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1.  Domestic violence and mental health: a cross-sectional survey of women seeking help from domestic violence support services 
Global Health Action  2014;7:10.3402/gha.v7.25519.
Background
Domestic violence and abuse (DVA) are associated with an increased risk of mental illness, but we know little about the mental health of female DVA survivors seeking support from domestic violence services.
Objective
To characterize the demography and mental health of women who access specialist DVA services in the United Kingdom and to investigate associations between severity of abuse and measures of mental health and health state utility, accounting for important confounders and moderators.
Design
Baseline data on 260 women enrolled in a randomized controlled trial of a psychological intervention for DVA survivors was analyzed. We report prevalence of and associations between mental health status and severity of abuse at the time of recruitment. We used logistic and normal regression models for binary and continuous outcomes, respectively. Mental health measures used were: Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM), Patient Health Questionnaire, Generalized Anxiety Disorder Assessment, and the Posttraumatic Diagnostic Scale (PDS) to measure posttraumatic stress disorder. The Composite Abuse Scale (CAS) measured abuse.
Results
Exposure to DVA was high, with a mean CAS score of 56 (SD 34). The mean CORE-OM score was 18 (SD 8) with 76% above the clinical threshold (95% confidence interval: 70–81%). Depression and anxiety levels were high, with means close to clinical thresholds, and all respondents recorded PTSD scores above the clinical threshold. Symptoms of mental illness increased stepwise with increasing severity of DVA.
Conclusions
Women DVA survivors who seek support from DVA services have recently experienced high levels of abuse, depression, anxiety, and especially PTSD. Clinicians need to be aware that patients presenting with mental health conditions or symptoms of depression or anxiety may be experiencing or may have experienced DVA. The high psychological morbidity in this population means that trauma-informed psychological support is needed for survivors who seek support from DVA services.
doi:10.3402/gha.v7.25519
PMCID: PMC4199331  PMID: 25319597
domestic violence and abuse; intimate partner violence; mental health; posttraumatic stress disorder; anxiety; CORE-OM; depression; women; advocacy
2.  Socioeconomic Deprivation and the Incidence of 12 Cardiovascular Diseases in 1.9 Million Women and Men: Implications for Risk Prediction and Prevention 
PLoS ONE  2014;9(8):e104671.
Background
Recent experimental evidence suggests that socioeconomic characteristics of neighbourhoods influence cardiovascular health, but observational studies which examine deprivation across a wide range of cardiovascular diseases (CVDs) are lacking.
Methods
Record-linkage cohort study of 1.93 million people to examine the association between small-area socioeconomic deprivation and 12 CVDs. Health records covered primary care, hospital admissions, a myocardial infarction registry and cause-specific mortality in England (CALIBER). Patients were aged ≥30 years and were initially free of CVD. Cox proportional hazard models stratified by general practice were used.
Findings
During a median follow-up of 5.5 years 114,859 people had one of 12 initial CVD presentations. In women the hazards of all CVDs except abdominal aortic aneurysm increased linearly with higher small-area socioeconomic deprivation (adjusted HR for most vs. least deprived ranged from 1.05, 95%CI 0.83–1.32 for abdominal aortic aneurysm to 1.55, 95%CI 1.42–1.70 for heart failure; I2 = 81.9%, τ2 = 0.01). In men heterogeneity was higher (HR ranged from 0.89, 95%CI 0.75–1.06 for cardiac arrest to 1.85, 95%CI 1.67–2.04 for peripheral arterial disease; I2 = 96.0%, τ2 = 0.06) and no association was observed with stable angina, sudden cardiac death, subarachnoid haemorrhage, transient ischaemic attack and abdominal aortic aneurysm. Lifetime risk difference between least and most deprived quintiles was most marked for peripheral arterial disease in women (4.3% least deprived, 5.8% most deprived) and men (4.6% least deprived, 7.8% in most deprived); but it was small or negligible for sudden cardiac death, transient ischaemic attack, abdominal aortic aneurysm and ischaemic and intracerebral haemorrhage, in both women and men.
Conclusions
Associations of small-area socioeconomic deprivation with 12 types of CVDs were heterogeneous, and in men absent for several diseases. Findings suggest that policies to reduce deprivation may impact more strongly on heart failure and peripheral arterial disease, and might be more effective in women.
doi:10.1371/journal.pone.0104671
PMCID: PMC4140710  PMID: 25144739
4.  Benefits of Aldosterone Receptor Antagonism in Chronic Kidney Disease (BARACK D) trial–a multi-centre, prospective, randomised, open, blinded end-point, 36-month study of 2,616 patients within primary care with stage 3b chronic kidney disease to compare the efficacy of spironolactone 25 mg once daily in addition to routine care on mortality and cardiovascular outcomes versus routine care alone: study protocol for a randomized controlled trial 
Trials  2014;15:160.
Background
Chronic kidney disease (CKD) is common and increasing in prevalence. Cardiovascular disease (CVD) is a major cause of morbidity and death in CKD, though of a different phenotype to the general CVD population. Few therapies have proved effective in modifying the increased CVD risk or rate of renal decline in CKD. There are accumulating data that aldosterone receptor antagonists (ARA) may offer cardio-protection and delay renal impairment in patients with the CV phenotype in CKD. The use of ARA in CKD has therefore been increasingly advocated. However, no large study of ARA with renal or CVD outcomes is underway.
Methods
The study is a prospective randomised open blinded endpoint (PROBE) trial set in primary care where patients will mainly be identified by their GPs or from existing CKD lists. They will be invited if they have been formally diagnosed with CKD stage 3b or there is evidence of stage 3b CKD from blood results (eGFR 30–44 mL/min/1.73 m2) and fulfil the other inclusion/exclusion criteria. Patients will be randomised to either spironolactone 25 mg once daily in addition to routine care or routine care alone and followed-up for 36 months.
Discussion
BARACK D is a PROBE trial to determine the effect of ARA on mortality and cardiovascular outcomes (onset or progression of CVD) in patients with stage 3b CKD.
Trial registration
EudraCT: 2012-002672-13
ISRTN: ISRCTN44522369
doi:10.1186/1745-6215-15-160
PMCID: PMC4113231  PMID: 24886488
Cardiovascular disease; Chronic kidney disease; CKD mortality; CKD aldosterone receptor antagonist
5.  Prognostic models for stable coronary artery disease based on electronic health record cohort of 102 023 patients 
European heart journal  2013;35(13):844-852.
Aims
The population with stable coronary artery disease (SCAD) is growing but validated models to guide their clinical management are lacking. We developed and validated prognostic models for all-cause mortality and non-fatal myocardial infarction (MI) or coronary death in SCAD.
Methods and results
Models were developed in a linked electronic health records cohort of 102 023 SCAD patients from the CALIBER programme, with mean follow-up of 4.4 (SD 2.8) years during which 20 817 deaths and 8856 coronary outcomes were observed. The Kaplan–Meier 5-year risk was 20.6% (95% CI, 20.3, 20.9) for mortality and 9.7% (95% CI, 9.4, 9.9) for non-fatal MI or coronary death. The predictors in the models were age, sex, CAD diagnosis, deprivation, smoking, hypertension, diabetes, lipids, heart failure, peripheral arterial disease, atrial fibrillation, stroke, chronic kidney disease, chronic pulmonary disease, liver disease, cancer, depression, anxiety, heart rate, creatinine, white cell count, and haemoglobin. The models had good calibration and discrimination in internal (external) validation with C-index 0.811 (0.735) for all-cause mortality and 0.778 (0.718) for non-fatal MI or coronary death. Using these models to identify patients at high risk (defined by guidelines as 3% annual mortality) and support a management decision associated with hazard ratio 0.8 could save an additional 13-16 life years or 15-18 coronary event-free years per 1000 patients screened, compared with models with just age, sex, and deprivation.
Conclusion
These validated prognostic models could be used in clinical practice to support risk stratification as recommended in clinical guidelines.
doi:10.1093/eurheartj/eht533
PMCID: PMC3971383  PMID: 24353280
Stable coronary artery disease; Stable angina; Prognosis; Myocardial infarction; Electronic health records; CALIBER
6.  Prognostic models for stable coronary artery disease based on electronic health record cohort of 102 023 patients 
European Heart Journal  2013;35(13):844-852.
Aims
The population with stable coronary artery disease (SCAD) is growing but validated models to guide their clinical management are lacking. We developed and validated prognostic models for all-cause mortality and non-fatal myocardial infarction (MI) or coronary death in SCAD.
Methods and results
Models were developed in a linked electronic health records cohort of 102 023 SCAD patients from the CALIBER programme, with mean follow-up of 4.4 (SD 2.8) years during which 20 817 deaths and 8856 coronary outcomes were observed. The Kaplan–Meier 5-year risk was 20.6% (95% CI, 20.3, 20.9) for mortality and 9.7% (95% CI, 9.4, 9.9) for non-fatal MI or coronary death. The predictors in the models were age, sex, CAD diagnosis, deprivation, smoking, hypertension, diabetes, lipids, heart failure, peripheral arterial disease, atrial fibrillation, stroke, chronic kidney disease, chronic pulmonary disease, liver disease, cancer, depression, anxiety, heart rate, creatinine, white cell count, and haemoglobin. The models had good calibration and discrimination in internal (external) validation with C-index 0.811 (0.735) for all-cause mortality and 0.778 (0.718) for non-fatal MI or coronary death. Using these models to identify patients at high risk (defined by guidelines as 3% annual mortality) and support a management decision associated with hazard ratio 0.8 could save an additional 13–16 life years or 15–18 coronary event-free years per 1000 patients screened, compared with models with just age, sex, and deprivation.
Conclusion
These validated prognostic models could be used in clinical practice to support risk stratification as recommended in clinical guidelines.
doi:10.1093/eurheartj/eht533
PMCID: PMC3971383  PMID: 24353280
Stable coronary artery disease; Stable angina; Prognosis; Myocardial infarction; Electronic health records; CALIBER
7.  English to Arabic Translation of the Composite Abuse Scale (CAS): A Multi-Method Approach 
PLoS ONE  2013;8(9):e75244.
Background
The composite abuse scale (CAS) is a comprehensive tool used to measure intimate partner violence (IPV). The aim of the present study is to translate the CAS from English to Arabic.
Methods
The translation of the CAS was conducted in four stages using a multi-method approach: 1) preliminary forward translation, 2) discussion with a panel of bilingual experts, 3) focus groups discussion, and 4) back-translation of the CAS. The discussion included a linguistic validation by a comparison of the Arabic translation with the original English by assessing conceptual and content equivalence.
Findings
In all the stages of translation, there was an agreement to remove the question from the CAS that asked women about the use of objects in the vagina. Wording, format and order of the items were refined according to comments and suggestions made by the experts’ panel and focus groups’ members. The back-translated CAS showed similar wording and language of the original English version.
Conclusions
The Arabic version of the CAS will help to measure the problem of IPV among Saudi women and possibly other Arabic-speaking women in future studies. This is important, particularly, in longitudinal studies or intervention studies among abused women and it allows a comparison of the results of studies from different cultures. However, further validations studies are needed to ensure accurate and equivalent Arabic translation of the CAS.
doi:10.1371/journal.pone.0075244
PMCID: PMC3783446  PMID: 24086478
8.  Domestic violence: knowledge, attitudes, and clinical practice of selected UK primary healthcare clinicians 
The British Journal of General Practice  2012;62(602):e647-e655.
Background
Domestic violence affects one in four women and has significant health consequences. Women experiencing abuse identify doctors and other health professionals as potential sources of support. Primary care clinicians agree that domestic violence is a healthcare issue but have been reluctant to ask women if they are experiencing abuse.
Aim
To measure selected UK primary care clinicians’ current levels of knowledge, attitudes, and clinical skills in this area.
Design and setting
Prospective observational cohort in 48 general practices from Hackney in London and Bristol, UK.
Method
Administration of the Physician Readiness to Manage Intimate Partner Violence Survey (PREMIS), comprising five sections: responder profile, background (perceived preparation and knowledge), actual knowledge, opinions, and practice issues.
Results
Two hundred and seventy-two (59%) clinicians responded. Minimal previous domestic violence training was reported by participants. Clinicians only had basic knowledge about domestic violence but expressed a positive attitude towards engaging with women experiencing abuse. Many clinicians felt poorly prepared to ask relevant questions about domestic violence or to make appropriate referrals if abuse was disclosed. Forty per cent of participants never or seldom asked about abuse when a woman presented with injuries. Eighty per cent said that they did not have an adequate knowledge of local domestic violence resources. GPs were better prepared and more knowledgeable than practice nurses; they also identified a higher number of domestic violence cases.
Conclusion
Primary care clinicians’ attitudes towards women experiencing domestic violence are generally positive but they only have basic knowledge of the area. Both GPs and practice nurses need more comprehensive training on assessment and intervention, including the availability of local domestic violence services.
doi:10.3399/bjgp12X654623
PMCID: PMC3426604  PMID: 22947586
cross-sectional studies; domestic violence; primary health care; women
9.  Psychological advocacy toward healing (PATH): study protocol for a randomized controlled trial 
Trials  2013;14:221.
Background
Domestic violence and abuse (DVA), defined as threatening behavior or abuse by adults who are intimate partners or family members, is a key public health and clinical priority. The prevalence of DVA in the United Kingdom and worldwide is high, and its impact on physical and mental health is detrimental and persistent. There is currently little support within healthcare settings for women experiencing DVA. Psychological problems in particular may be difficult to manage outside specialist services, as conventional forms of therapy such as counseling that do not address the violence may be ineffective or even harmful. The aim of this study is to assess the overall effectiveness and cost-effectiveness of a novel psychological intervention tailored specifically for survivors of DVA and delivered by domestic violence advocates based in third-sector organizations.
Methods and study design
This study is an open, pragmatic, parallel group, individually randomized controlled trial. Women ages 16 years and older experiencing domestic violence are being enrolled and randomly allocated to receive usual DVA agency advocacy support (control) or usual DVA agency support plus psychological intervention (intervention). Those in the intervention group will receive eight specialist psychological advocacy (SPA) sessions weekly or fortnightly, with two follow-up sessions, 1 month and then 3 months later. This will be in addition to any advocacy support sessions each woman receives. Women in the control group will receive usual DVA agency support but no additional SPA sessions. The aim is to recruit 250 women to reach the target sample size. The primary outcomes are psychological well-being and depression severity at 1 yr from baseline, as measured by the Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM) and the Patient Health Questionnaire (PHQ-9), respectively. Secondary outcome measures include anxiety, posttraumatic stress, severity and frequency of abuse, quality of life and cost-effectiveness of the intervention. Data from a subsample of women in both groups will contribute to a nested qualitative study with repeat interviews during the year of follow-up.
Discussion
This study will contribute to the evidence base for management of the psychological needs of women experiencing DVA. The findings will have important implications for healthcare commissioners and providers, as well as third sector specialist DVA agencies providing services to this client group.
Trial registration
ISRCTN58561170
doi:10.1186/1745-6215-14-221
PMCID: PMC3718639  PMID: 23866771
10.  Longitudinal measurement of cortisol in association with mental health and experience of domestic violence and abuse: study protocol 
BMC Psychiatry  2013;13:188.
Background
Domestic violence and abuse is threatening behavior, violence/abuse used by one person to control the other within an intimate or family-type relationship. Women experience more severe physical and sexual domestic violence and abuse and more mental health consequences than men. The current study aims at exploring of the role of hypothalamic-pituitary-adrenocortical axis activity in abuse impact on women's mental health. Study objectives: 1) To evaluate diurnal cortisol slope, cortisol awakening response, and the mean cortisol concentration in women with a current or recent experience of abuse; 2) To estimate whether cortisol secretion is associated with type, severity, duration and cessation of abuse; 3) To investigate whether cortisol acts as mediator between abuse and mental health condition; 4) To examine whether there is any distinction in cortisol levels between those women exposed to both childhood abuse and domestic violence and abuse and those experienced only the latter. 4) To explore whether cortisol secretion differs between women living in refuge and those still living in the community.
Methods/Design
To meet study objectives 128 women will be recruited in a domestic violence agency and local communities. Baseline and 3-month follow-up measures will be taken over 6 months after recruitment. Each assessment will include: (1) standardized self-administered questionnaires to evaluate socio-demographics, experience of violence and abuse, mental and physical health; (2) weight and height measurement; (3) self-completion of wakening, post-wakening and evening saliva samples. Saliva will be analysed for cortisol and cortisone using Ultra performance liquid chromatography – tandem mass spectrometry.
We will compare diurnal cortisol parameters between non-abused controls and abuse survivors with and without mental health conditions. First following descriptive statistics for all the cortisol and mental health outcomes, relationships between them will be investigated using appropriate regression models. Second, these techniques will be used to investigate the extent to which cortisol measures act as potential mediators between type, severity, duration of abuse and mental disorders.
Discussion
Results of the study will increase our understanding of the pathophysiological mechanisms of abuse-related mental health disorders in women and inform researchers and practitioners on the possibility of using salivary cortisol as a biological marker for prognosis, diagnosis, and treatment evaluation among abuse survivors.
Trial registration
ClinicalTrials.gov registration NCT01632553
doi:10.1186/1471-244X-13-188
PMCID: PMC3716999  PMID: 23849084
Domestic violence; Partner abuse; Spousal abuse; Battered women; Abused women; Cortisol; Mental health; Depression; Anxiety; Posttraumatic stress disorder
11.  Domestic Violence and Perinatal Mental Disorders: A Systematic Review and Meta-Analysis 
PLoS Medicine  2013;10(5):e1001452.
Louise Howard and colleagues conduct a systematic review and meta-analysis to estimate the prevalence and odds of experience of domestic violence experience among women with antenatal and postnatal mental health disorders.
Please see later in the article for the Editors' Summary
Background
Domestic violence in the perinatal period is associated with adverse obstetric outcomes, but evidence is limited on its association with perinatal mental disorders. We aimed to estimate the prevalence and odds of having experienced domestic violence among women with antenatal and postnatal mental disorders (depression and anxiety disorders including post-traumatic stress disorder [PTSD], eating disorders, and psychoses).
Methods and Findings
We conducted a systematic review and meta-analysis (PROSPERO reference CRD42012002048). Data sources included searches of electronic databases (to 15 February 2013), hand searches, citation tracking, update of a review on victimisation and mental disorder, and expert recommendations. Included studies were peer-reviewed experimental or observational studies that reported on women aged 16 y or older, that assessed the prevalence and/or odds of having experienced domestic violence, and that assessed symptoms of perinatal mental disorder using a validated instrument. Two reviewers screened 1,125 full-text papers, extracted data, and independently appraised study quality. Odds ratios were pooled using meta-analysis.
Sixty-seven papers were included. Pooled estimates from longitudinal studies suggest a 3-fold increase in the odds of high levels of depressive symptoms in the postnatal period after having experienced partner violence during pregnancy (odds ratio 3.1, 95% CI 2.7–3.6). Increased odds of having experienced domestic violence among women with high levels of depressive, anxiety, and PTSD symptoms in the antenatal and postnatal periods were consistently reported in cross-sectional studies. No studies were identified on eating disorders or puerperal psychosis. Analyses were limited because of study heterogeneity and lack of data on baseline symptoms, preventing clear findings on causal directionality.
Conclusions
High levels of symptoms of perinatal depression, anxiety, and PTSD are significantly associated with having experienced domestic violence. High-quality evidence is now needed on how maternity and mental health services should address domestic violence and improve health outcomes for women and their infants in the perinatal period.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Domestic violence—physical, sexual, or emotional abuse by an intimate partner or family member—is a major public health problem and although more common in women, can also affect men. Due to the nature of the problem, it is difficult to collect accurate figures on the scale of domestic violence, but a study by the World Health Organization in ten countries found that 15%–71% of women aged 15–49 years reported physical and/or sexual violence by an intimate partner at some point in their lives. Women experiencing domestic violence have significant short- and long-term health problems, particularly regarding their mental health: experience of domestic violence can lead to a range of mental health disorders such as depression, psychosis, eating disorders, and even suicide attempts.
Why Was This Study Done?
As perinatal mental health disorders are among the commonest health problems in pregnancy and the postpartum period, and given the rate of domestic violence during pregnancy (previous studies have suggested a domestic violence prevalence of 4%–8% during pregnancy and the postnatal period), it is plausible that there may be a link between perinatal mental health disorders and having experienced domestic violence. Indeed, previous reviews have suggested the existence of such an association but were limited by the small number of included studies and focused on depression only, rather than the full range of antenatal and postnatal mental health disorders. So in this study the researchers systematically reviewed published studies to provide more robust estimates of the prevalence of having experienced domestic violence among women with antenatal and postnatal mental health disorders; the researchers also used a meta-analysis to estimate the odds (chance) of having experienced domestic violence among women with antenatal and postnatal mental health disorders.
What Did the Researchers Do and Find?
The researchers searched multiple databases and hand searched three relevant journals using key search terms to identify all types of relevant studies. Using specific criteria, the researchers retrieved and assessed over 1,000 full papers, of which 67 met the criteria for their systematic review. The researchers assessed the quality of each selected study and included only those studies that used validated diagnostic instruments and screening tools to assess mental health disorders in their calculations of the pooled (combined) odds ratio (OR) through meta-analysis.
Using these methods, in cross-sectional studies (studies conducted at one point in time), the researchers found that women with probable depression in the antenatal period reported a high prevalence and increased odds of having experienced partner violence during their lifetime (OR = 3), during the past year (OR = 2.8), and during pregnancy (OR = 5). The results were similar for the postnatal period. The evidence was less robust for anxiety disorders: among women with probable anxiety in the antenatal period, the researchers found an OR of 2.9 of having experienced lifetime partner violence. The odds were less in the postnatal period (OR = 1.4) In their analysis of longitudinal studies (follow-up studies over a period of time), the researchers found an increased odds of probable postnatal depression both among women who reported having ever experienced partner violence in their lifetime (OR = 2.9) and among women who reported having experienced partner violence during pregnancy (OR = 3.1). The researchers also found a combined prevalence estimate of 12.7% for probable depression during the postnatal period following experiences of partner violence during pregnancy. Because of limited data, the researchers could not calculate an OR of the association between probable antenatal depression and later experiences of partner violence.
What Do These Findings Mean?
These findings suggest that women with high levels of symptoms of perinatal mental health disorders—antenatal and postnatal anxiety, depression, and post-traumatic stress disorder—have a high prevalence and increased odds of having experienced domestic violence both over their lifetime and during pregnancy. However, these findings cannot prove causality, they fail to show a two-way association (that is, perinatal mental health disorders leading to subsequent domestic violence), and no information on other perinatal mental disorders, such as eating disorders and puerperal psychosis, was available. The variation of the quality of the included studies also limits the results, highlighting the need for high-quality data to suggest how maternity and mental health services could address domestic violence and improve health outcomes for women and their infants in the future. Nevertheless, this study emphasizes the importance of identifying and responding to possible domestic violence among women attending antenatal and mental health services.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001452.
The World Health Organization provides information and statistics about violence against women and also about mental health disorders during pregnancy
The UK Royal College of Psychiatrists has information for professionals and patients about mental health disorders during pregnancy
doi:10.1371/journal.pmed.1001452
PMCID: PMC3665851  PMID: 23723741
12.  Experiences of Domestic Violence and Mental Disorders: A Systematic Review and Meta-Analysis 
PLoS ONE  2012;7(12):e51740.
Background
Little is known about the extent to which being a victim of domestic violence is associated with different mental disorders in men and women. We aimed to estimate the prevalence and odds of being a victim of domestic violence by diagnostic category and sex.
Methods
Study design: Systematic review and meta-analysis. Data Sources: Eighteen biomedical and social sciences databases (including MEDLINE, EMBASE, PsycINFO); journal hand searches; scrutiny of references and citation tracking of included articles; expert recommendations, and an update of a systematic review on victimisation and mental disorder. Inclusion criteria: observational and intervention studies reporting prevalence or odds of being a victim of domestic violence in men and women (aged ≥16 years), using validated diagnostic measures of mental disorder. Procedure: Data were extracted and study quality independently appraised by two reviewers. Analysis: Random effects meta-analyses were used to pool estimates of prevalence and odds.
Results
Forty-one studies were included. There is a higher risk of experiencing adult lifetime partner violence among women with depressive disorders (OR 2.77 (95% CI 1.96–3.92), anxiety disorders (OR 4.08 (95% CI 2.39–6.97), and PTSD (OR 7.34 95% CI 4.50–11.98), compared to women without mental disorders. Insufficient data were available to calculate pooled odds for other mental disorders, family violence (i.e. violence perpetrated by a non-partner), or violence experienced by men. Individual studies reported increased odds for women and men for all diagnostic categories, including psychoses, with a higher prevalence reported for women. Few longitudinal studies were found so the direction of causality could not be investigated.
Conclusions
There is a high prevalence and increased likelihood of being a victim of domestic violence in men and women across all diagnostic categories, compared to people without disorders. Longitudinal studies are needed to identify pathways to being a victim of domestic violence to optimise healthcare responses.
doi:10.1371/journal.pone.0051740
PMCID: PMC3530507  PMID: 23300562
13.  Impact of Asthma on Educational Attainment in a Socioeconomically Deprived Population: A Study Linking Health, Education and Social Care Datasets 
PLoS ONE  2012;7(11):e43977.
Background
Asthma has the potential to adversely affect children's school examination performance, and hence longer term life chances. Asthma morbidity is especially high amongst UK ethnic minority children and those experiencing social adversity, populations which also have poor educational outcomes. We tested the hypothesis that asthma adversely affects performance in national school examinations in a large cohort from an area of ethnic diversity and social deprivation.
Methods and Findings
With a novel method (using patient and address-matching algorithms) we linked administrative and clinical data for 2002–2005 for children in east London aged 5–14 years to contemporaneous education and social care datasets. We modelled children's performance in school examinations in relation to socio-demographic and clinical variables.
The dataset captured examination performance for 12,136 children who sat at least one national examination at Key Stages 1–3. For illustration, estimates are presented as percentage changes in Key Stage 2 results. Having asthma was associated with a 1.1% increase in examination scores (95%CI 0.4 to 1.7)%,p = 0.02. Worse scores were associated with Bangladeshi ethnicity −1.3%(−2.5 to −0.1)%,p = 0.03; special educational need −14.6%(−15.7 to −13.5)%,p = 0.02; mental health problems −2.5%(−4.1 to −0.9)%,p = 0.003, and social adversity: living in a smoking household −1.2(−1.7 to −0.6)%,p<0.001; living in social housing −0.8%(−1.3 to −0.2)% p = 0.01, and entitlement to free school meals −0.8%(−1.5 to −0.1)%,p<0.001.
Conclusions
Social adversity and ethnicity, but not asthma, are associated with poorer performance in national school examinations. Policies to improve educational attainment in socially deprived areas should focus on these factors.
doi:10.1371/journal.pone.0043977
PMCID: PMC3498297  PMID: 23155367
14.  Responding to Domestic Violence in General Practice: A Qualitative Study on Perceptions and Experiences 
The perceptions and experiences among general practitioners (GPs) and nurses in identifying female patients experiencing domestic violence and referring patients to specialist agencies need to be clarified. Eleven GPs and six nurses participating in a multidisciplinary domestic violence training and support programme in east London and Bristol were interviewed. All participants recognised that identification of women experiencing domestic violence and offering support were part of their clinical roles. Perceived differences between GPs and nurses, including time constraints, level of patient interaction, awareness of patients' social history, scope of clinical interview, and patient expectations were used to explain their levels of domestic violence inquiry. Barriers to inquiry included lack of time, experience, awareness of community resources, and availability of effective interventions postdisclosure. Longstanding relationships with patients were cited both as barrier and facilitator to domestic violence disclosure. Some nurses reported discomfort with direct inquiry due to the lack of clinical experience in responding to domestic violence despite satisfaction with training. Future domestic violence training programmes should take into account potential differences between GPs and nurses, in terms of their clinical roles and the unique barriers encountered, in order to improve self-efficacy and to facilitate collaborative and effective responses.
doi:10.1155/2012/960523
PMCID: PMC3502852  PMID: 23259062
15.  Cost-effectiveness of Identification and Referral to Improve Safety (IRIS), a domestic violence training and support programme for primary care: a modelling study based on a randomised controlled trial 
BMJ Open  2012;2(3):e001008.
Objective
The Identification and Referral to Improve Safety (IRIS) cluster randomised controlled trial tested the effectiveness of a training and support intervention to improve the response of primary care to women experiencing domestic violence (DV). The aim of this study is to estimate the cost-effectiveness of this intervention.
Design
Markov model-based cost-effectiveness analysis.
Setting
General practices in two urban areas in the UK.
Participants
Simulated female individuals from the general UK population who were registered at general practices, aged 16 years and older.
Intervention
General practices received staff training, prompts to ask women about DV embedded in the electronic medical record, a care pathway including referral to a specialist DV agency and continuing contact from that agency. The trial compared the rate of referrals of women with specialist DV agencies from 24 general practices that received the IRIS programme with 24 general practices not receiving the programme. The trial did not measure outcomes for women beyond the intermediate outcome of referral to specialist agencies. The Markov model extrapolated the trial results to estimate the long-term healthcare and societal costs and benefits using data from other trials and epidemiological studies.
Results
The intervention would produce societal cost savings per woman registered in the general practice of UK£37 (95% CI £178 saved to a cost of £136) over 1 year. The incremental quality-adjusted life-year was estimated to be 0.0010 (95% CI −0.0157 to 0.0101) per woman. Probabilistic sensitivity analysis found 78% of model replications under a willingness to pay threshold of £20 000 per quality-adjusted life-year.
Conclusions
The IRIS programme is likely to be cost-effective and possibly cost saving from a societal perspective. Better data on the trajectory of abuse and the effect of advocacy are needed for a more robust model.
Trial registration
Current Controlled Trials, ISRCTN74012786.
Article summary
Article focus
The aim of this study was to assess the cost-effectiveness of the IRIS training and support intervention for primary care clinicians from the UK societal and NHS perspectives.
Key messages
The intervention is likely to be cost saving from a societal perspective with a high likelihood of being under a £20 000 per quality-adjusted life-year willingness to pay threshold.
Strengths and limitations of this study
We have minimised bias in estimating the effect size of the IRIS programme by basing it on a randomised controlled trial.
By using epidemiological and cost data external to the trial, we were able to extrapolate from directly measured trial outcomes (DV disclosure and referral rates) to quality of life, health and economic outcomes.
The uncertainty of the transition probabilities based on assumptions was addressed by probabilistic sensitivity analysis, contributing to the robustness of the model.
Important limitations of that data are the paucity of longitudinal studies measuring the trajectory of abuse and uncertainty about the effect of DV advocacy for women not living in a refuge or shelter.
doi:10.1136/bmjopen-2012-001008
PMCID: PMC3383977  PMID: 22730555
16.  Is access to specialist assessment of chest pain equitable by age, gender, ethnicity and socioeconomic status? An enhanced ecological analysis 
BMJ Open  2012;2(3):e001025.
Objectives
To determine whether access to rapid access chest pain clinics of people with recent onset symptoms is equitable by age, socioeconomic status, ethnicity and gender, according to need.
Design
Retrospective cohort study with ecological analysis.
Setting
Patients referred from primary care to five rapid access chest pain clinics in secondary care, across England.
Participants
Of 8647 patients aged ≥35 years referred to chest pain clinics with new-onset stable chest pain but no known cardiac history, 7570 with documented census ward codes, age, gender and ethnicity comprised the study group. Patients excluded were those with missing date of birth, gender or ethnicity (n=782) and those with missing census ward codes (n=295).
Outcome measures
Effects of age, gender, ethnicity and socioeconomic status on clinic attendance were calculated as attendance rate ratios, with number of attendances as the outcome and resident population-years as the exposure in each stratum, using Poisson regression. Attendance rate ratios were then compared with coronary heart disease (CHD) mortality ratios to determine whether attendance was equitable according to need.
Results
Adjusted attendance rate ratios for patients aged >65 years were similar to younger patients (1.1, 95% CI 1.05 to 1.16), despite population CHD mortality rate ratios nearly 15 times higher in the older age group. Women had lower attendance rate ratios (0.81, 95% CI 0.77 to 0.84) and also lower population CHD mortality rate ratios compared with men. South Asians had higher attendance rates (1.67, 95% CI 1.57 to 1.77) compared with whites and had a higher standardised CHD mortality ratio of 1.46 (95% CI 1.41 to 1.51). Although univariable analysis showed that the most deprived patients (quintile 5) had an attendance rate twice that of less deprived quintiles, the adjusted analysis showed their attendance to be 13% lower (0.87, 95% CI 0.81 to 0.94) despite a higher population CHD mortality rate.
Conclusion
There is evidence of underutilisation of chest pain clinics by older people and those from lower socioeconomic status. More robust and patient focused administrative pathways need to be developed to detect inequity, correction of which has the potential to substantially reduce coronary mortality.
Article summary
Article focus
Is access to chest pain clinics of people with recent onset symptoms equitable according to local need and consistent with national policy.
Key messages
Need for evaluation in chest pain clinics will vary according to the variable incidence of heart disease in different age, gender, socioeconomic and ethnic groups.
There is evidence of underutilisation of chest pain clinics by older people and those from lower socioeconomic status.
Strengths and limitations of this study
Large, diverse and unselected patient population with uniformly collected patient-level data, allowing robust comparisons between demographic and clinical groups.
Ecological fallacy with respect to age and sex has been avoided by applying an enhanced ecological analysis.
Need to use census wards, not postcodes, as the smallest geographical areas for which mortality and demographic data were available.
Ethnicity was not based on self-ascription.
doi:10.1136/bmjopen-2012-001025
PMCID: PMC3378943  PMID: 22700834
17.  Treading carefully: a qualitative ethnographic study of the clinical, social and educational uses of exercise ECG in evaluating stable chest pain 
BMJ Open  2012;2(1):e000508.
Objective
To examine functions of the exercise ECG in the light of the recent National Institute for Health and Clinical Excellence guidelines recommending that it should not be used for the diagnosis or exclusion of stable angina.
Design
Qualitative ethnographic study based on interviews and observations of clinical practice.
Setting
3 rapid access chest pain clinics in England.
Participants
Observation of 89 consultations in chest pain clinics, 18 patient interviews and 12 clinician interviews.
Main outcome measure
Accounts and observations of consultations in chest pain clinics.
Results
The exercise ECG was observed to have functions that extended beyond diagnosis. It was used to clarify a patient's story and revise the initial account. The act of walking on the treadmill created an additional opportunity for dialogue between clinician and patient and engagement of the patient in the diagnostic process through precipitation of symptoms and further elaboration of symptoms. The exercise ECG facilitated reassurance in relation to exercise capacity and tolerance, providing a platform for behavioural advice particularly when exercise was promoted by the clinician.
Conclusions
Many of the practices that have been built up around the use of the exercise ECG are potentially beneficial to patients and need to be considered in the re-design of services without that test. Through its contribution to the patient's history and to subsequent advice to the patient, the exercise ECG continues to inform the specialist assessment and management of patients with new onset stable chest pain, beyond its now marginalised role in diagnosis.
Article summary
Article focus
Given the widespread use of the exercise ECG in assessments of patients with stable chest pain, this paper seeks to understand its role in the light of emerging evidence about its poor performance as a diagnostic test.
This paper reports on the functions of the exercise ECG in UK chest pain clinics, highlighting those uses that go beyond its diagnostic function.
This paper is part of an international debate about the appropriate initial tests for patients with new onset stable chest pain.
Key messages
The exercise ECG has additional functions that transcend its technical contribution to diagnosis: it can help clarify symptoms and other aspects of the clinical history, engage the patient in the diagnostic process, provide a context for guidance on reversible cardiovascular risk factors, be used to better involve and reassure patients and has the potential use for tailored lifestyle advice.
Through its contribution to the patient's history and to subsequent advice to the patient, the exercise ECG continues to inform the specialist assessment and management of patients with new onset stable chest pain, beyond its now marginalised role in diagnosis.
Many of the practices that have been built up around the use of the exercise ECG are potentially beneficial to patients. As chest pain clinic services are re-configured without the test, in line with UK national (National Institute for Health and Clinical Excellence (NICE)) guidance, these practices need to be integrated into new diagnostic pathways.
Strengths and limitations of this study
A strength of our study is its ethnographic design incorporating the observation of patient–clinician consultations and combining these data with interviews: we knew what participants did as well as said.
The fieldwork was undertaken at a key time just before the introduction of the UK's 2010 NICE guidelines and therefore provides an understanding of current practice that can inform their implementation.
A limitation of our study is that data were collected largely from two chest pain clinics, potentially limiting the transferability of the findings, although the clinicians in the research team thought that the clinics were not atypical compared to others they had experienced.
doi:10.1136/bmjopen-2011-000508
PMCID: PMC3277903  PMID: 22318662
19.  Patients' descriptions of angina symptoms: a qualitative study of primary care patients 
Background
Initial diagnosis of angina in primary care is based on the history of symptoms as described by the patient in consultation with their GP. Deciphering and categorising often complex symptom narratives, therefore, represents an ongoing challenge in the early diagnosis of angina in primary care.
Aim
To explore how patients with a preexisting angina diagnosis describe their symptoms.
Method
Semi-structured interviews were conducted with 64 males and females, identified from general practice records as having received a diagnosis of angina within the previous 5 years.
Results
While some patients described their angina symptoms in narratives consistent with typical anginal symptoms, others offered more complex descriptions of their angina experiences, which were less easy to classify. The latter was particularly the case for severe coronary artery disease, where some patients tended to downplay chest pain or attribute their experience to other causes.
Conclusion
Patients with a known diagnosis of angina do not always describe their symptoms in a way that is consistent with Diamond and Forrester’s diagnostic framework for typicality of angina. Early diagnosis of angina in primary care requires that GPs operate with a broad level of awareness of the various ways in which their patients describe their symptoms.
doi:10.3399/bjgp10X532378
PMCID: PMC2944932  PMID: 20883622
angina pectoris; coronary artery disease; diagnosis; qualitative research; primary health care
20.  Does self-regulation and autonomic regulation have an influence on survival in breast and colon carcinoma patients? results of a prospective outcome study 
Background
Cancer Related Fatigue (CRF) and circadian rhythm have a great impact on the quality of life (HRQL) of patients with breast (BC) and colon cancer (CRC). Other patient related outcomes in oncology are measured by new instruments focusing on adaptive characteristics such as sense of coherence or self-regulation, which could be more appropriate as a prognostic tool than classical HRQL. The aim of this study was to assess the association of autonomic regulation (aR) and self-regulation (SR) with survival.
Methods
146 cancer patients and 120 healthy controls took part in an initial evaluation in 2000/2001. At a median follow up of 5.9 years later, 62 of 95 BC, 17 of 51 CRC patients, and 85 of 117 healthy controls took part in the follow-up study. 41 participants had died. For the follow-up evaluation, participants were requested to complete the standardized aR and SR questionnaires.
Results
On average, cancer patients had survived for 10.1 years with the disease. Using a Cox proportional hazard regression with stepwise variables such as age, diagnosis group, Charlson co-morbidity index, body mass index (BMI)) aR and SR. SR were identified as independent parameters with potential prognostic relevance on survival While aR did not significantly influence survival, SR showed a positive and independent impact on survival (OR = 0.589; 95%-CI: 0.354 - 0.979). This positive effect persisted significantly in the sensitivity analysis of the subgroup of tumour patients and in the subscale 'Achieve satisfaction and well-being' and by tendency in the UICC stages nested for the different diagnoses groups.
Conclusions
Self-regulation might be an independent prognostic factor for the survival of breast and colon carcinoma patients and merits further prospective studies.
doi:10.1186/1477-7525-9-85
PMCID: PMC3192663  PMID: 21961625
Autonomic regulation (aR); breast cancer; colorectal cancer; coping; self-regulation (SR)
21.  Threshold Haemoglobin Levels and the Prognosis of Stable Coronary Disease: Two New Cohorts and a Systematic Review and Meta-Analysis 
PLoS Medicine  2011;8(5):e1000439.
Anoop Shah and colleagues performed a retrospective cohort study and a systematic review, and show evidence that in people with stable coronary disease there were threshold hemoglobin values below which mortality increased in a graded, continuous fashion.
Background
Low haemoglobin concentration has been associated with adverse prognosis in patients with angina and myocardial infarction (MI), but the strength and shape of the association and the presence of any threshold has not been precisely evaluated.
Methods and findings
A retrospective cohort study was carried out using the UK General Practice Research Database. 20,131 people with a new diagnosis of stable angina and no previous acute coronary syndrome, and 14,171 people with first MI who survived for at least 7 days were followed up for a mean of 3.2 years. Using semi-parametric Cox regression and multiple adjustment, there was evidence of threshold haemoglobin values below which mortality increased in a graded continuous fashion. For men with MI, the threshold value was 13.5 g/dl (95% confidence interval [CI] 13.2–13.9); the 29.5% of patients with haemoglobin below this threshold had an associated hazard ratio for mortality of 2.00 (95% CI 1.76–2.29) compared to those with haemoglobin values in the lowest risk range. Women tended to have lower threshold haemoglobin values (e.g, for MI 12.8 g/dl; 95% CI 12.1–13.5) but the shape and strength of association did not differ between the genders, nor between patients with angina and MI. We did a systematic review and meta-analysis that identified ten previously published studies, reporting a total of only 1,127 endpoints, but none evaluated thresholds of risk.
Conclusions
There is an association between low haemoglobin concentration and increased mortality. A large proportion of patients with coronary disease have haemoglobin concentrations below the thresholds of risk defined here. Intervention trials would clarify whether increasing the haemoglobin concentration reduces mortality.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Coronary artery disease is the main cause of death in high-income countries and the second most common cause of death in middle- and low-income countries, accounting for 16.3%, 13.9%, and 9.4% of all deaths, respectively, in 2004. Many risks factors, such as high blood pressure and high blood cholesterol level, are known to be associated with coronary artery disease, and prevention and treatment of such factors remains one of the key strategies in the management of coronary artery disease. Recent studies have suggested that low hemoglobin may be associated with mortality in patients with coronary artery disease. Therefore, using blood hemoglobin level as a prognostic biomarker for patients with stable coronary artery disease may be of potential benefit especially as measurement of hemoglobin is almost universal in such patients and there are available interventions that effectively increase hemoglobin concentration.
Why was This Study Done?
Much more needs to be understood about the relationship between low hemoglobin and coronary artery disease before hemoglobin levels can potentially be used as a clinical prognostic biomarker. Previous studies have been limited in their ability to describe the shape of this relationship—which means that it is uncertain whether there is a “best” hemoglobin threshold or a continuous graded relationship from “good” to “bad”—to assess gender differences, and to compare patients with angina or who have experienced previous myocardial infarction. In order to inform these knowledge gaps, the researchers conducted a retrospective analysis of patients from a prospective observational cohort as well as a systematic review and meta-analysis (statistical analysis) of previous studies.
What Did the Researchers Do and Find?
The researchers conducted a systematic review and meta-analysis of previous studies and found ten relevant studies, but none evaluated thresholds of risk, only linear relationships.
The researchers carried out a new study using the UK's General Practice Research Database—a national research tool that uses anonymized electronic clinical records of a representative sample of the UK population, with details of consultations, diagnoses, referrals, prescriptions, and test results—as the basis for their analysis. They identified and collected information from two cohorts of patients: those with new onset stable angina and no previous acute coronary syndrome; and those with a first myocardial infarction (heart attack). For these patients, the researchers also looked at all values of routinely recorded blood parameters (including hemoglobin) and information on established cardiovascular risk factors, such as smoking. The researchers followed up patients using death of any cause as a primary endpoint and put this data into a statistical model to identify upper and lower thresholds of an optimal hemoglobin range beyond which mortality risk increased.
The researchers found that there was a threshold hemoglobin value below which mortality continuously increased in a graded manner. For men with myocardial infarction, the threshold value was 13.5 g/dl: 29.5% of patients had hemoglobin below this threshold and had a hazard ratio for mortality of 2.00 compared to those with hemoglobin values in the lowest risk range. Women had a lower threshold hemoglobin value than men: 12.8 g/dl for women with myocardial infarction, but the shape and strength of association did not differ between the genders, or between patients with angina and myocardial infarction.
What Do These Findings Mean?
These findings suggest that there are thresholds of hemoglobin that are associated with increased risk of mortality in patients with angina or myocardial infarction. A substantial proportion of patients (15%–30%) have a hemoglobin level that places them at markedly higher risk of death compared to patients with lowest risk hemoglobin levels and importantly, these thresholds are higher than clinicians might anticipate—and are remarkably similar to World Health Organization anemia thresholds of 12 g/dl for women and 13 g/dl for men. Despite the limitations of these observational findings, this study supports the rationale for conducting future randomized controlled trials to assess whether hemoglobin levels are causal and whether clinicians should intervene to increase hemoglobin levels, for example by oral iron supplementation.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000439.
Wikipedia provides information about hemoglobin (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The World Health Organization provides an overview of the global prevalence of coronary artery disease, a factsheet on the top ten causes of death, as well as information on anemia
doi:10.1371/journal.pmed.1000439
PMCID: PMC3104976  PMID: 21655315
22.  Development of the AGREE II, part 1: performance, usefulness and areas for improvement 
Background
We undertook research to improve the AGREE instrument, a tool used to evaluate guidelines. We tested a new seven-point scale, evaluated the usefulness of the original items in the instrument, investigated evidence to support shorter, tailored versions of the tool, and identified areas for improvement.
Method
We report on one component of a larger study that used a mixed design with four factors (user type, clinical topic, guideline and condition). For the analysis reported in this article, we asked participants to read a guideline and use the AGREE items to evaluate it based on a seven-point scale, to complete three outcome measures related to adoption of the guideline, and to provide feedback on the instrument’s usefulness and how to improve it.
Results
Guideline developers gave lower-quality ratings than did clinicians or policy-makers. Five of six domains were significant predictors of participants’ outcome measures (p < 0.05). All domains and items were rated as useful by stakeholders (mean scores > 4.0) with no significant differences by user type (p > 0.05). Internal consistency ranged between 0.64 and 0.89. Inter-rater reliability was satisfactory. We received feedback on how to improve the instrument.
Interpretation
Quality ratings of the AGREE domains were significant predictors of outcome measures associated with guideline adoption: guideline endorsements, overall intentions to use guidelines, and overall quality of guidelines. All AGREE items were assessed as useful in determining whether a participant would use a guideline. No clusters of items were found more useful by some users than others. The measurement properties of the seven-point scale were promising. These data contributed to the refinements and release of the AGREE II.
doi:10.1503/cmaj.091714
PMCID: PMC2900328  PMID: 20513780
23.  Development of the AGREE II, part 2: assessment of validity of items and tools to support application 
Background
We established a program of research to improve the development, reporting and evaluation of practice guidelines. We assessed the construct validity of the items and user’s manual in the β version of the AGREE II.
Methods
We designed guideline excerpts reflecting high-and low-quality guideline content for 21 of the 23 items in the tool. We designed two study packages so that one low-quality and one high-quality version of each item were randomly assigned to each package. We randomly assigned 30 participants to one of the two packages. Participants reviewed and rated the guideline content according to the instructions of the user’s manual and completed a survey assessing the manual.
Results
In all cases, content designed to be of high quality was rated higher than low-quality content; in 18 of 21 cases, the differences were significant (p < 0.05). The manual was rated by participants as appropriate, easy to use, and helpful in differentiating guidelines of varying quality, with all scores above the mid-point of the seven-point scale. Considerable feedback was offered on how the items and manual of the β-AGREE II could be improved.
Interpretation
The validity of the items was established and the user’s manual was rated as highly useful by users. We used these results and those of our study presented in part 1 to modify the items and user’s manual. We recommend AGREE II (available at www.agreetrust.org) as the revised standard for guideline development, reporting and evaluation.
doi:10.1503/cmaj.091716
PMCID: PMC2900368  PMID: 20513779
24.  Prognosis of stable angina pectoris: why we need larger population studies with higher endpoint resolution 
Heart  2006;93(7):786-791.
The prognosis of angina was described as “"unhappy” by the Framingham investigators and as little different from that of 1‐year survivors of acute myocardial infarction. Yet recent clinical trials now report that angina has a good prognosis with adverse outcomes reduced to “normal levels”. These disparate prognostic assessments may not be incompatible, applying as they do to population cohorts (Framingham) and selected participants in clinical trials. Comparisons between studies are further complicated by the absence of agreed case definitions for stable angina (contrast this with acute coronary syndromes). Our recent data show that for patients with recent onset symptoms attending chest pain clinics, angina remains a high‐risk diagnosis and although many patients receive symptomatic benefit from revascularisation, prognosis is usually unaffected. This leaves little room for complacency and, with angina the commonest initial manifestation of coronary artery disease, there is the opportunity for early detection, risk stratification and treatment to modify outcomes. Meanwhile, larger population‐based studies are needed to define the patient journey from earliest presentation through the various syndrome transitions to coronary or noncardiac death in order to increase understanding of the aetiological and prognostic differences between the different coronary disease phenotypes.
doi:10.1136/hrt.2006.103119
PMCID: PMC1994448  PMID: 16952966
25.  Cardiothoracic ratio within the “normal” range independently predicts mortality in patients undergoing coronary angiography 
Heart  2006;93(4):491-494.
Objective
To determine whether cardiothoracic ratio (CTR), within the range conventionally considered normal, predicted prognosis in patients undergoing coronary angiography.
Design
Cohort study with a median of 7‐years follow‐up.
Setting
Consecutive patients undergoing coronary angiography at Barts and The London National Health Service (NHS) Trust.
Subjects
1005 patients with CTRs measured by chest radiography, and who subsequently underwent coronary angiography. Of these patients, 7.3% had a CTR ⩾0.5 and were excluded from the analyses.
Outcomes
All‐cause mortality and coronary event (non‐fatal myocardial infarction or coronary death). Adjustments were made for age, left ventricular dysfunction, ACE inhibitor treatment, body mass index, number of diseased coronary vessels and past coronary artery bypass graft.
Results
The risk of death was increased among patients with a CTR in the upper part of the normal range. In total, 94 (18.9%) of those with a CTR below the median of 0.42 died compared with 120 (27.8%) of those with a CTR between 0.42 and 0.49 (log rank test p<0.001). After adjusting for potential confounders, this increased risk remained (adjusted HR 1.45, 95% CI 1.03 to 2.05). CTR, at values below 0.5, was linearly related to the risk of coronary event (test for trend p = 0.024).
Conclusion
: In patients undergoing coronary angiography, CTR between 0.42 and 0.49 was associated with higher mortality than in patients with smaller hearts. There was evidence of a continuous increase in risk with higher CTR. These findings, along with those in healthy populations, question the conventional textbook cut‐off point of ⩾0.5 being an abnormal CTR.
doi:10.1136/hrt.2006.101238
PMCID: PMC1861494  PMID: 17164481

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