Scottish Population Research Articles

Oral Health and Risk of Arthritis in the Scottish Population: Results from the Scottish Health Survey.

ABSTRACTObjectivesTo investigate the link between self-reported oral health and arthritis in the Scottish population using data from the Scottish Health Survey.Material and MethodsData were available from 2008 to 2013 on self-reported arthritis, oral health conditions and oral hygiene habits from the Scottish Health Survey. Arthritis was defined in this survey by self-reported long standing illness, those who reported having arthritis, rheumatism and/or fibrositis. Oral conditions were defined by self-reported bleeding gums, toothache, biting difficulties and/or edentulousness. Oral hygiene habits were defined by self-reported brushing teeth and/or using dental floss on daily basis. Logistic regression was used for statistical analysis adjusted for age, gender, qualification, smoking and body mass index.ResultsPrevalence of self-reported arthritis was 9.3% (95% confidence interval [CI] = 9.03 to 9.57). Those who reported having bleeding gums (adjusted odds ratio [OR] = 1.63; 95% CI = 1.35 to 1.96), toothache (OR = 1.32; 95% CI = 1.16 to 1.5), biting difficulties (OR = 1.95; 95% CI = 1.62 to 2.34), and being edentulous (OR = 1.22; 95% CI = 1.08 to 1.37) had an increased risk of arthritis. Brushing teeth (OR = 1.25; 95% CI = 0.74 to 2.12), and using dental floss (OR = 1.11; 95% CI = 0.89 to 1.39) were not associated with arthritis.ConclusionsSelf-reported oral conditions were associated with increased risk of self-reported arthritis. Oral hygiene habits were not associated with self-reported arthritis. Further investigation is required to assess the causal association between oral hygiene, oral disease and arthritis.

Per-protocol investigation of a best practice exercise referral scheme

ObjectivesTo investigate the effects of an exercise referral scheme (ERS) aligned to the UK best practice guidelines on a range of outcomes including those associated with key health concerns of the Scottish population. Study designA longitudinal design with data collection at three time points (baseline, midway and post) during a 12-week ERS intervention was employed. MethodsHealth-related physical fitness was assessed through measurement of resting heart rate, blood pressure, FEV1:FEV6 (ratio of forced expiratory volume over one [FEV1] and six [FEV6] seconds), body mass and peak oxygen uptake (VO2 peak), whilst functional capacity was assessed through the five times sit to stand test. Psychosocial well-being and quality of life were measured using the World Health Organization Quality of Life questionnaire (WHOQOL-BREF) and the Profile of Mood State questionnaires. Growth curve analyses were used to model each outcome variable across the three time periods. ResultsA range of effects were obtained with significant linear improvements in physical performance tests (P < 0.001) and psychosocial assessments (P ≤ 0.002). Additionally, significant quadratic effects of time were obtained for body composition variables and physical activity levels (P < 0.001) with the greatest improvements obtained between baseline and midway assessments. ConclusionsAn ERS aligned to the UK best practice guidelines can positively influence a range of health outcomes including those associated with lung function and cardiovascular fitness which are prevalent medical conditions in Scotland. In addition, results indicate that ERS can positively affect outcomes related to functional capacity as well as mental well-being and perceptions of health. The findings of the study identify the need for further investigation including consideration of the initial health status of referred clients.

Persistent Pain After Caesarean Section and Its Association With Maternal Anxiety and Socioeconomic Background

(Abstracted from Int J Obstet Anesth, 29:57–63, 2017) The purpose of this prospective longitudinal observational cohort study was to define the incidence of new persistent pain after elective cesarean delivery in a largely socially deprived, urban Scottish population. The authors also aimed to correlate antenatal anxiety with persistent pain.

The subversive challenges of multimorbidity.

Epidemiology often reveals important insights by applying simple definitions and measurements to large numbers of people so that they can be studied in groups. A common approach is to define multimorbidity as having two or more conditions. A landmark study that used this approach showed multimorbidity increased with age, with an onset 10–15 years earlier in socioeconomically deprived areas.1 In this Scottish population, although prevalence rose with age, the demographic shape of the population determined that most people with multimorbidity were <65 years of age. Such observations are useful but in clinical practice a definition based on two or more conditions can be of little consequence. The commonest comorbidity in older people is hypertension, so that only one other condition is required to meet the definition of multimorbidity. This case definition offers little new challenge to clinicians or to services. On the other hand, the commonest comorbidity in deprived areas is a mental health problem,1 whose combination with another condition is likely to complicate the care that patients need and receive. More demanding case definitions — such as five or more conditions, the combination of a physical and psychological health problem, or three or more chronic conditions from three or more body systems — have smaller prevalences but steeper social gradients, and present a significantly greater clinical challenge.2,3 Even so, many patients with multiple conditions are not ‘complex’, whereas some patients with single conditions are very ‘complex’. Such distinctions draw on a wider body of knowledge concerning not only the individual but also their circumstances. For example, in the Care Plus Study, involving a randomised controlled trial of increased consultation time with a GP for patients ‘with complex problems’ in very deprived areas, it was impossible to agree on an operational definition of ‘complexity’.4 …

Socioeconomic status and susceptibility to alcohol-related harm

Socioeconomic status and susceptibility to alcohol-related harm

The impact of dapagliflozin on HbA1c, systolic blood pressure and weight: a review of dapagliflozin use in a Scottish city

AbstractWe aimed to determine the efficacy of dapagliflozin in the management of type 2 diabetes in a Scottish population through measurements of glycaemic control, blood pressure and weight.Dapagliflozin was effective in improving HbA1c by 10 mmol/mol (SE 1.8, p &lt; 0.001), systolic blood pressure by 9.8mmHg (SE 2.2, p &lt; 0.001) and weight by 3.2 kg (SE 0.6, p &lt; 0.001). There was a significant proportion of people with diabetes who reported side effects with dapagliflozin relating to genital and urinary tract infections.Dapagliflozin appears to be an effective drug in improving HbA1c, systolic blood pressure and weight in people with type 2 diabetes. However, in this cohort a substantial proportion of people with diabetes did not tolerate this drug due to side effects. Copyright © 2017 John Wiley &amp; Sons.

Religious Change and Secularisation in Scotland: An Analysis of Affiliation and Attendance

Building on Brown (1997) and Field's (2001) research into religious decline and secularisation in Scotland in the later decades of the 20th-century, this article uses data from recurrent social surveys, nationally-representative of the Scottish adult population, to assess the nature and extent of religious change in the 21st-century. It examines recent trends in religious affiliation and attendance in Scotland, compares key indicators in England and Scotland to assess areas of similarity and difference in terms of religion and secularity, and assesses the contemporary socio-demographic basis of affiliation and attendance in Scotland. The empirical results show that religious affiliation and attendance have further attenuated in Scotland in recent years, with a growing proportion of adults reporting that they were raised outside of any religious tradition. Indicators of secularity are most marked amongst younger age groups. The ‘haemorrhage of faith’ documented in the latter part of the 20th-century in Scotland has continued into the early part of the 21st-century.

Long term health effects of NEET experiences: evidence from a longitudinal analysis of young people in Scotland

ABSTRACTBackgroundThis paper examines whether experiences of young people who are not in employment, education or training (NEET) are associated with adverse long-term outcomes in health. We used the Scottish Longitudinal Study (SLS), which includes information from the 1991, 2001, and 2011 censuses as well as from vital events, for a 5.3% representative sample of the Scottish population. Linked health data such as hospital admissions and prescribing in general practice are also available. We followed around 14,000 young people who were aged 16-19 in 1991 up to 2011.&#x0D; MethodWe explored whether NEET young people in 1991 displayed higher risks of poor physical and mental health in the follow-up period. Poor physical health is measured by any admission into hospital and poor mental health is measured by prescription of anti-depressant and anti-anxiety medicine. We used descriptive and modelling approaches in our analysis. Covariates include a number of individual socioeconomic characteristics and local area characteristics in the models.&#x0D; ResultsOur research found that over 40% of the cohort members have been admitted into hospital, while over 30% have been prescribed with anti-depressant and anti-anxiety drugs. The NEET status in 1991 appears to be associated with hospitalisation with adjusted odds ratio (OR) of 1.24 (95% Confidence Intervals (CIs): 1.08 – 1.42). Also the NEET experiences are associated with poor mental health with OR of 1.47 (95% CI: 1.27 – 1.71). Policy intervention is necessary in assisting NEET young people to re-engage in education or employment.

Lessons learned from linking to 2001 census in Scotland

ABSTRACT&#x0D; ObjectivesSHELS (Scottish Health and Ethnicity Linkage Study) linked Scotland's 2001 census to various hospital and death data sets with national coverage. Census ethnicity data were assigned to the study records to build a cohort of most of the Scottish population; included in the cohort were people with no health records.&#x0D; ApproachCreate a lookup table of a person's census index to the Scottish eHealth index, the CHI, equivalent of English new national health number. A modified versionof the eHealth administrative matching system was used to satisfy census confidentiality requirements. There were two linkages performed in 2004 and 2008. 2004 was a feasibility run; the 2008 applied lessons learned from the previous linkage and used much more completely indexed health records.&#x0D; ResultsThe first linkage produced match rate of 95% of 4.9 million 2001 census entries; the second 96%.&#x0D; Conclusions&#x0D; Lessons learned. Linking datasets using indexes is the most accurate and efficient way to produce study cohorts. Indices change over time; a methodology called 'reconciliation' was devised to retrospectively and continually adjust previously indexed (linked) records.&#x0D; How to Track members who migrate out of the cohort. A linkage resource called a residential events dataset (RESEVENT) was built for the 2008 linkage run; it holds merged history of linkage identifier fields by date from january 2000 to the present based on GP registrations.&#x0D; This introduces a time dimension to indexed linking.How to build RESEVENT like linkage resources; should they be census based? What should they contain? How to do daily national census and select controls for case/control cohorts from RESEVENT resource.&#x0D; How postcode changes over time can be handled (reconciled) - same address, different postcode, but no address present. Proposal for an index of national indices based on national administrative datasets starting with NHS number (new and old NHSCR) and NI number to make linking even more efficient - this is not a RESEVENT resource; this resource would mean data need be matched to index only once, all subsequent linkages would be deterministic links of reconciled indices.

Parental social position, in utero growth and risk of child development disorders: an administrative data based prospective cohort study

ABSTRACTObjectivesTo evaluate the influences of low birthweight and socioeconomic status upon child development disorders&#x0D; ApproachIt has been recognised that low birthweight and socio-economic status impact cognitive development in children. Previous studies in Scotland investigated this relationship using the Scottish Mental Health Survey 1932, the Growing Up in Scotland (GUS) longitudinal survey, and the Aberdeen Children of the 1950s study. This paper examines this using the Scottish Longitudinal Study (SLS) linked with Maternity Inpatient and Day Case records and Child Health Systems Programme Pre-School (CHSP Pre-School) records. This is original because it extends previous work through large-scale contemporary data which has been routinely collected and is representative of the Scottish population. It also includes a novel design through the use of birth data from parents and children recorded within the SLS.&#x0D; ResultsFrom this research it was identified that these child development measures were strongly associated with gestational-age specific birthweight and that fine motor, social and hearing abnormalities were much more likely for children with parents in lower grade occupations or who were long-term unemployed. These associations were net of other indicators of family socioeconomic position and birth outcomes, suggesting that infants from disadvantaged backgrounds remained more likely to experience these conditions beyond the differences that could be explained by other relevant factors (such as their birthweight).&#x0D; ConclusionThese findings confirm and build upon previous analysis through the use of linked administrative data.

Ethnic Variations in Liver- and Alcohol-Related Disease Hospitalisations and Mortality: The Scottish Health and Ethnicity Linkage Study.

Aims Preventing alcohol-related harms, including those causing liver disease, is a public health priority in the UK, especially in Scotland, but the effects of ethnicity are not known. We assessed liver- and alcohol-related events (hospitalisations and deaths) in Scotland using self-reported measures of ethnicity. Methods Linking Scottish NHS hospital admissions and mortality to the Scottish Census 2001, we explored ethnic differences in hospitalisations and mortality (2001–2010) of all liver diseases, alcoholic liver disease (ALD) and specific alcohol-related diseases (ARD). Risk ratios (RR) were calculated using Poisson regression with robust variance, by sex, adjusted for age, country of birth and the Scottish Index of Multiple Deprivation (SIMD) presented below. The White Scottish population was the standard reference population with 95% confidence intervals (CI) calculated to enable comparison (multiplied by 100 for results). Results For all liver diseases, Chinese had around 50% higher risks for men (RR 162; 95% CI 127–207) and women (141; 109–184), as did Other South Asian men (144; 104–201) and Pakistani women (140; 116–168). Lower risks for all liver diseases occurred in African origin men (42; 24–74), other White British men (72; 63–82) and women (80; 70–90) and other White women (80; 67–94). For ALD, White Irish had a 75% higher risk for men (175; 107–287). Other White British men had about a third lower risk of ALD (63; 50–78), as did Pakistani men (65; 42–99). For ARD, almost 2-fold higher risks existed for White Irish men (182; 161–206) and Any Mixed Background women (199; 152–261). Lower risks of ARD existed in Pakistani men (67; 55–80) and women (48; 33–70), and Chinese men (55; 41–73) and women (54; 32–90). Conclusions Substantial variations by ethnicity exist for both alcohol-related and liver disease hospitalisations and deaths in Scotland: these exist in subgroups of both White and non-White populations and practical actions are required to ameliorate these differences.

Development of an Australian cardiovascular disease mortality risk score using multiple imputation and recalibration from national statistics

ObjectiveTo develop and recalibrate an Australian 5-year cardiovascular disease (CVD) mortality risk score to produce contemporary predictions of risk.MethodsData were pooled from six Australian cohort studies (n = 54,829), with baseline data collected between 1989 and 2003. Participants included were aged 40–74 years and free of CVD at baseline. Variables were harmonised across studies and missing data were imputed using multiple imputation. Cox proportional hazards models were used to estimate the risk of CVD mortality associated with factors mutually independently predictive (p < 0.05) and a 5-year risk prediction algorithm was constructed. This algorithm was recalibrated to reflect contemporary national levels of CVD mortality and risk factors using national statistics.ResultsOver a mean 16.6 years follow-up, 1375 participants in the six studies died from CVD. The prediction model included age, sex, smoking, diabetes, systolic blood pressure, total and high-density lipoprotein cholesterol (HDLC), a social deprivation score, estimated glomerular filtration rate and its square and interactions of sex with diabetes, HDLC and deprivation score, and of age with systolic blood pressure and smoking. This model discriminated well when applied to a Scottish study population (c-statistic (95% confidence interval): 0.751 (0.709, 0.793)). Recalibration generally increased estimated risks, but well below those predicted by the European SCORE models.ConclusionsThe resulting risk score, which includes markers of both chronic kidney disease and socioeconomic deprivation, is the first CVD mortality risk prediction tool for Australia to be derived using Australian data. The primary model, and the method of recalibration, is applicable elsewhere.

OA14.07 The Relationship between Lung Cancer Stigma and Patient Reported Outcomes

Patients with lung cancer (LC) report lower quality of life (QoL) and higher levels of psychological distress compared to other cancer populations (Hewitt et al, 2013). Lung cancer stigma (LCS) may in part explain these findings. Evidence from studies in the Unites States has shown associations between LCS and lower QoL, higher symptom burden and higher levels of anxiety and depression (Cataldo et al, 2013). Whether these associations exist in people diagnosed with LC in the United Kingdom is unknown. Therefore this study explored the prevalence of LCS and its relationship with patient outcomes as well as QoL in a Scottish population. This study was a cross-sectional study. Patients (n=201) diagnosed with LC were recruited by health care professionals at follow-up clinics at four hospitals in Scotland. Participants completed questionnaires to collect demographic data and assess perceived LCS, QoL, symptom severity and level of depression. Clinical data was collected by case note review. Bivariate correlations were performed to investigate the relationships between stigma, demographics, and patient outcomes. Multiple regression further explored the individual contributions of LCS on symptom burden and quality of life. Participants had a mean age of 69 years (range 41-89 years), 46.8% were males, 92.0% were ever smokers, 17.9% current smokers. The mean LCS score was 53.1 (SD=14.1, range 31-124,). There were significant correlations between higher LCS and age (r= -0.28, p<0.001), being a current smoker (r= 0.17, p<0.05), deprivation index (r=0.15, p<0.05) depression (r=0.40, p<0.001), symptom burden (r=2.60, p<0.001), and QoL (r= - 0.52, p<0.001). Multiple regression revealed an overall model that explained 30.6% of the total variance of stigma (F=14.82, p<0.001). Perceived stigma also accounted for significant unique variance in QoL (4.3%, p<0.001) and depression (3.6%, p<0.001) above and beyond that accounted for by relevant variables. No contribution of stigma on symptom burden was found. Stigma was correlated with depression, and QoL. Therefore, it is expected that depression and stigma share some of the explanation of variance of QoL. Nevertheless, stigma was found to have a unique contribution on QoL, and on depression. With this in mind, management of patients with LC could determine the patients’ experience of stigma to tailor treatment plans to improve QoL and psychosocial outcomes. Being younger was correlated with higher LCS. This might reflect changed attitudes toward smoking due to changed marketing strategies in the 1960s.

Development of a diet quality index for the Scottish population

Secondary analysis of food purchase data has been used to monitor progress towards Scottish Dietary Targets (Goals) since 2001, however little work has been carried out to assess the overall quality of the diet of the Scottish population. A diet quality index (DQI) is a useful tool that provides an overall rating of an individual's dietary intake in reference to nutrient and/or dietary recommendations or a diet pattern that is considered to be beneficial to health. Numerous diet quality indices have been created as summary measures of diet, but to our knowledge, none are available that include all of the Scottish Dietary Goals.

P1.02-007 Alk Translocated NSCLC in the West of Scotland: Patient Demographics and Outcomes

A translocation in the anaplastic lymphoma kinase gene is found in 3-5% of non-small cell lung cancer (NSCLC). Patients with this mutation (ALK+) have shown marked responses to the tyrosine kinase inhibitor crizotinib. Second line Crizotinib has been available in Scotland since October 2013 for patients with ALK+ NSCLC. Since January 2014, reflex testing at diagnosis of all non-squamous NSCLC has been carried out in the West of Scotland (WoS) regardless of stage. Here we present the demographics of an Alk +ve cohort from an unselected Scottish NSCLC population and their clinical outcomes. Details of patients with Alk+ NSCLC were obtained from the regional molecular genetics laboratory. 60 patients with NSCLC from WoS tested ALK+ between 1st January 2014 and 30th June 2016. Patient records were reviewed retrospectively. Median laboratory turnaround for alk testing was 21 days in 2014, 14 days in 2015 and 13 days in 2016. 3 (5%) patients were under 50 years, 8 (13%) 50-60 years, 23 (38%) 60-70 years, 17 (28%) 70-80 years and 9 (15%) patients were > 80 years old at time of testing. Median age was 69. 55% were male and 45% female. 67% were current or ex-smokers. Only 22% were never-smokers. The majority (82%) had stage 3 or 4 disease at diagnosis. Only 39% (17/38) of patients with stage 4 ALK+ NSCLC were well enough to receive chemotherapy and 4 of these (24%) did not complete all planned cycles. 10 patients have received crizotinib so far. Median number of cycles is 3 overall (range 1-9). Where documented, reasons for discontinuation were disease progression or death from NSCLC (4), sudden death not related to NSCLC (2), intercurrent illness (2) and pneumonitis (1) . 3 patients continue on crizotinib as of June 2016. Of the 13 patients who have received crizotinib, 3 have had a PR, 4 SD 2 PD and 4 NE. Updated outcomes will be presented. A high quality reflex ALK testing service is being delivered in WoS with clinically acceptable turnaround times. Our ALK+ patients do not entirely reflect the literature and are frequently elderly, current or ex-smokers with advanced and aggressive disease. This may reflect the unselected nature of this population. Many Alk+ patients were too unwell to receive chemotherapy or tolerated it poorly and did not have the opportunity to access an alk inhibitor. First line Alk inhibitors may improve outcomes for this group of patients.

Minimising orphaning in the brown hare Lepus europaeus in England and Wales: should a close season be introduced?

The European brown hare Lepus europaeus is an r‐selected species showing relatively high fecundity, and changes in the hare population can be influenced by the timing of hunting and reproductive activity. Between February and August in Europe, the majority of female hares are either pregnant or suckling young, or both, and if a female is killed during the suckling period, the young hares (leverets) are orphaned and are likely to die of starvation. In England and Wales, in contrast with other European countries, there is no close season when hunting hares is prohibited, and the peak time of hunting in February coincides with the start of reproductive activity. We explore the impact of hunting practices on the risk of death by starvation of dependent young. By modelling scenarios of hunting at the highest documented rate at times of the year based on practices adopted in England and Wales, and by comparing this with the close season practice in Scotland, we quantify seasonally variable risks of orphaning and death by starvation of leverets. Hunting in February leads to a profoundly damaging combination of population shrinkage (λ = 0.534) and levels of orphaning of leverets corresponding to 7.6% of the year start population and thus providing poor welfare and poor population recovery outcomes for the hare. These illustrative figures compare very unfavourably with the modelled Scottish population which has a growth rate of λ = 1.404 and levels of orphaning of leverets corresponding to 0.3% of the year start population. We anticipate that these findings will stimulate consideration of the impact of hunting practices, and that increased understanding of the effects of the timing of hunting may aid policy development aimed at protecting dependent young hares.

Genetic epidemiology of motor neuron disease-associated variants in the Scottish population

Genetic understanding of motor neuron disease (MND) has evolved greatly in the past 10 years, including the recent identification of association between MND and variants in TBK1 and NEK1. Our aim was to determine the frequency of pathogenic variants in known MND genes and to assess whether variants in TBK1 and NEK1 contribute to the burden of MND in the Scottish population. SOD1, TARDBP, OPTN, TBK1, and NEK1 were sequenced in 441 cases and 400 controls. In addition to 44 cases known to carry a C9orf72 hexanucleotide repeat expansion, we identified 31 cases and 2 controls that carried a loss-of-function or pathogenic variant. Loss-of-function variants were found in TBK1 in 3 cases and no controls and, separately, in NEK1 in 3 cases and no controls. This study provides an accurate description of the genetic epidemiology of MND in Scotland and provides support for the contribution of both TBK1 and NEK1 to MND susceptibility in the Scottish population.

Familial hypercholesterolaemia (FH) – Finding the needle in a haystack in a Scottish population

Familial hypercholesterolaemia (FH) – Finding the needle in a haystack in a Scottish population

Effect of a national 4C antibiotic stewardship intervention on the clinical and molecular epidemiology of Clostridium difficile infections in a region of Scotland: a non-linear time-series analysis

Whereas many antibiotics increase risk of Clostridium difficile infection through dysbiosis, epidemic C difficile ribotypes characterised by multidrug resistance might depend on antibiotic selection pressures arising from population use of specific drugs. We examined the effect of a national antibiotic stewardship intervention limiting the use of 4C antibiotics (fluoroquinolones, clindamycin, co-amoxiclav, and cephalosporins) and other infection prevention and control strategies on the clinical and molecular epidemiology of C difficile infections in northeast Scotland. We did a non-linear time-series analysis and quasi-experimental study to explore ecological determinants of clinical burdens from C difficile infections and ribotype distributions in a health board serving 11% of the Scottish population. Study populations were adults (aged ≥16 years) registered with primary carer providers in the community (mean 455 508 inhabitants) or admitted to tertiary level, district general, or geriatric hospitals (mean 33 049 total admissions per month). A mixed persuasive-restrictive 4C antibiotic stewardship intervention was initiated in all populations on May 1, 2009. Other population-specific interventions considered included limiting indications for macrolide prescriptions, introduction of alcohol-based hand sanitiser, a national hand-hygiene campaign, national auditing and inspections of hospital environment cleanliness, and reminders to reduce inappropriate use of proton-pump inhibitors. The total effect of interventions was defined as the difference between observations and projected scenarios without intervention. Primary outcomes were prevalence density of C difficile infection per 1000 occupied bed-days in hospitals or per 100 000 inhabitant-days in the community. Between Jan 1, 1997, and Dec 31, 2012, we identified 4885 cases of hospital-onset C difficile infection among 1 289 929 admissions to study hospitals, and a further 1625 cases of community-onset C difficile infection among 455 508 adults registered in primary care. Use of 4C antibiotics was reduced by 50% in both hospitals (mean reduction 193 defined daily doses per 1000 occupied bed-days, 95% CI 45-328, p=0·008) and the community (1·85 defined daily doses per 1000 inhabitant-days, 95% CI 0·23-3·48, p=0·025) during antibiotic stewardship. Falling 4C use predicted rapid declines in multidrug-resistant ribotypes R001 and R027. Hospital-onset C difficile infection prevalence densities were associated with fluoroquinolone, third-generation cephalosporin, macrolides, and carbapenem use, exceeding hospital population specific total use thresholds. Community-onset C difficile infection prevalence density was predicted by recent hospital C difficile infection rates, introduction of mandatory surveillance in individuals older than 65 years, and primary-case use of fluoroquinolones and clindamycin exceeding total use thresholds. Compared with predictions without intervention, C difficile infection prevalence density fell by 68% (mean reduction 1·01 per 1000 occupied bed-days, 0·27-1·76, p=0·008) in hospitals and 45% (0·083, 0·045-0·121 cases per 100 000 inhabitant-days, p<0·0001) in the community, during antibiotic stewardship. We identified no significant effects from other interventions. Limiting population use of 4C antibiotics reduced selective pressures favouring multidrug-resistant epidemic ribotypes and was associated with substantial declines in total C difficile infections in northeast Scotland. Efforts to control C difficile through antibiotic stewardship should account for ribotype distributions and non-linear effects. NHS Grampian Microbiology Endowment Fund.

The SCottish Alcoholic Liver disease Evaluation: A Population-Level Matched Cohort Study of Hospital-Based Costs, 1991-2011.

Studies assessing the costs of alcoholic liver disease are lacking. We aimed to calculate the costs of hospitalisations before and after diagnosis compared to population controls matched by age, sex and socio-economic deprivation. We aimed to use population level data to identify a cohort of individuals hospitalised for the first time with alcoholic liver disease in Scotland between 1991 and 2011.Incident cases were classified by disease severity, sex, age group, socio-economic deprivation and year of index admission. 5 matched controls for every incident case were identified from the Scottish population level primary care database. Hospital costs were calculated for both cases and controls using length of stay from morbidity records and hospital-specific daily rates by specialty. Remaining lifetime costs were estimated using parametric survival models and predicted annual costs. 35,208 incident alcoholic liver disease hospitalisations were identified. Mean annual hospital costs for cases were 2.3 times that of controls pre diagnosis (£804 higher) and 10.2 times (£12,774 higher) post diagnosis. Mean incident admission cost was £6,663. Remaining lifetime cost for a male, 50–59 years old, living in the most deprived area diagnosed with acoholic liver disease was estimated to be £65,999 higher than the matched controls (£12,474 for 7.43 years remaining life compared to £1,224 for 21.8 years). In Scotland, alcoholic liver disease diagnosis is associated with significant increases in admissions to hospital both before and after diagnosis. Our results provide robust population level estimates of costs of alcoholic liver disease for the purposes of health-care delivery, planning and future cost-effectiveness analyses.