses of blood lipids and stroke subtypes. The objective of this report is to produce reliable estimates of the associations of major lipids and apolipoproteins in relation to coronary heart disease (CHD) and ischemic stroke, incorporating adjustment for confounding caused by other risk factors and correction for regression dilution.12
    JAMA The Journal of the American Medical Association 01/2009; 302(18):1993-2000. DOI:10.1001/jama.2009.1619 · 30.39 Impact Factor
  • Statistics in Medicine 01/2009; 28(8):1218-37. DOI:10.1002/sim.3540 · 2.04 Impact Factor
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    ABSTRACT: Little research has been devoted to telangiectasia. The purpose of this study was to analyse the data in the Edinburgh Vein Study to determine the prevalence of telangiectasia in the general population, to analyse the demographic characteristics and association with symptoms and to compare the findings to those relating to varices of the saphenous systems. Cross-sectional population study. Twelve general practices with catchment areas geographically and socioeconomically distributed throughout Edinburgh. An age stratified random sample of 1566 people (699 men and 867 women) aged 16-64 selected from computerised age-sex registers of participating practices. Included in the population screening was a clinical examination, photography and duplex ultrasonography of the superficial veins and the deep veins down to popliteal level. Telangiectases and varicose veins were graded 1-3 according to severity. A total of 1322 (84%) of the population were classified as having telangiectasias in their right legs; 555 (79%) of men and 767 (88%) of women; 1226 (92%) as grade 1 and 96 (8%) as grades 2 and 3. There were no significant differences between left and right legs (p=0.144). The commonest locations for telangiectases were the postero-medial aspects of the thigh, popliteal fossa and upper one third of calf. There was a highly significant association between the degree of severity of varicose veins and the grade of telangiectasia (p<0.001). Less than 1% of subjects with grades 2-3 trunk varices were free of telangiectasia, but 51% of subjects with grades 2-3 telangiectasia had no clinical evidence of varicose veins. There was a significant linear trend in the proportion of subjects reporting heaviness, swelling, aching and cramps being highest among those with neither telangiectasia nor varicose veins, lower in those with telangiectasia or varicose veins only and lowest in subjects having both. The highest frequency of most symptoms was found in subjects with both telangiectasia and varicose veins. Telangiectasia is so common in the general population, especially in women, as to represent the norm. The anatomical distribution is entirely different from the distribution of the skin and subcutaneous manifestations of chronic venous insufficiency. Our confirmation of a strong association between trunk varices and grades 2-3 telangiectasia suggests the need for controlled studies into which condition should be treated. We found no evidence that telangiectasia per se was entirely responsible for leg symptoms.
    European journal of vascular and endovascular surgery: the official journal of the European Society for Vascular Surgery 10/2008; 36(6):719-24. DOI:10.1016/j.ejvs.2008.08.012 · 3.07 Impact Factor
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    ABSTRACT: Prediction models to identify healthy individuals at high risk of cardiovascular disease have limited accuracy. A low ankle brachial index (ABI) is an indicator of atherosclerosis and has the potential to improve prediction. To determine if the ABI provides information on the risk of cardiovascular events and mortality independently of the Framingham risk score (FRS) and can improve risk prediction. Relevant studies were identified. A search of MEDLINE (1950 to February 2008) and EMBASE (1980 to February 2008) was conducted using common text words for the term ankle brachial index combined with text words and Medical Subject Headings to capture prospective cohort designs. Review of reference lists and conference proceedings, and correspondence with experts was conducted to identify additional published and unpublished studies. Studies were included if participants were derived from a general population, ABI was measured at baseline, and individuals were followed up to detect total and cardiovascular mortality. Prespecified data on individuals in each selected study were extracted into a combined data set and an individual participant data meta-analysis was conducted on individuals who had no previous history of coronary heart disease. Sixteen population cohort studies fulfilling the inclusion criteria were included. During 480,325 person-years of follow-up of 24,955 men and 23,339 women, the risk of death by ABI had a reverse J-shaped distribution with a normal (low risk) ABI of 1.11 to 1.40. The 10-year cardiovascular mortality in men with a low ABI (< or = 0.90) was 18.7% (95% confidence interval [CI], 13.3%-24.1%) and with normal ABI (1.11-1.40) was 4.4% (95% CI, 3.2%-5.7%) (hazard ratio [HR], 4.2; 95% CI, 3.3-5.4). Corresponding mortalities in women were 12.6% (95% CI, 6.2%-19.0%) and 4.1% (95% CI, 2.2%-6.1%) (HR, 3.5; 95% CI, 2.4-5.1). The HRs remained elevated after adjusting for FRS (2.9 [95% CI, 2.3-3.7] for men vs 3.0 [95% CI, 2.0-4.4] for women). A low ABI (< or = 0.90) was associated with approximately twice the 10-year total mortality, cardiovascular mortality, and major coronary event rate compared with the overall rate in each FRS category. Inclusion of the ABI in cardiovascular risk stratification using the FRS would result in reclassification of the risk category and modification of treatment recommendations in approximately 19% of men and 36% of women. Measurement of the ABI may improve the accuracy of cardiovascular risk prediction beyond the FRS.
    JAMA The Journal of the American Medical Association 07/2008; 300(2):197-208. DOI:10.1001/jama.300.2.197 · 30.39 Impact Factor
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    ABSTRACT: This prospective observational study aimed to assess the impact of employment status and deprivation on quality of life 12 months after percutaneous coronary intervention (PCI). Patients completed a questionnaire at baseline and at 1 year follow-up including a health utility score (EQ-5D), symptoms and employment status. Deprivation was assessed using the Carstairs' deprivation category based on area postcodes. The majority (79.6%) of patients of working age returned to work within 12 months. Unemployment was associated with a lower quality of life (QoL) at baseline (0.49 (0.32) vs 0.61 (0.27), p=0.002) and less improvement in QoL 1 year after PCI (0.15 (0.37) vs 0.26 (0.31), p<0.012). Furthermore, unemployed patients had significantly less improvement in chest pain score (p=0.002) and breathlessness (p<0.001). Unemployed patients from the most deprived areas had lowest QoL at follow-up and least improvement in QoL at 1 year. Unemployment and deprivation are associated with poorer outcomes following PCI.
    International journal of cardiology 12/2007; 122(2):168-9. DOI:10.1016/j.ijcard.2006.11.052 · 6.18 Impact Factor
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    ABSTRACT: Many long-term prospective studies have reported on associations of cardiovascular diseases with circulating lipid markers and/or inflammatory markers. Studies have not, however, generally been designed to provide reliable estimates under different circumstances and to correct for within-person variability. The Emerging Risk Factors Collaboration has established a central database on over 1.1 million participants from 104 prospective population-based studies, in which subsets have information on lipid and inflammatory markers, other characteristics, as well as major cardiovascular morbidity and cause-specific mortality. Information on repeat measurements on relevant characteristics has been collected in approximately 340,000 participants to enable estimation of and correction for within-person variability. Re-analysis of individual data will yield up to approximately 69,000 incident fatal or nonfatal first ever major cardiovascular outcomes recorded during about 11.7 million person years at risk. The primary analyses will involve age-specific regression models in people without known baseline cardiovascular disease in relation to fatal or nonfatal first ever coronary heart disease outcomes. This initiative will characterize more precisely and in greater detail than has previously been possible the shape and strength of the age- and sex-specific associations of several lipid and inflammatory markers with incident coronary heart disease outcomes (and, secondarily, with other incident cardiovascular outcomes) under a wide range of circumstances. It will, therefore, help to determine to what extent such associations are independent from possible confounding factors and to what extent such markers (separately and in combination) provide incremental predictive value.
    European Journal of Epidemiology 02/2007; 22(12):839-69. DOI:10.1007/s10654-007-9165-7 · 5.15 Impact Factor
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    ABSTRACT: To assess the effect of changing clinical practice on the costs and outcomes of percutaneous coronary intervention (PCI) between 1998 and 2002. Two tertiary interventional centres. Consecutive patients undergoing PCI over a 12-month period between 1998 and 2002. Comparative observational study of costs and 12-month clinical outcomes of consecutive PCI procedures in 1998 (n = 1047) and 2002 (n = 1346). Clinical data were recorded in the Scottish PCI register. Repeat PCI, coronary artery bypass graft and mortality were obtained by record linkage. Costs of equipment were calculated using a computerised bar-code system and standard National Health Service reference costs. Between 1998 and 2002, the use of bare metal stents increased from 44% to 81%, and the use of glycoprotein IIB/IIIA inhibitors increased from 0% to 14% of cases. During this time, a significant reduction was observed in repeat target-vessel PCI (from 8.4% to 5.1%, p = 0.001), any repeat PCI (from 11.7% to 9.2%, p = 0.05) and any repeat revascularisation (from 15.1% to 11.3%, p = 0.009) within 12 months. Significantly higher cost per case in 2002 compared with 1998 (mean (standard deviation) 2311 pounds (1158) v 1785 pounds (907), p<0.001) was mainly due to increased contribution from bed-day costs in 2002 (45.0% (16.3%) v 26.2% (12.6%), p = 0.01) associated with non-elective cases spending significantly longer in hospital (6.22 (4.3) v 4.6 (4.3) days, p = 0.01). Greater use of stents and glycoprotein IIb/IIIa inhibitors between 1998 and 2002 has been accompanied by a marked reduction in the need for repeat revascularisation. Longer duration of hospital stay for non-elective cases is mainly responsible for increasing costs. Strategies to reduce the length of stay could considerably reduce the costs of PCI.
    Heart (British Cardiac Society) 02/2007; 93(2):195-9. DOI:10.1136/hrt.2006.090134 · 6.02 Impact Factor
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    ABSTRACT: To determine whether socioeconomic status (SES) influences clinical outcomes and quality of life after percutaneous coronary intervention (PCI). Prospective observational study. Two interventional cardiac centres. 1346 consecutive patients undergoing PCI over a 12-month period. Outcomes: Self reported health-related quality of life (HRQoL; EuroQol-5 Dimensions (EQ-5D); EuroQol Visual Analogue Scale (EQ-VAS)), repeat angiography, revascularisation, hospital admission, myocardial infarction and death within 12 months, by SES derived using postal address code. No significant differences were found between patients with high and low SES in the occurrence of repeat angiography (p = 0.55), repeat revascularisation (PCI, p = 0.81, CAEG, p = 0.27), total cardiac hospitalisation (p = 0.10), myocardial infarction (p = 0.97) or death 12 months after PCI (p = 0.88). Non-procedure-related readmissions were higher in patients with low SES (18.6% v 13.7%; p = 0.025). After adjustment for confounding factors, patients with low SES had lower HRQoL scores at baseline (95% CI for difference 0.01 to 0.14; p = 0.003) and at 12 months (95% CI 0.07 to 0.17; p<0.001) compared with those with high SES. Clinical outcomes were similar for patients in different SES groups. Patients with low SES had considerably more non-procedure-related readmissions and lower quality-of-life scores. Future studies on HRQoL after coronary revascularisation should take account of these important differences related to SES.
    Journal of Epidemiology &amp Community Health 12/2006; 60(12):1085-8. DOI:10.1136/jech.2005.044255 · 3.29 Impact Factor
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    ABSTRACT: To define the pressures and gradients achieved by different bandages when applied by alternative bandaging techniques. An experienced bandager applied six bandages to the same leg of a volunteer using three application techniques. Pressure measurements were taken at the ankle, gaiter, calf and upper calf in three postures. All bandages gave consistent pressures with all standard deviations falling below 7 mmHg. The percentage increase in pressure from resting leg to standing was inversely related to bandage elasticity. Pressures were similar at the upper calf among the bandages for each application technique in each posture (differences <10 mmHg). Small differences in pressure among the bandages (4-15 mmHg) occurred at the ankle for the resting leg with a reduction in pressure between 6 and 63% at the upper calf compared to the ankle. These differences in ankle pressure were more marked on sitting (differences 15-18 mmHg) and standing (differences 15-27 mmHg), which resulted in substantial differences in gradients. Striking variations in pressures and gradients were observed between bandages of different physical properties applied using alternative application techniques. In order to achieve clinical benefits without tissue damage, it is essential that the therapist appreciates how a bandage will react with a specific application technique.
    European Journal of Vascular and Endovascular Surgery 05/2006; 31(5):542-52. DOI:10.1016/j.ejvs.2005.10.023 · 3.07 Impact Factor
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    ABSTRACT: To assess variations in decisions to revascularise patients with coronary heart disease between general cardiologists, interventional cardiologists and cardiac surgeons Six cases of coronary heart disease were presented at an open meeting in a standard format including clinical details which might influence the decision to revascularise. Clinicians (n = 53) were then asked to vote using an anonymous electronic system for one of 5 treatment options: medical, surgical (CABG), percutaneous coronary intervention (PCI) or initially medical proceeding to revascularisation if symptoms dictated. Each case was then discussed in an open forum following which clinicians were asked to revote. Differences in treatment preference were compared by chi squared test and agreement between groups and between voting rounds compared using Kappa. Surgeons were more likely to choose surgery as a form of treatment (p = 0.034) while interventional cardiologists were more likely to choose PCI (p = 0.056). There were no significant differences between non-interventional and interventional cardiologists (p = 0.13) in their choice of treatment. There was poor agreement between all clinicians in the first round of voting (Kappa 0.26) but this improved to a moderate level of agreement after open discussion for the second vote (Kappa 0.44). The level of agreement among surgeons (0.15) was less than that for cardiologists (0.34) in Round 1, but was similar in Round 2 (0.45 and 0.45 respectively). In this case series, there was poor agreement between cardiac clinical specialists in the choice of treatment offered to patients. Open discussion appeared to improve agreement. These results would support the need for decisions to revascularise to be made by a multidisciplinary panel.
    Journal of Cardiothoracic Surgery 02/2006; 1(1):2. DOI:10.1186/1749-8090-1-2 · 1.03 Impact Factor
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    ABSTRACT: Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD) and stroke. To assess the relationships of fibrinogen levels with risk of major vascular and with risk of nonvascular outcomes based on individual participant data. Relevant studies were identified by computer-assisted searches, hand searches of reference lists, and personal communication with relevant investigators. All identified prospective studies were included with information available on baseline fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific mortality during at least 1 year of follow-up. Studies were excluded if they recruited participants on the basis of having had a previous history of cardiovascular disease; participants with known preexisting CHD or stroke were excluded. Individual records were provided on each of 154,211 participants in 31 prospective studies. During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial infarctions or stroke events and 13,210 deaths. Cause-specific mortality was generally available. Analyses involved proportional hazards modeling with adjustment for confounding by known cardiovascular risk factors and for regression dilution bias. Within each age group considered (40-59, 60-69, and > or =70 years), there was an approximately log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other vascular (eg, non-CHD, nonstroke) mortality, and nonvascular mortality. There was no evidence of a threshold within the range of usual fibrinogen level studied at any age. The age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was 2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further adjustment for measured values of several established vascular risk factors. In a subset of 7011 participants with available C-reactive protein values, the findings for CHD were essentially unchanged following additional adjustment for C-reactive protein. The associations of fibrinogen level with CHD or stroke did not differ substantially according to sex, smoking, blood pressure, blood lipid levels, or several features of study design. In this large individual participant meta-analysis, moderately strong associations were found between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality, and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults. Assessment of any causal relevance of elevated fibrinogen levels to disease requires additional research.
    JAMA The Journal of the American Medical Association 10/2005; 294(14):1799-809. DOI:10.1001/jama.294.14.1799 · 30.39 Impact Factor

Publication Stats

6k Citations
669.35 Total Impact Points

Institutions

  • 2004–2014
    • University of Aberdeen
      • • Division of Applied Health Sciences
      • • Academic Primary Care
      Aberdeen, Scotland, United Kingdom
  • 1995–2009
    • The University of Edinburgh
      • • Medical Genetics Unit
      • • Division of Health Sciences
      Edinburgh, SCT, United Kingdom
  • 1997
    • WWF United Kingdom
      Londinium, England, United Kingdom
  • 1994
    • University of Dundee
      Dundee, Scotland, United Kingdom
  • 1991
    • Ninewells Hospital
      • Department of Surgery
      Dundee, Scotland, United Kingdom