Thrombolytic therapy
4.5% is low and for instance compares unfavourably with the 13% angiography rate for the conservative group of the SWIFf Tria1.6 Thrombolytic therapy has proved to be a very significant advance in the management of patients with myocardial infarction. It should be given as early as possible preferably within the first hour? Out of hospital thrombolysis will need to be greatly expanded to achieve this but cardiac care units can contribute by critical attention to admission policies'' and procedures. It is important that facilities for angiography are readily available when indicated and our present excellent links with cardiology centres in Edinburgh must be maintained. ACKNOWLEDGEMENTS We thank the medical and nursing staff ofthe CCU and Medical Unit for their valuable help and also Mrs W Wilson for secretarial assistance.
Lawrie, Halliday, Mageed
REFERENCES
2 3 4 5 6 7 8
Julian DG, Pentecost BL, Chamberlain DA. A milestone for myocardial infarction. BMJ 1988; 297: 497-498. GISSI I Study. Effectiveness of intravenous thrombolytic therapy treatment in acute myocardial infarction. Lancet 1986; i: 397 -401. ISIS-2 (Second International Study of Infarct Survival). Randomised trial of intravenous streptokinase, oral aspirin both or neither among 17,187 cases of suspected acute myocardial infarction. Lancet 1988; ii: 349-360. Mackenzie GJ, Ogilvie BC, Turner TL, Fulton M, Lutz Z. Coronary care unit in a District General Hospital. Lancet 1971; ii: 200-203. AIMS Trial Study Group. Effects of intravenous APSAC on mortality after acute myocardial infarction: preliminary report of a placebo controlled clinical trial. Lancet 1988; ii: 545-549. Swift trial of delayed intervention v conservative treatment after thrombolysis with anistreplase in acute myocardial infarction. BMJ 1991; 302: 555-560. McNeil AJ, Flannery DJ, Wilson CM et al. Thrombolytic therapy within one hour of the onset of acute myocardial infarction. QJ Med 1991; 79: 487-494. Burns JMA, Hogg KJ, Rae AP, Hillis WS, Dunn FG. Impact of a policy of direct admission to a coronary care unit on use of thrombolytic therapy. Br Heart J 1989; 61: 322-325.
Scot Med J 1992; 37: 112-115
0036-9330/92/13291/112 $2.00 in USA © 1992 Scottish Medical Journal
TIME TRENDS AND GEOGRAPHICAL VARIATION IN PARKINSON'S DISEASE IN SCOTLAND W.C.S. Smith, *W.J. Mutch Department of Community, Occupational and Family Medicine, National University Hospital, National University of Singapore. *University Department of Medicine, Ninewells Hospital and Medical School, Dundee
Abstract: Parkinson's disease is a common and disabling condition which principally affects the elderly. The time and space distribution ofParkinson' s disease has been examined to determine if it provides clues as to aetiology and factors affecting its distribution. Previous studies have used mortality data/ datafrom epidemiological studies,2 andprescribing 3 information particularly with regard to the use of levodopa. These studies have looked within countries and between countries.
Introduction
W
e have used information on Parkinson's disease from death certification in Scotland for the period covering 1974 to 1986, using both Parkinson's disease as the primary cause of death and also when it is mentioned on the death certificate as another significant condition. The information is used to examine time trends in both men and women, and to look at geographical variation across the 56 local government districts in Scotland. (Information on coronary heart disease has been used to examine time trends and geographical variation in Scotland.)4,5
Methods Information on Parkinson's disease as both the primary or underlying cause of death and also when mentioned as another significant condition has been collated from data available from the Registrar General, Scotland and rates of disease calculated from the mid-year estimate of the population size within each specific five year age group for the period from 1974 through to 6 1986. The ICD (International Classification of Diseases) rubric
Correspondence to: Dr W J Mutch, University Department of Medicine, Ninewells Hospital and Medical School, Dundee.
112
for Parkinson's disease was ICD 342 for the period 1974-1978 (8th revision) and for 1979-1986 was ICD 332.1,8 Rates of mortality associated with Parkinson's disease (per 100,000) have been calculated for men and women for the age groups 45-54 years, 55-64 years, 65-74 years and 75-84 years. The younger age groups have been excluded because the numbers in any 10 year age group under 45 years never exceed two. Standardised Mortality Ratios (SMRs) have been calculated for each of the 56 districts in each of the two time periods (1974-1978 and 1979-1986) using the Scottish rates as the standard and using the 5 years age groups from 15 years through to 84 years. Districts with SMRs which are significantly high or low are those whose confidence interval does not include 100.
Results (a) Time Trends: The time trend for the mortality rate from Parkinson's disease as the primary or underlying cause of death for men and women for the time period 1974 to 1986 is plotted out in Figures 1and 2. The mortality rate from Parkinson's disease in men under the age of 75 appears static as do the rates for men 75-84 years up to 1979 after which the rates increase. The ICD rubrics changed in 1979 but the increase does not in fact start until 1980. The mortality rates in men in the age group 74-85 years
Parkinsons disease in Scotland
Smith, Mutch
80
Mortality rate per 100,000
~~~-~--~--------------,
60
40
20
o
1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 ~ 55-64 years
-+-- 65-74 years
---+-- 75-84 years
_
45-54 years
Rates per 100,000
Fig 1. Primary cause -
Parkinson's Disease, Men 1974-1986
40 ~M-=-or~t.::..al~itY~R_at_e
and women separately, and where Parkinson's disease appears as the primary cause and where it appears as another significant condition. The distribution of district SMRs for Parkinson's disease as the primary cause of death in men and women for the period 1979-86 is shown in Figures 5 and 6 (the other maps are also available based on the top and bottom quintiles of the distribution of SMRs). The geographical pattern in men shows a general north to south pattern, however the pattern is complex, the map for women shows no obvious pattern and there is some overlap between which districts are the highest in men and women. There were eight analyses of the geographical variation looking at men and women separately over two time periods and whether Parkinson's disease was the primary cause of death or noted as another significant condition. There were six districts in which the SMR was greater than 100 in at least seven out of the eight analyses, and these were Skye, Nairn, Angus, Edinburgh, Strathkelvin and Motherwell. There were also six districts with SMRs lower than 100 on at least seven out of the eight analyses, and these were Kincardine, Kirkcaldy, NE Fife, Dunfermline, Ettrick and Monklands. The confidence interval of the SMRs allows districts with SMRs which are significantly (5% level) different from 100 to be
_
Table I Districts with SMRs significantly different from 100
30
A. Primary Cause (1974-78)
20
Men
ocC::::::::e:=:::::;==:;======.1;::===:==e====