Search

IntroductionThe association between allergic diseases and autoimmune disorders is not well established. Our objective was to determine incidence rates of autoimmune disorders in allergic rhinitis/conjunctivitis (ARC), atopic eczema and asthma, and to investigate for co-occurring patterns.MethodsThis was a retrospective cohort study (1990–2018) employing data extracted from The Health Improvement Network (UK primary care database). The exposure group comprised ARC, atopic eczema and asthma (all ages). For each exposed patient, up to two randomly selected age- and sex-matched controls with no documented allergic disease were used. Adjusted incidence rate ratios (aIRRs) were calculated using Poisson regression. A cross-sectional study was also conducted employing Association Rule Mining (ARM) to investigate disease clusters.Results782 320, 1 393 570 and 1 049 868 patients with ARC, atopic eczema and asthma, respectively, were included. aIRRs of systemic lupus erythematosus (SLE), Sjögren's syndrome, vitiligo, rheumatoid arthritis, psoriasis, pernicious anaemia, inflammatory bowel disease, coeliac disease and autoimmune thyroiditis were uniformly higher in the three allergic diseases compared with controls. Specifically, aIRRs of SLE (1.45) and Sjögren's syndrome (1.88) were higher in ARC; aIRRs of SLE (1.44), Sjögren's syndrome (1.61) and myasthenia (1.56) were higher in asthma; and aIRRs of SLE (1.86), Sjögren's syndrome (1.48), vitiligo (1.54) and psoriasis (2.41) were higher in atopic eczema. There was no significant effect of the three allergic diseases on multiple sclerosis or of ARC and atopic eczema on myasthenia. Using ARM, allergic diseases clustered with multiple autoimmune disorders. Three age- and sex-related clusters were identified, with a relatively complex pattern in females ≥55 years old.ConclusionsThe long-term risks of autoimmune disorders are significantly higher in patients with allergic diseases. Allergic diseases and autoimmune disorders show age- and sex-related clustering patterns.

Introduction A growing body of evidence is identifying the link between a history of child maltreatment and a variety of adverse health outcomes ultimately leading to significant social and healthcare burden. Initial work has identified a potential association between child maltreatment and the development of a selection of somatic and visceral central sensitivity syndromes: fibromyalgia, chronic fatigue syndrome, temporomandibular joint disorder, chronic lower back pain, chronic neck pain, chronic pelvic pain, interstitial cystitis, vulvodynia, chronic prostatitis, tension-type headache, migraine, myofascial pain syndrome, irritable bowel syndrome and restless legs syndrome. Methods and analysis Primary electronic searches will be performed in the Embase, MEDLINE, PubMed, Scopus, PyscINFO, CINAHL and Cochrane Library databases and a number of Grey Literature sources including child protection and paediatric conference proceedings. Following independent screening of studies by two review authors, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses template will be used to aid extraction. A meta-analysis will be conducted on the included case-control and cohort studies. The Newcastle-Ottawa grading system will be used to assess the quality of included studies. Results will be expressed as pooled ORs for binary data and mean differences for continuous data. Ethics and dissemination Ethics approval will not be required. The final results of the review and meta-analysis will be submitted for peer-review publication and also disseminated at relevant conference presentations. PROSPERO registration number CRD42018089258.

Aims Non-Alcoholic Fatty Liver Disease (NAFLD) is one of the leading causes of liver transplantation in the West. This study seeks to examine whether women with gestational diabetes mellitus (GDM) are at increased risk of developing NAFLD compared to women without GDM. Methods We conducted a population-based retrospective matched-controlled cohort study utilising The Health Improvement Network (THIN), a large primary care database representative of the United Kingdom population, between 01/01/1990 to 31/05/2016 followed by systematic review of available literature. The study population included 9640 women with GDM and 31,296 controls without GDM, matched for age, body mass index (BMI) and time of pregnancy. All study participants were free from NAFLD diagnosis at study entry. Patients with GDM and patients developing NAFLD were identified by clinical codes. Results The median (range) follow-up duration was similar in women with and without GDM (2.95 (1.21–6.01) vs 2.85 (1.14–5.75) years respectively). Unadjusted incidence rate ratio (IRR) for NAFLD development in women with vs without GDM was 3.28 (95% CI 2.14–5.02), which remained significant after adjustment for wide range of potential confounders (IRR 2.70; 95% CI 1.744–4.19). The risk of NAFLD in GDM remained high (IRR 2.46: 95% CI 1.51–4.00) despite women being censored after they developed type 2 diabetes. The meta-analysis of 3 studies (including the current study) showed increased NAFLD risk in women with vs without GDM (OR 2.60; 95% CI 1.90–3.57, I2 = 0%). As our study is based on routine clinical diagnosis of NAFLD, this study could potentially have underestimated the risk of NAFLD development. Conclusions Women with GDM are at increased risk of developing NAFLD in their later life compared to women without GDM regardless of the development of type 2 diabetes. Clinicians should have a low threshold to investigate women with history of GDM for the presence of NAFLD. Further studies to identify screening strategies are needed.

With the increasing incidence of diabetic retinopathy and its improved detection, there is increased demand for diabetic retinopathy treatment services. Prognostic prediction models have been used to optimise services but these were intended for early detection of sight-threatening retinopathy and are mostly used in diabetic retinopathy screening services. We wanted to look into the predictive ability and applicability of the existing models for the higher-risk patients referred into hospitals. We searched MEDLINE, EMBASE, COCHRANE CENTRAL, conference abstracts and reference lists of included publications for studies of any design using search terms related to diabetes, diabetic retinopathy and prognostic models. Search results were screened for relevance to the review question. Included studies had data extracted on model characteristics, predictive ability and validation. They were assessed for quality using criteria specified by PROBAST and CHARMS checklists, independently by two reviewers. Twenty-two articles reporting on 14 prognostic models (including four updates) met the selection criteria. Eleven models had internal validation, eight had external validation and one had neither. Discriminative ability with c-statistics ranged from 0.57 to 0.91. Studies ranged from low to high risk of bias, mostly due to the need for external validation or missing data. Participants, outcomes, predictors handling and modelling methods varied. Most models focussed on lower-risk patients, the majority had high risk of bias and doubtful applicability, but three models had some applicability for higher-risk patients. However, these models will also need updating and external validation in multiple hospital settings before being implemented into clinical practice.

Supplemental material, Supplementary_1_depression_and_anxiety_v2 for Intimate Partner Violence and the Risk of Developing Fibromyalgia and Chronic Fatigue Syndrome by Joht Singh Chandan, Tom Thomas, Karim Raza, Caroline Bradbury-Jones, Julie Taylor, Siddhartha Bandyopadhyay and Krishnarajah Nirantharakumar in Journal of Interpersonal Violence

ObjectiveTo investigate the long-term risk of developing hypertension and cardiovascular disease (CVD) among those women who suffered a postpartum haemorrhage (PPH) compared with those women who did not.DesignPopulation-based longitudinal open cohort study.SettingEnglish primary care (The Health Improvement Network (THIN)) and secondary care (Hospital Episode Statistics (HES)) databases.PopulationWomen exposed to PPH during the study period matched for age and date of delivery, and unexposed.MethodsWe conducted an open cohort study using linked primary care THIN and HES Databases, from 1 January 1997 to 31 January 2018. A total of 42 327 women were included: 14 109 of them exposed to PPH during the study period and 28 218 matched for age and date of delivery, and unexposed to PPH. HRs for cardiovascular outcomes among women who had and did not have PPH were estimated after controlling for covariates using multivariate Cox regression models.Outcome measuresRisk of hypertensive disease, ischaemic heart disease, heart failure, stroke or transient ischaemic attack.ResultsDuring a median follow-up of over 4 years, there was no significant difference in the risk of hypertensive disease after adjustment for covariates (adjusted HR (aHR): 1.03 (95% CI: 0.87 to 1.22); p=0.71). We also did not observe a statistically significant difference in the risk of composite CVD (ischaemic heart disease, heart failure, stroke or transient ischaemic attack) between the exposed and the unexposed cohort (aHR: 0.86 (95% CI: 0.52 to 1.43; p=0.57).ConclusionOver a median follow-up of 4 years, we did not observe an association between PPH and hypertension or CVD.

Importance Epidemiologic data on optic neuritis (ON) incidence and associations with immune-mediated inflammatory diseases (IMIDs) are sparse. Objective To estimate 22-year trends in ON prevalence and incidence and association with IMIDs in the United Kingdom. Design, setting, and participants This cohort study analyzed data from The Health Improvement Network from January 1, 1995, to September 1, 2019. The study included 10 937 511 patients 1 year or older with 75.2 million person-years' follow-up. Annual ON incidence rates were estimated yearly (January 1, 1997, to December 31, 2018), and annual ON prevalence was estimated by performing sequential cross-sectional studies on data collected on January 1 each year for the same period. Data for 1995, 1996, and 2019 were excluded as incomplete. Risk factors for ON were explored in a cohort analysis from January 1, 1997, to December 31, 2018. Matched case-control and retrospective cohort studies were performed using data from January 1, 1995, to September 1, 2019, to explore the odds of antecedent diagnosis and hazard of incident diagnosis of 66 IMIDs in patients compared with controls. Exposures Optic neuritis. Main outcomes and measures Annual point prevalence and incidence rates of ON, adjusted incident rate ratios (IRRs) for risk factors, and adjusted odds ratios (ORs) and adjusted hazard ratios (HRs) for 66 IMIDs. Results A total of 10 937 511 patients (median [IQR] age at cohort entry, 32.6 [18.0-50.4] years; 5 571 282 [50.9%] female) were studied. A total of 1962 of 2826 patients (69.4%) with incident ON were female and 1192 of 1290 92.4%) were White, with a mean (SD) age of 35.6 (15.6) years. Overall incidence across 22 years was stable at 3.7 (95% CI, 3.6-3.9) per 100 000 person-years. Annual point prevalence (per 100 000 population) increased with database maturity, from 69.3 (95% CI, 57.2-81.3) in 1997 to 114.8 (95% CI, 111.0-118.6) in 2018. The highest risk of incident ON was associated with female sex, obesity, reproductive age, smoking, and residence at higher latitude, with significantly lower risk in South Asian or mixed race/ethnicity compared with White people. Patients with ON had significantly higher odds of prior multiple sclerosis (MS) (OR, 98.22; 95% CI, 65.40-147.52), syphilis (OR, 5.76; 95% CI, 1.39-23.96), Mycoplasma (OR, 3.90; 95% CI, 1.09-13.93), vasculitis (OR, 3.70; 95% CI, 1.68-8.15), sarcoidosis (OR, 2.50; 95% CI, 1.21-5.18), Epstein-Barr virus (OR, 2.29; 95% CI, 1.80-2.92), Crohn disease (OR, 1.97; 95% CI, 1.13-3.43), and psoriasis (OR, 1.28; 95% CI, 1.03-1.58). Patients with ON had a significantly higher hazard of incident MS (HR, 284.97; 95% CI, 167.85-483.81), Behcet disease (HR, 17.39; 95% CI, 1.55-195.53), sarcoidosis (HR, 14.80; 95% CI, 4.86-45.08), vasculitis (HR, 4.89; 95% CI, 1.82-13.10), Sjogren syndrome (HR, 3.48; 95% CI, 1.38-8.76), and herpetic infection (HR, 1.68; 95% CI, 1.24-2.28). Conclusions and relevance The UK incidence of ON is stable. Even though predominantly associated with MS, ON has numerous other associations with IMIDs. Although individually rare, together these associations outnumber MS-associated ON and typically require urgent management to preserve sight.

Aims/Hypothesis The aim of this research was to explore the relationship between incident epilepsy and type 1 diabetes in British participants. Methods Using The Health Improvement Network database, we conducted a retrospective, open-cohort study. Patients who were newly diagnosed with type 1 diabetes mellitus at the age of ≤40 years were identified and followed-up from 1 January 1990 to 15 September 2015. These patients, identified as not suffering from epilepsy at the time of diagnosis, were randomly matched with up to four individuals without type 1 diabetes mellitus, based on age, sex and participating general practice. A Cox regression analysis was subsequently performed using Townsend deprivation index, cerebral palsy, head injury and learning disabilities as model covariates. Results The study population consisted of a total of 24,610 individuals (4922 with type 1 diabetes and 19,688 controls). These individuals were followed up for a mean of 5.4 years (approximately 132,000 person-years of follow up). Patients with type 1 diabetes were significantly more likely to be diagnosed with epilepsy during the observation period compared with controls (crude HR [95% CI]: 3.02 [1.95, 4.69]). The incidence rate was estimated to be 132 and 44 per 100,000 person-years in patients and controls, respectively. This finding persisted after adjusting for model covariates (adjusted HR [95% CI]: 3.01 [1.93, 4.68]) and was also robust to sensitivity analysis, excluding adult-onset type 1 diabetes mellitus. Conclusions/Interpretation Patients with type 1 diabetes are at approximately three-times greater risk of developing epilepsy compared with matched controls without type 1 diabetes. This should be considered when investigating seizure-related disorders in patients with type 1 diabetes mellitus.

ObjectivesDescribe the epidemiology of childhood maltreatment and domestic abuse (in women).DesignAnalysis of longitudinal records between 1 January 1995 to 31 December 2018.SettingUK primary care database: ‘The Health Improvement Network’ (THIN).Participants11 831 850 eligible patients from 787 contributing practices. Childhood maltreatment and domestic abuse (women only) were defined as the presence of a recorded Read code.Outcome measuresThe incidence rate (IR) and prevalence of childhood maltreatment (in children aged 0–18 years) and domestic abuse (in women aged over 18) between 1996 and 2017. An adjusted incidence rate ratio (aIRR) is given to examine the differences in IRs based on sex, ethnicity and deprivation.ResultsThe age and gender breakdown of THIN has been previously reported to be representative of the UK population, however, there is substantial missing information on deprivation quintiles (ConclusionDespite recent improvements in recording, there is still a substantial under-recording of maltreatment and abuse within UK primary care records, compared with currently existing sources of childhood maltreatment and domestic abuse data. Approaches must be implemented to improve recording and detection of childhood maltreatment and domestic abuse within medical records.

Ramadan is the fasting month in Islam. Muslims around the world observe Ramadan every year, including people with diabetes. Data on the association of fasting in people with diabetes are sparse. The purpose of this study is to assess the association of fasting on cardiovascular risk factors and events in people with diabetes. A comprehensive search was conducted in the following database: Embase, Medline, Cochrane library and CINAHL. The following key terms were used: Ramadan, Ramazan, Ramadhan, Muslim, Islam and fasting. Studies were eligible if they included people with Type 2 diabetes who fasted during Ramadan and reporting results on cardiovascular risk factors or events. Overall 22 studies met inclusion criteria for the review; five studies reported cardiovascular outcomes and 17 reported changes in risk factors. There is insufficient evidence to link Ramadan fasting with increased or reduced incidence of cardiovascular events in people with diabetes, though there were some indication stroke risk may be increased. Findings were inconsistent in term of risk factors as some favoured Ramadan and others did not.‬‬‬‬

Glucagon-like peptide 1 receptor agonists (GLP1-RA) are prominent agents in the therapeutics of type 2 diabetes mellitus due to their exemplary efficacy in both preprandial and postprandial glycemia, their safety, low risk of hypoglycemia, their multilevel pathophysiological superiority, weight loss and importantly the observed benefits in cardiovascular disease reduction. Their major drawback is the subcutaneous route of administration, constituting a barrier to adoption and reason for treatment discontinuation. Thus, the development of an oral GLP1-RA agent would promote medication adherence and quality of life, further consolidating its beneficial effects in real-life clinical practice. However, this task is hampered by suboptimal gastrointestinal protein absorption. Yet, the introduction of oral semaglutide, a modified form of semaglutide with the addition of a carrier sodium N-(8-[2-hydroxybenzoyl] amino) caprylate, may have provided a safe and effective way to reach systemic circulation while other molecules are in development. Whether this molecule still has the impressive cardiovascular effects demonstrated with the use of its precursor remains to be explored. However, to date, its efficacy and safety have already been showcased in a randomized trial. More research is warranted in order to further consolidate these findings across different type 2 diabetes mellitus (T2DM) subpopulations, and adequately powered studies with a longer follow-up that would allow the exploration of microvascular and macrovascular complications are needed. Finally, studies comparing oral semaglutide and similar molecules with other currently established antidiabetic agents to evaluate the relative efficacy, the cost-effectiveness and further understand its place in T2DM therapeutic algorithm are needed. This review focuses on the development of oral GLP1-RA agents and summarizes the challenges, milestones and expected benefits associated with a successful introduction.

2017 WHO Classification of Pituitary Tumors grades silent corticotroph adenomas (SCAs) as "high-risk adenomas" due to their aggressive clinical behavior (high probability of recurrence). However, studies comparing recurrence rates of SCAs with other non-functioning pituitary adenoma (NFPAs) subtypes have provided conflicting results.Estimate recurrence rates of SCAs after primary treatment (surgery±radiotherapy) and recurrence rate ratios (RRR) between SCAs and other NFPA subtypes.Systematic review of published literature reporting on outcomes of SCAs up to October 31, 2017 was conducted. Recurrence rates, RRRs, 95% confidence intervals (CIs) were estimated from each study and pooled using random effects meta-analysis model.For determination of SCAs recurrence rates, 14 studies (low risk of bias, 297 patients) were selected; recurrence rate was 5.96 (95% CI, 4.3-7.84) per 100 person-years. Based on studies with mean follow-up5 or ≥5 years, 25% (cumulative incidence 0.25; 95% CI, 0.13-0.38) and 31% (cumulative incidence 0.31; 95% CI, 0.23-0.40) of SCAs had recurrence, respectively. Recurrence rates after surgery or surgery+radiotherapy were 5.41 (95% CI, 3.28-7.96) and 4.88 (95% CI, 0.67-11.54) cases per 100 person-years, respectively. Analysis of 10 eligible studies (moderate risk of bias, 244 SCAs, 1622 NFPAs) showed no significant RRR (1.44; 95% CI, 0.9-2.33, p=0.130) between the groups. Focus on tumors treated solely by surgery also revealed no significant RRR (1.17; 95% CI, 0.79-1.75, p=0.429).Based on studies with mean follow-up ≥5 years, 31% of SCAs have recurrence. No evidence supporting higher recurrence risk of SCAs compared with other NFPA subtypes was found.

Objective: To investigate the relationship between maternal metabolic parameters with birth weight (BW) and cord blood insulin level(CBI). Research Design and Methods: Participants were mother-baby pairs (n=1,522) from the Born in Guangzhou Cohort Study (delivered during January 2015 to June 2016). Data on maternal pre-pregnancy BMI, Gestational Weight Gain (GWG), mid-pregnancy fasting glucose and lipid levels were collected; and associations with new-born BW and CBI (z-score) were assessed using multivariable linear regression model, controlling for maternal age, ethnic group, parity and early pregnancy cigarettes exposure. The effect estimates (Regression Co-Efficient: RCE) were standardised to compare the strength of associations of the exposures on BW and CBI z-score. Results: Z-scores for pre-pregnancy BMI (RCE: 0.20[95% CI: 0.15, 0.24]), early GWG (RCE: 0.18[95% CI: 0.13, 0.23]), glucose (RCE: 0.08[95% CI: 0.04, 0.12]) and triglycerides (RCE: 0.12[95% CI: 0.08, 0.16])) were positively associated with BW z-score. Similar associations were observed with CBI z-score (pre-pregnancy BMI (RCE: 0.11[95% CI: 0.06, 0.16]), early GWG (RCE: 0.07[95% CI: 0.00, 0.13]), glucose (RCE: 0.14[95% CI: 0.09, 0.19]) and triglycerides (RCE: 0.07[95% CI: 0.02, 0.12]). Maternal fasting high-density lipoprotein was negatively associated with BW z-score (RCE:-0.04[95% CI:-0.09, -0.00]) and CBI z-score (RCE: -0.04[95% CI:-0.09, 0.01]) but the 95% CI for the latter included the null. Conclusions: Maternal pre-pregnancy BMI had the strongest association with BW and CBI, emphasising the importance of optimising preconception BMI. Our results also suggest potential under-recognised adverse effects of intrauterine exposure to gestational dyslipidaemia and that this may warrant clinical attention. Disclosure J. Wang: None. Y. Kuang: None. M.J. Price: None. J. Lu: None. J. He: None. H. Xia: None. X. Qiu: None. K. Cheng: None. K. Nirantharakumar: None.

Objective Type 2 diabetes is associated with an increased risk of fracture. Any factor that incrementally increases this risk should be taken into account when individualising treatment. Hypoglycaemia is a common complication of antidiabetes medications and suggested as a risk factor for fractures; yet, its real-life clinical impact is unclear. Design A population-based, retrospective open cohort study using routinely collected data between 1st of January 1995 and 1st of May 2016 in The Health Improvement Network (THIN) database. Methods Patients with type 2 diabetes mellitus with documented hypoglycaemic events were compared to randomly matched patients with type 2 diabetes mellitus without documented hypoglycaemic events matched to exposed patients on age, sex, duration of diabetes and BMI. The primary outcome was any incident fracture. Secondary outcome was incident fragility (osteoporotic) fracture. Results A total of 41 163 patients with type 2 diabetes were included: 14 147 patients in the exposed cohort and 27 016 patients in the unexposed cohort. Patients with a documented hypoglycaemic event were significantly more likely to sustain any fracture compared to patients with no record of hypoglycaemic events: adjusted IRR = 1.20 (95% CI: 1.12–1.30; P P Conclusions Hypoglycaemic events are a significant risk factor for fractures in patients with diabetes mellitus. This observation is clinically relevant when individualising targets for glycaemic control and selecting antidiabetic agents.

ObjectivesTo determine rates of stroke or transient ischaemic attack (TIA) and all cause mortality in patients with a diagnosis of “resolved” atrial fibrillation compared to patients with unresolved atrial fibrillation and without atrial fibrillation.DesignTwo retrospective cohort studies.SettingGeneral practices contributing to The Health Improvement Network, 1 January 2000 to 15 May 2016.ParticipantsAdults aged 18 years or more with no previous stroke or TIA: 11 159 with resolved atrial fibrillation, 15 059 controls with atrial fibrillation, and 22 266 controls without atrial fibrillation.Main outcome measuresPrimary outcome was incidence of stroke or TIA. Secondary outcome was all cause mortality.ResultsAdjusted incidence rate ratios for stroke or TIA in patients with resolved atrial fibrillation were 0.76 (95% confidence interval 0.67 to 0.85, PConclusionPatients with resolved atrial fibrillation remain at higher risk of stroke or TIA than patients without atrial fibrillation. The risk is increased even in those in whom recurrent atrial fibrillation is not documented. Guidelines should be updated to advocate continued use of anticoagulants in patients with resolved atrial fibrillation.

Aim To temporally and externally validate our previously developed prediction model, which used data from University Hospitals Birmingham to identify inpatients with diabetes at high risk of adverse outcome (mortality or excessive length of stay), in order to demonstrate its applicability to other hospital populations within the UK. Methods Temporal validation was performed using data from University Hospitals Birmingham and external validation was performed using data from both the Heart of England NHS Foundation Trust and Ipswich Hospital. All adult inpatients with diabetes were included. Variables included in the model were age, gender, ethnicity, admission type, intensive therapy unit admission, insulin therapy, albumin, sodium, potassium, haemoglobin, C-reactive protein, estimated GFR and neutrophil count. Adverse outcome was defined as excessive length of stay or death. Results Model discrimination in the temporal and external validation datasets was good. In temporal validation using data from University Hospitals Birmingham, the area under the curve was 0.797 (95% CI 0.785-0.810), sensitivity was 70% (95% CI 67-72) and specificity was 75% (95% CI 74-76). In external validation using data from Heart of England NHS Foundation Trust, the area under the curve was 0.758 (95% CI 0.747-0.768), sensitivity was 73% (95% CI 71-74) and specificity was 66% (95% CI 65-67). In external validation using data from Ipswich, the area under the curve was 0.736 (95% CI 0.711-0.761), sensitivity was 63% (95% CI 59-68) and specificity was 69% (95% CI 67-72). These results were similar to those for the internally validated model derived from University Hospitals Birmingham. Conclusions The prediction model to identify patients with diabetes at high risk of developing an adverse event while in hospital performed well in temporal and external validation. The externally validated prediction model is a novel tool that can be used to improve care pathways for inpatients with diabetes. Further research to assess clinical utility is needed.

This includes the survey questions and selected quotes (DOCX 33 kb)

OBJECTIVE: Effective contraceptive use has the potential to prevent around 230 million births each year. An estimated 222 million women want to delay pregnancy or cease childbearing but are not actively using contraception. Lack of education is a known barrier for effective contraceptive use. Motivational interviews are presumed to improve effective contraceptive use but studies to date report varied findings. Some studies demonstrate an improvement and others report no effect. STUDY DESIGN: A systematic review of evidence on the impact of motivational interviews on contraceptive use in women of childbearing age was carried out using MEDLINE EMBASE BNI Cochrane library CINHAL African Index Medicus Web of Science the Reproductive Health Library and the Science Citation Index (inception-January 2013) without language restriction. Search terms included motivational interview* AND contraception OR family planning OR maternal OR pregnancy. Randomised controlled trials comparing the effect of motivational interviews with standard practice on effective contraception use in women of reproductive age were included. The outcome measures were use of effective contraception or use of high-level contraception and subsequent births or pregnancies. The random effects model was used to pool the risk ratios from individual studies. RESULTS: Eight randomised controlled trials were included in the review with a total of 3424 women at high risk of pregnancy. Meta-analysis showed an increase in effective contraceptive use with motivational interviews when compared with control (RR 1.32 95%CI 1.11 1.56: P=0.002) in the period of zero to four months post intervention. No difference in effective contraceptive use was shown at four to eight months (RR 1.10 95%CI 0.93 1.32: P=0.27) and between eight to twelve months (RR 1.18 95%CI 0.96 1.46: P=0.12). No evidence of effect in the reduction of subsequent pregnancies or births at twelve to twenty-four months was seen with motivational interviews (RR 0.80 95%CI 0.51 1.26: P=0.34). CONCLUSION: Motivational interviews significantly increase effective contraceptive use immediately after and up to four months post-intervention. The effect without reinforcement is short lasting as no evidence of effect is seen after four months post-intervention. Copyright (c) 2015 Elsevier Ireland Ltd. All rights reserved.

Evidence suggests that the human skeleton might be involved in the regulation of glucose homeostasis.The objective of the study was to investigate the effect of exposure to bisphosphonates on the risk of incident type 2 diabetes mellitus (T2DM).This was a population-based, retrospective, open cohort study over the period 1995-2010.The study was conducted from The Health Improvement Network database from the United Kingdom in a primary care setting.A total of 35 998 individuals aged older than 60 years, without diabetes at baseline and with more than 1 year's exposure to bisphosphonates, and 126 459 age-, gender-, body mass index- and general practice-matched unexposed individuals participated in the study.There were no interventions.A new diagnosis of T2DM during the 16-year-long observation period, determined by Read codes and adjusted incidence rate ratio in bisphosphonate-exposed compared with unexposed groups, was the main outcome measure.The risk of incident T2DM was significantly lower in patients exposed to bisphosphonates compared with matched controls [adjusted incidence rate ratio 0.52, 95% confidence interval (CI) 0.48-0.56, P.0001]. In subgroup analyses, the findings remained consistent in males [0.77 (95% CI 0.66-0.89)], females [0.49 (95% CI 0.45-0.53)], obese [0.54 (95% CI 0.50-0.59)], individuals exposed to steroid treatment [0.47 (95% CI 0.34-0.64)], and over different types of bisphosphonate medication. Analysis of duration of treatment suggested a brief increase in the risk of T2DM (1 to 2.5 y of exposure), followed by a progressive, sustained decrease as the years of exposure accumulated.This observational evidence suggests exposure to bisphosphonates was associated with a significant 50% reduction in the risk of incident T2DM.

Background Previous studies have been unclear about the cardiovascular risks for metabolically healthy obese individuals. Objectives This study examined the associations among metabolically healthy obese individuals and 4 different presentations of incident cardiovascular disease in a contemporary population. Methods We used linked electronic health records (1995 to 2015) in The Health Improvement Network (THIN) to assemble a cohort of 3.5 million individuals, 18 years of age or older and initially free of cardiovascular disease. We created body size phenotypes defined by body mass index categories (underweight, normal weight, overweight, and obesity) and 3 metabolic abnormalities (diabetes, hypertension, and hyperlipidemia). The primary endpoints were the first record of 1 of 4 cardiovascular presentations (coronary heart disease [CHD], cerebrovascular disease, heart failure, and peripheral vascular disease). Results During a mean follow-up of 5.4 years, obese individuals with no metabolic abnormalities had a higher risk of CHD (multivariate-adjusted hazard ratio [HR]: 1.49; 95% confidence interval [CI]: 1.45 to 1.54), cerebrovascular disease (HR: 1.07; 95% CI: 1.04 to 1.11), and heart failure (HR: 1.96; 95% CI: 1.86 to 2.06) compared with normal weight individuals with 0 metabolic abnormalities. Risk of CHD, cerebrovascular disease, and heart failure in normal weight, overweight, and obese individuals increased with increasing number of metabolic abnormalities. Conclusions Metabolically healthy obese individuals had a higher risk of coronary heart disease, cerebrovascular disease, and heart failure than normal weight metabolically healthy individuals. Even individuals who are normal weight can have metabolic abnormalities and similar risks for cardiovascular disease events.

Objective To investigate whether the risk of incident cardiovascular disease (CVD) is increased in patients with prolactinoma. Design Population-based, retrospective, open-cohort study using The Health Improvement Network (THIN) database. Patients 2,233 patients with prolactinoma and 10,355 matched controls (1:5 ratio) from UK General Practices contributing to THIN were included. Sex, age, body mass index, and smoking status were used as matching parametres. The primary outcome was any incident CVD, defined by Read codes suggesting myocardial infarction, angina pectoris, stroke, transient ischaemic attack or heart failure. Sex-specific adjusted incidence rate ratios (aIRRs) were calculated with Poisson regression, using clinically relevant parameters as model covariates. Sensitivity analyses were performed to check whether a change in the initial assumptions could have an impact on the findings. Results During the 6-year observation period, the composite CVD outcome was recorded in 54 patients with prolactinoma and 180 “non-exposed” individuals. The incidence rate was 1.8 and 14.8 per 1000 person-years for the females and males with prolactinoma, respectively. The aIRRs for CVD were estimated at 0.99 [95% Confidence Interval (CI): 0.61-1.61, p=0.968)] in female patients and 1.94 (95% CI: 1.29-2.91, p-=0.001) in male patients. These findings remained robust in sensitivity analyses restricting to patients with documented record of dopamine agonist treatment and those with newly diagnosed prolactinoma. Conclusions In contrast to females, men with prolactinoma have increased risk for incident CVD; the aetiology of this gender-specific finding remains to be elucidated This article is protected by copyright. All rights reserved.

Aims To explore whether a quantitative approach to identifying hospitalized patients with diabetes at risk of hypoglycaemia would be feasible through incorporation of routine biochemical, haematological and prescription data. Methods A retrospective cross-sectional analysis of all diabetic admissions (n=9584) from 1 January 2014 to 31 December 2014 was performed. Hypoglycaemia was defined as a blood glucose level of

Essentials We estimated the cardiovascular risk of patients with idiopathic thrombocytopenic purpura (ITP). The risk of cardiovascular disease was 38% higher in ITP patients compared with controls. Among the ITP patients, splenectomy was associated with higher cardiovascular disease. Clinicians should consider cardiovascular risk when managing ITP patients.Background Idiopathic thrombocytopenic purpura (ITP) is classically characterized by a transient or persistent decrease of platelet count. Mortality is higher in the ITP population than the general population, with a possible association with increased cardiovascular disease (CVD). Objectives The objective was to assess the strength of the association between ITP and CVD, with a secondary aim to assess the impact of splenectomy on CVD. Methods A population-based retrospective, open cohort study using clinical codes was performed using data from 6591 patients with ITP and 24 275 randomly matched controls (up to 1:4 ratio matched by age, sex, body mass index and smoking status). The main outcome was the risk of CVD, which included ischemic heart disease, stroke, trans-ischemic attack and heart failure. Adjusted incidence rate ratios were calculated using Poisson regression. Results During a median 6-year observation period there was a CVD diagnosis recorded in 392 (5.9%) ITP patients and 1114 (4.5%) control patients. There was an increased risk of developing CVD in the ITP cohort (incidence rate ratio [IRR], 1.38; 95% confidence interval [CI], 1.23-1.55), which remained robust even after a sensitivity analysis only including incident cases of ITP. Findings suggested that patients who had undergone splenectomy were at even further increased risk of developing CVD when compared with the ITP population who had not undergone splenectomy (adjusted IRR, 1.69; 95% CI, 1.22-2.34). Conclusion There is an increased risk of developing CVD in patients with ITP and even further increased risk for those patients with ITP who underwent splenectomy.

We thank the respondents for their interest in our paper. We agree with Drs. Leggio, Lavie, and their colleagues that measures of physical activity (PA)/exercise/cardiorespiratory fitness would have been useful, but these measures are not routinely documented in general practice. Dr. Lavie and

IntroductionIn the UK, about a quarter of women give birth by caesarean section (CS) and are offered prophylactic broad-spectrum antibiotics to reduce the risk of maternal postpartum infection. In 2011, national guidance was changed from recommending antibiotics after the umbilical cord was cut to giving antibiotics prior to skin incision based on evidence that earlier administration reduces maternal infectious morbidity. Although antibiotics cross the placenta, there are no known short-term harms to the baby. This study aims to address the research gap on longer term impact of these antibiotics on child health.Methods and analysisA controlled interrupted time series study will use anonymised mother-baby linked routine electronic health records for children born during 2006–2018 recorded in UK primary care (The Health Improvement Network, THIN and Clinical Practice Research Datalink, CPRD) and secondary care (Hospital Episode Statistics, HES) databases. The primary outcomes of interest are asthma and eczema, two common allergy-related diseases in childhood. In-utero exposure to antibiotics immediately prior to CS will be compared with no exposure when given after cord clamping. The risk of outcomes in children delivered by CS will also be compared with a control cohort delivered vaginally to account for time effects. We will use all available data from THIN, CPRD and HES with estimated power of 80% and 90% to detect relative increase in risk of asthma of 16% and 18%, respectively at the 5% significance level.Ethics and disseminationEthical approval has been obtained from the University of Birmingham Ethical Review Committee with scientific approvals obtained from the independent scientific advisory committees from the Medicines and Healthcare products Regulatory Agency for CPRD and the data provider, IQVIA for THIN. The results will be published in peer-reviewed journals, presented at national and international conferences and disseminated to stakeholders.

Cardiovascular disease (CVD) risk has not been previously evaluated in a large matched cohort study in idiopathic intracranial hypertension (IIH).To estimate the risk of composite cardiovascular events, heart failure, ischemic heart disease, stroke/transient ischemic attack (TIA), type 2 diabetes, and hypertension in women with idiopathic intracranial hypertension and compare it with the risk in women, matched on body mass index (BMI) and age, without the condition; and to evaluate the prevalence and incidence of IIH.This population-based matched controlled cohort study used 28 years of data, from January 1, 1990, to January 17, 2018, from The Health Improvement Network (THIN), an anonymized, nationally representative electronic medical records database in the United Kingdom. All female patients aged 16 years or older were eligible for inclusion. Female patients with IIH (n = 2760) were included and randomly matched with up to 10 control patients (n = 27 125) by BMI and age.Adjusted hazard ratios (aHRs) of cardiovascular outcomes were calculated using Cox regression models. The primary outcome was a composite of any CVD (heart failure, ischemic heart disease, and stroke/TIA), and the secondary outcomes were each CVD outcome, type 2 diabetes, and hypertension.In total, 2760 women with IIH and 27 125 women without IIH were included. Age and BMI were similar between the 2 groups, with a median (interquartile range) age of 32.1 (25.6-42.0) years in the exposed group and 32.1 (25.7-42.1) years in the control group; in the exposed group 1728 women (62.6%) were obese, and in the control group 16514 women (60.9%) were obese. Higher absolute risks for all cardiovascular outcomes were observed in women with IIH compared with control patients. The aHRs were as follows: composite cardiovascular events, 2.10 (95% CI, 1.61-2.74; P .001); heart failure, 1.97 (95% CI, 1.16-3.37; P = .01); ischemic heart disease, 1.94 (95% CI, 1.27-2.94; P = .002); stroke/TIA, 2.27 (95% CI, 1.61-3.21; P .001); type 2 diabetes, 1.30 (95% CI, 1.07-1.57; P = .009); and hypertension, 1.55 (95% CI, 1.30-1.84; P .001). The incidence of IIH in female patients more than tripled between 2005 and 2017, from 2.5 to 9.3 per 100 000 person-years. Similarly, IIH prevalence increased in the same period, from 26 to 79 per 100 000 women. Incidence increased markedly with BMI higher than 30.Idiopathic intracranial hypertension in women appeared to be associated with a 2-fold increase in CVD risk; change in patient care to modify risk factors for CVD may reduce long-term morbidity for women with IIH and warrants further evaluation.

We thank Hocevar and colleagues for their comments on our recently published work on the epidemiology of IgA vasculitis (IgAV) in adults and children.1 2 We agree that there is some uncertainty regarding the incidence of adult-onset IgAV as this has not previously been widely studied. Our calculated incidence of 2.20 (95% CI 2.08 to 2.37) per 100 000 person-years in adults is slightly higher than most previous work has suggested, but is lower than that reported by Hocevar et al in a Slovenian tertiary centre study with no clearly demarcated denominator population.2–4 This disparity may be related to interpopulation differences, for example, in exposure to environmental risk factors such as viral infections.5 Alternatively, the difference may be due to contrasting strategies used to identify cases of IgAV. Hocevar and colleagues used both clinical and …

We aimed to determine whether in-patient mortality and length of stay were greater in diabetes patients with foot disease compared to those without foot disease.Retrospective data analysis of admissions over four years (2007-2010) to University Hospital Birmingham. Based on discharge diagnostic codes we grouped admissions into those 1) with amputation, 2) with foot disease and 3) without foot disease. Inpatient mortality and length of stay were compared between the three groups, adjusting for confounders.We identified 25,118 admissions with diabetes of which 1149 admissions (4.6%) had foot disease and another 195 (0.8%) had a code for lower limb amputation. When compared to those without foot disease the adjusted odds ratio for inpatient mortality was 1.31 (95% CI 1.04-1.65 P=0.02) in the foot disease group, and 1.02 (95% CI 0.56-1.85 P=0.95) in the amputation group; and the adjusted relative ratio for length of stay was 2.01 (95 CI 1.86-2.16 P0.001) in the foot disease group and 3.08 (95% CI 2.60-3.65 P0.001) in the amputation group.Foot disease in hospitalised patients with diabetes is associated with increased length of stay and inpatient mortality. Our study adds to evidence on excess mortality associated with diabetic foot disease and to evidence on excess mortality observed in people with diabetes admitted to hospitals.

The glucagon-like peptide-1 receptor agonist (GLP1a) liraglutide has been described to benefit patients with type 2 diabetes mellitus (T2DM) at high cardiovascular risk. However, there are still uncertainties relating to these cardiovascular benefits: whether they also apply to an unselected diabetic population that includes low-risk patients, represent a class-effect, and could be observed in a real-world setting. We conducted a population-based, retrospective open cohort study using data derived from The Health Improvement Network database between Jan 2008 to Sept 2015. Patients with T2DM exposed to GLP1a (n=8345) were compared to age, gender, body mass index, duration of T2DM and smoking status-matched patients with T2DM unexposed to GLP1a (n=16,541). Patients with diabetes receiving GLP1a were significantly less likely to die from any cause compared to matched control patients with diabetes (adjusted incidence rate ratio [aIRR]: 0.64, 95% CI: 0.56-0.74, P-value

Objectives To explore the clinical utility of glycated hemoglobin (A1C) levels as an early marker of albuminuria, macrovascular disease and subclinical cardiovascular disease in comparison to fasting and postprandial glucose levels in a well-characterized Chinese population with no history of diabetes. Methods The study population consisted of 1223 individuals who were enrolled in the Guangzhou Biobank Cohort Study, Cardiovascular Disease Subcohort, and who had undergone oral glucose tolerance tests. The associations between each glycemic measure and albuminuria, carotid intima-media thickness (CIMT) and CIMT-based presence of carotid plaques and aortic arch calcification were assessed by chest radiographs. Results The overall prevalence of albuminuria, carotid plaque and any aortic arch calcification was 20.6%, 22.8% and 25.8%, respectively. All 3 glycemia indices were significantly associated with albuminuria, but only 1 (fasting glucose) was associated with carotid plaques. No significant difference was detected among them in the area under the curve for albuminuria (chi-square test; p=0.84), carotid plaques (p=0.28) or calcifications (p=0.29). In sensitivity analysis, adjusted for age and sex, the above findings remained unchanged. Conclusions Although there was evidence suggesting differential associations, the performance of the glycemic indices was similar, and their association with macrovascular disease and albuminuria was modest.

Context: Empagliflozin was found to decrease mortality in patients with type 2 diabetes mellitus (T2DM) and a prior cardiovascular disease (CVD) event. Objectives: To establish whether these benefits can be replicated in a real-world setting, should be expected with the use of dapagliflozin, and apply to T2DM patients at low risk of CVD. Design: General practice, population-based, retrospective cohort study (January 2013 to September 2015). Setting: The Health Improvement Network database. Participants: A total of 22,124 T2DM patients (4444 exposed to dapagliflozin; 17,680 unexposed T2DM patients) matched for age, sex, body mass index, T2DM duration, and smoking. Main Outcome Measures: The primary outcome was all-cause mortality (high and low risk for CVD) in the total study population, expressed as the adjusted incidence rate ratio (aIRR) with 95% confidence intervals (CIs). As a secondary analysis in the low-risk population, all-cause mortality and incident CVD were considered. Results: Patients with T2DM exposed to dapagliflozin were significantly less likely to die of any cause (aIRR: 0.50; 95% CI: 0.33 to 0.75; P = 0.001). Similarly, in low-risk patients, death from any cause was significantly lower in the cohort exposed to dapagliflozin (aIRR: 0.44; 95% CI: 0.25 to 0.78; P = 0.002). The difference in the risk of incident CVD did not reach statistical significance between groups in low-risk patients (aIRR: 0.89; 95% CI: 0.61 to 1.31; P = 0.546). Conclusions: Patients with T2DM who were exposed to dapagliflozin had a lower risk of death from any cause irrespective of baseline CVD status.

Diabet. Med. 29, e445–e448 (2012) Abstract Aim To study the length of stay and inpatient mortality of patients with diabetes who had an episode of hypoglycaemia in a non critical care setting at University Hospital Birmingham, UK. Methods Retrospective analysis of routinely available electronic data of 6374 admissions with a recording of either laboratory or point-of-care blood glucose value. Based on the lowest recorded blood glucose values, patients were categorized into a group without hypoglycaemia (> 3.9 mmol/l), a group with mild to moderate hypoglycaemia (2.3–3.9 mmol/l) and a group with severe hypoglycaemic (≤ 2.2 mmol/l). Length of stay and inpatient mortality were compared between the three groups, adjusting for age, gender, ethnicity, deprivation, admission type, use of insulin and modified Charlson co-morbidity score. Results There were 148 admissions (2.3%) with severe hypoglycaemia (≤ 2.2 mmol/l), 500 admissions (7.8%) with mild to moderate hypoglycaemia (2.2–3.9 mmol/l) and 5726 admissions with no recorded hypoglycaemic episode (> 3.9 mmol/l). After adjustment, length of stay, when compared with those without a recorded hypoglycaemic episode, was 1.51 (95% CI 1.35–1.68) times higher in the group with blood glucose values of 2.3–3.9 mmol/l and 2.33 (95% CI 1.91–2.84) higher in the group with blood glucose values ≤ 2.2 mmol/l. Adjusted odds ratio of inpatient mortality when compared with the group without hypoglycaemia was 1.62 (95% CI 1.16–2.27) in the group with blood glucose values of 2.3–3.9 mmol/l and 2.05 (95% CI 1.24–3.38) in the group with blood glucose values ≤ 2.2 mmol/l. Conclusion Hypoglycaemia is associated with increased length of stay and inpatient mortality. Whilst causative evidence is lacking, our data are consistent with the need to avoid hypoglycaemia in our current and continued approach for optimal glycaemic control in people with diabetes admitted to hospital.

To test if two of the adverse event triggers proposed by the Institute of Healthcare Improvement can detect adverse drug events (ADEs) in a UK secondary care setting, using an electronic prescribing and health record system.In order to identify triggers for over-anticoagulation and potential opioid overdose and we undertook a retrospective review of electronic medical and prescription records from 54,244 hospital admissions over a 1-year period, alongside a review of medical incident reports. Once prescription data were linked to triggers and duplicates were removed, case note review eliminated the false positive ADEs. Additionally, we tested the use of an electronic algorithm for the International Normalized Ratio (INR) ≥6 trigger.The INR ≥6 electronic trigger identified 46 potential ADEs and the naloxone electronic trigger identified 82 ADEs. Based on the available case note review, the INR ≥6 trigger had a positive predictive value (PPV) of 38 % (14/37) and the naloxone trigger had a PPV of 91 % (61/67). The electronic algorithm for the INR ≥6 trigger identified 12 ADEs, thus reducing the need of case note review. This was in comparison with one and two critical incidents reported in the trust medical incident reports system, which respectively related to over-coagulation with warfarin and over-sedation with opioid medication.We have integrated automated and manual methods of detecting ADEs using previously defined triggers. Incorporating electronic triggers in already established electronic health records with prescription and laboratory test data can improve the detection of ADEs, and potentially lead to methods to avert them.

BACKGROUND: Computerized clinical decision support systems have been claimed to reduce prescription errors and improve patient care. They may play an important role in the care of hospitalized patients with diabetes. AIM: To collate evidence for the use of clinical decision support systems in improving the care of hospitalized patients with diabetes in a non-critical care setting and to assess their effectiveness. METHODS: We searched four databases from 1980 to 2010 without language restrictions. All types of studies other than case reports were included. Data extraction and quality assessment were carried out based on the Centre for Review and Dissemination guidance. A narrative synthesis was conducted. RESULTS: Fourteen studies met the inclusion criteria, including two cluster randomized controlled trials, eight before-and-after studies and four other descriptive studies. Generally, the quality of the studies was not very high. Nine out of 10 studies reported reduction in mean blood glucose or similar measures (patient-day-weighted mean blood glucose) during inpatient stay. The reduction using computerized physician order entry system in patient-day-weighted mean blood glucose ranged from 0.6 to 0.8 mmol/l (10.8-15.6 mg/dl). Other beneficial effects during inpatient stay included reduced use of sliding scale insulin and greater use of basal-bolus insulin regimen. Only one study found a significant increase in hypoglycaemic events. CONCLUSIONS: Clinical decision support systems have been used, often as part of a complex programme, to improve the care of hospitalized patients with diabetes. There is some evidence that they may have a beneficial effect, but this needs further confirmation.

Health inequalities exist between ethnic groups, an important example of this being infant mortality with babies of mothers born in Pakistan having double and babies of mothers born in the Caribbean having 63% higher rates than the national average. West Midlands Ethnic Minority Liaison Committee (WELCOME) and partners organised a conference to arrive at consensus among experts and stakeholders and to make recommendations around reducing infant mortality. One key area discussed, which is often contentious, was cousin marriage: its potential impact on infant and perinatal mortality and what health service response to this should be. Recommendations included: the setting up of a community genetic service in areas with higher risk of recessive disorders as a consequence of cousin marriage; genetic education to the wider public and health professionals; and community engagement, including community and religious leaders. This paper outlines how these recommendations were arrived at, the potential barriers identified in addressing this issue and the process by which service change was achieved with an aim to improve the outcome of infant and perinatal health among groups with higher burdens of genetic disorders in Walsall.

Background Gestational diabetes mellitus (GDM) is associated with developing type 2 diabetes, but very few studies have examined its effect on developing cardiovascular disease. Methods and findings We conducted a retrospective cohort study utilizing a large primary care database in the United Kingdom. From 1 February 1990 to 15 May 2016, 9,118 women diagnosed with GDM were identified and randomly matched with 37,281 control women by age and timing of pregnancy (up to 3 months). Adjusted incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated for cardiovascular risk factors and cardiovascular disease. Women with GDM were more likely to develop type 2 diabetes (IRR = 21.96; 95% CI 18.31–26.34) and hypertension (IRR = 1.85; 95% CI 1.59–2.16) after adjusting for age, Townsend (deprivation) quintile, body mass index, and smoking. For ischemic heart disease (IHD), the IRR was 2.78 (95% CI 1.37–5.66), and for cerebrovascular disease 0.95 (95% CI 0.51–1.77; p-value = 0.87), after adjusting for the above covariates and lipid-lowering medication and hypertension at baseline. Follow-up screening for type 2 diabetes and cardiovascular risk factors was poor. Limitations include potential selective documentation of severe GDM for women in primary care, higher surveillance for outcomes in women diagnosed with GDM than control women, and a short median follow-up postpartum period, with a small number of outcomes for IHD and cerebrovascular disease. Conclusions Women diagnosed with GDM were at very high risk of developing type 2 diabetes and had a significantly increased incidence of hypertension and IHD. Identifying this group of women in general practice and targeting cardiovascular risk factors could improve long-term outcomes., Krishnarajah Nirantharakumar and colleagues present results from a cohort of women with gestational diabetes and identify these as a target group for preventative interventions for cardiovascular disease and type 2 diabetes., Author summary Why was this study done? The prevalence of gestational diabetes mellitus (GDM) is increasing rapidly in most developed countries. Although it is well documented that women diagnosed with GDM have a greatly increased lifetime risk of developing type 2 diabetes, there is a paucity of reports on its association with cardiovascular disease. Only 3 previous population-based cohort studies have reported on GDM and the long-term risk of cardiovascular events (including 1 utilizing a primary care database), and no studies have been reported from the United Kingdom (UK). What did the researchers do and find? This population-based retrospective cohort study utilized a large UK primary care database that included more than 9,000 women diagnosed with GDM between 1 February 1990 and 15 May 2016. The association between GDM and the development of type 2 diabetes, hypertension, and cardiovascular disease postpartum was examined. Women diagnosed with GDM were over 20 times more likely to develop type 2 diabetes, 2.8 times more likely to develop ischemic heart disease, and twice as likely to develop hypertension, although no association was found for cerebrovascular disease. Less than 60% of women diagnosed with GDM were screened in primary care for type 2 diabetes in the first year postpartum, and the proportion screened rapidly declined after this period. Screening rates were also low for cardiovascular risk factors such as smoking, high body mass index, hypertension, and dyslipidemia, and were similar to the screening rates in control women. What do these findings mean? GDM in women increases the risk for hypertension and ischemic heart disease in addition to type 2 diabetes. Although the National Institute for Health and Care Excellence guidelines recommend annual screening for type 2 diabetes in women diagnosed with GDM, this study found that follow-up screening was poor for type 2 diabetes and other cardiovascular risk factors such as hypertension. Women diagnosed with GDM are an identifiable group of at-risk women and ideal for targeting preventative metabolic and cardiovascular interventions. Clinical guidelines should include postpartum screening and management for all cardiovascular risk factors in women diagnosed with GDM and not restrict it to diabetes.

Summary background Polycystic ovary syndrome (PCOS) is associated with insulin resistance and premature coronary artery disease (CAD). Hyperhomocysteinaemia is a recognized risk factor for atherosclerosis, particularly among migrant South Asians, and has recently been shown to be correlated positively with the degree of insulin resistance/hyperinsulinaemia. objectives To compare total plasma homocysteine (Hcy) in PCOS with controls from ethnic groups at high and low risk of insulin resistance. methods Case control study of three ethnic groups, Sri Lankans (SL), British Asians (BA) and white Europeans (C), with and without PCOS at specialist centres in Sri Lanka and Yorkshire, UK. Fasting total plasma Hcy concentration was analysed by fluorescence polarization immunoassay and examined for any correlation with age, body mass index (BMI), central obesity, fasting insulin and insulin sensitivity [calculated by the Quantitative Insulin Sensitivity Check Index (QUICKI) method], lipids and testosterone in each ethnic group. results Eighty SL with PCOS and 45 controls, 47 BA with PCOS and 11 controls, and 40 C with PCOS and 22 controls were studied. Both Asian groups with PCOS were younger than affected Europeans (P = 0·008). Sri Lankans with PCOS had significantly lower BMI values than other affected groups: mean ± SEM (SL) 26·3 ± 0·95; (BA) 30·59 ± 7·54; (C) 32·1 ± 5·95 kg/m2 (P = 0·006). However, waist : hip ratios (WHR) of Sri Lankans with PCOS were similar to others: mean ± SEM (SL) 0·97 ± 0·01 (BA) 1·04 ± 0·02 (C) 0·92 ± 0·01, P = 0·33. Mean plasma Hcy was significantly higher in all PCOS groups than in their ethnically matched controls (Student's t-test): (SL) 10·2 ± 1·9 vs 9·0 ± 3·8, P = 0·01; (BA) 7·9 ± 1·9 vs 6·8 ± 2·5, P

Background Clinicians are advised to ask patients about their alcohol use and provide brief interventions and specialist referral, but this is poorly implemented in practice. We undertook a national consultation to develop appropriate standards for recording information about alcohol use in electronic health records in the UK. Methods A wide range of stakeholders in the UK was consulted about recording alcohol use in electronic health records via a multidisciplinary stakeholder workshop and online survey. Stakeholders were identified by the Royal College of Physicians Health Informatics Unit and the project team. Notes were taken at the workshop and used to inform the survey. The survey asked participants about the appropriateness of the proposed information standards, implementation barriers and facilitators, potential applications for patient care, and patient safety concerns. Responses were thematically analysed using the Consolidated Framework for Implementation Research. Findings 31 stakeholders participated in the workshop and 105 in the online survey. Participants included patients, health-care professionals, researchers, public health specialists, informaticians, and clinical information system suppliers. There was broad consensus that the Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-Consumption (AUDIT-C) questionnaires were the optimal tools for recording alcohol use in electronic health records but that information should also be captured on relevant interventions. Stakeholders highlighted various factors that could influence implementation, including having clear care pathways and implementation guidance, information sharing between health service providers (potentially through summary care records), resourcing the implementation process, integrating alcohol screening with existing clinical pathways, having accessible clinical information systems (including a simple interface that aids understanding of alcohol units), financial incentives, training of health-care professionals, and strong clinical leadership and engagement. Implementation of the standards would need to ensure patients are not stigmatised and that patient confidentiality is maintained. Interpretation A wide range of stakeholders agreed that AUDIT and AUDIT-C are appropriate standards for recording alcohol use in electronic health records with the addition of recording interventions for alcohol misuse. The findings of this consultation will be used to develop an appropriate information model and implementation guide. Further research is needed to pilot the standards in primary and secondary care electronic health records. Funding Funding for patient involvement was provided by the National Institute for Health Research Patient Involvement Fund.

OBJECTIVE There are no formal prognostic models predicting adverse outcomes (excessive length of stay or mortality) in hospitalized patients with diabetes. In this study, we aimed to develop a prediction model that will help identify patients with diabetes who are most likely to have an adverse event during their hospital stay. RESEARCH DESIGN AND METHODS Analysis was based on 25,118 admissions with diabetes to University Hospital Birmingham, Birmingham, U.K., over 4 years (2007–2010). Adverse events are defined as either excessive length of stay or inpatient mortality. Key predictors were variables that are often available in the first 72 h of admission and included demographic characteristics, clinical pathological test results, and use of insulin. Models were constructed using logistic regression, discrimination and calibration was assessed, and internal validation was carried out. RESULTS The model performed well with an area under the curve (AUC) of 0.802 with only a mild reduction being noted in the internal validation (AUC 0.798). At a cutoff value of 25% probability of having an adverse outcome the sensitivity was 76%, specificity was 70%, and the positive predictive value was 49%. If it is used for a case-finding approach limiting to noncritical care settings, then at the same cutoff value, two-thirds (sensitivity 69%) of the admissions with adverse outcomes could potentially be identified. CONCLUSIONS Once externally validated, we suggest that our model will be a useful tool for identifying diabetic patients who are at risk for poor outcomes when admitted to hospital.

By meta-analysis, the risk of fracture was 15 % lower in patients treated with β-adrenergic blockers compared to controls independent of gender, fracture site, and dose. This might be attributable to β1-selective blockers. The aim of this study is to determine by meta-analysis whether β-adrenergic blockers (BBs) reduce fracture risk and whether the effect, if demonstrable, is dependent upon selectivity, dose, gender, or fracture site. A literature search was performed in electronic databases MEDLINE, EMBASE, and reference sections of relevant articles to identify eligible studies. Adjusted estimates of fracture risk effect size (ES) were pooled across studies using fixed or random-effects (RE) meta-analysis as appropriate. Dose-related effects were evaluated using meta-regression. To explore the relative efficacy of β1-selective blockers in comparison to nonselective BBs, adjusted indirect comparison was performed. A total of 16 studies (7 cohort and 9 case–control studies), involving 1,644,570 subjects, were identified. The risk of any fracture was found to be significantly reduced in subjects receiving BBs as compared to control subjects (16 studies, RE pooled ES = 0.86, 95 % CI 0.78–0.93; I2 = 87 %). In a sensitivity analysis limited to those studies deemed to be most robust, the BB effect to reduce fracture risk was sustained (four studies, pooled ES = 0.79, 95 % CI 0.67–0.94; I2 = 96 %). The risk of a hip fracture was lower in both women and men receiving BBs (women: pooled ES = 0.86, 95 % CI 0.80–0.91; I2 = 1 % and men: pooled ES = 0.80, 95 % CI 0.71–0.90; I2 = 0 %). Similar risk reductions were found for clinical vertebral and forearm fractures, although statistical significance was not reached. The reduction in risk did not appear to be dose-related (test for a linear trend p value 0.150). Using adjusted indirect comparisons, it was estimated that β1-selective agents were significantly more effective than nonselective BBs in reducing the risk of any fracture (six studies, β1-selective blockers vs. nonselective BBs: RE pooled ES = 0.82, 95 % CI = 0.69–0.97). The findings suggest that the risk of fracture is approximately 15 % lower in patients treated with BBs compared to controls independent of gender, fracture site, and dose. This risk reduction might be associated with the effects of β1-selective blockers.

Macrovascular disease (MVD) is a major complication of type 1 diabetes mellitus. However, accurate data on the prevalence and impact of macrovascular disease in the elderly with type 1 diabetes is lacking. This is despite life expectancy increasing in this population. Using data from over 400 general practices in the UK, the prevalence of macrovascular disease and factors associated with it were identified in elderly (over 65years) patients with type 1 diabetes for the year 2008.In this population, there was high prevalence of macrovascular disease(39.5%). Patients with macrovascular disease were significantly older, had a longer duration of diabetes, a positive history of smoking and higher HbA1cvalues. Our analysis demonstrates a high burden of macrovascular disease in elderly patients with type 1 diabetes. We need to explore how best to address this disease in this population.

Background Despite the proven efficacy of warfarin, its use in patients with Atrial Fibrillation (AF) is reportedly low. We investigated the underuse and overuse of warfarin in the management of AF in general practices in the United Kingdom (UK) against the National Institute of Clinical Excellence (NICE, UK) guidelines whilst seeking to identify subgroups of AF patients to inform efforts to optimise warfarin use. Methodology A retrospective database analysis to determine warfarin prescribing using tree models based on 50361 patients with AF (classified as low, moderate and high risk of stroke using CHADS2) from 430 general practices in the UK. Results Over one-third (37.0%, 4573/12351) of low risk AF patients were on warfarin, compared with 47.1% (8349/17709) moderate risk AF patients and 54.9% (11142/20301) high risk AF patients. Clinical subgroups (n = 15 low risk subgroups, n = 15 medium risk subgroups, n = 22 high risk subgroups) were identified. Several factors not supported by current guidelines (age, BMI, dementia, gender) were associated with the use of warfarin. Gender and BMI were associated with warfarin use in low and medium risk AF patients but not in high risk AF patients. Conclusion Whilst NICE guidelines suggest that all high risk AF patients should be on warfarin, half of those at moderate risk should be on warfarin and none of those at low risk should be on warfarin, we found evidence of over and under use of warfarin. Interventions to optimise warfarin therapy tailored to and targeting specific subgroups of AF patients identified by the tree models are required.