Association between surgical volume and failure of primary total hip replacement in England and Wales: findings from a prospective national joint replacement register

OBJECTIVE

To investigate the association of volume of total hip arthroplasty (THA) between consultants and within the same consultant in the previous year and the hazard of revision using multilevel survival models.

DESIGN

Prospective cohort study using data from a national joint replacement register.

SETTING

Elective THA across all private and public centres in England and Wales between April 2003 and February 2017.

PARTICIPANTS

Patients aged 50 years or more undergoing THA for osteoarthritis.

INTERVENTION

The volume of THA conducted in the preceding 365 days to the index procedure.

MAIN OUTCOME AND MEASURE

Revision surgery (excision, addition or replacement) of a primary THA.

RESULTS

Of the 579 858 patients undergoing primary THA (mean baseline age 69.8 years (SD 10.2)), 61.1% were women. Multilevel survival found differing results for between and within-consultant effects. There was a strong volume-revision association between consultants, with a near-linear 43.3% (95% CI 29.1% to 57.4%) reduction of the risk of revision comparing consultants with volumes between 1 and 200 procedures annually. Changes in individual surgeons (within-consultant) case volume showed no evidence of an association with revision.

CONCLUSION

Separation of between-consultant and within-consultant effects of surgical volume reveals how volume contributes to the risk of revision after THA. The lack of association within-consultants suggests that individual changes to consultant volume alone will have little effect on outcomes following THA.These novel findings provide strong evidence supporting the practice of specialisation of hip arthroplasty. It does not support the practice of low-volume consultants increasing their personal volume as it is unlikely their results would improve if this is the only change. Limiting the exposure of patients to consultants with low volumes of THA and greater utilisation of centres with higher volume surgeons with better outcomes may be beneficial to patients.

Interventions to reduce the time to diagnosis of brain tumours

BACKGROUND

Brain tumours are recognised as one of the most difficult cancers to diagnose because presenting symptoms, such as headache, cognitive symptoms, and seizures, may be more commonly attributable to other, more benign conditions. Interventions to reduce the time to diagnosis of brain tumours include national awareness initiatives, expedited pathways, and protocols to diagnose brain tumours, based on a person's presenting symptoms and signs; and interventions to reduce waiting times for brain imaging pathways. If such interventions reduce the time to diagnosis, it may make it less likely that people experience clinical deterioration, and different treatment options may be available.

OBJECTIVES

To systematically evaluate evidence on the effectiveness of interventions that may influence: symptomatic participants to present early (shortening the patient interval), thresholds for primary care referral (shortening the primary care interval), and time to imaging diagnosis (shortening the secondary care interval and diagnostic interval). To produce a brief economic commentary, summarising the economic evaluations relevant to these interventions.

SEARCH METHODS

For evidence on effectiveness, we searched CENTRAL, MEDLINE, and Embase from January 2000 to January 2020; Clinicaltrials.gov to May 2020, and conference proceedings from 2014 to 2018. For economic evidence, we searched the UK National Health Services Economic Evaluation Database from 2000 to December 2014.

SELECTION CRITERIA

We planned to include studies evaluating any active intervention that may influence the diagnostic pathway, e.g. clinical guidelines, direct access imaging, public health campaigns, educational initiatives, and other interventions that might lead to early identification of primary brain tumours. We planned to include randomised and non-randomised comparative studies. Included studies would include people of any age, with a presentation that might suggest a brain tumour.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles identified by the search strategy, and the full texts of potentially eligible studies. We resolved discrepancies through discussion or, if required, by consulting another review author.

MAIN RESULTS

We did not identify any studies for inclusion in this review. We excluded 115 studies. The main reason for exclusion of potentially eligible intervention studies was their study design, due to a lack of control groups. We found no economic evidence to inform a brief economic commentary on this topic.

AUTHORS' CONCLUSIONS

In this version of the review, we did not identify any studies that met the review inclusion criteria for either effectiveness or cost-effectiveness. Therefore, there is no evidence from good quality studies on the best strategies to reduce the time to diagnosis of brain tumours, despite the prioritisation of research on early diagnosis by the James Lind Alliance in 2015. This review highlights the need for research in this area.

Trans-ethnic and Ancestry-Specific Blood-Cell Genetics in 746,667 Individuals from 5 Global Populations

Most loci identified by GWASs have been found in populations of European ancestry (EUR). In trans-ethnic meta-analyses for 15 hematological traits in 746,667 participants, including 184,535 non-EUR individuals, we identified 5,552 trait-variant associations at p < 5 × 10-9, including 71 novel associations not found in EUR populations. We also identified 28 additional novel variants in ancestry-specific, non-EUR meta-analyses, including an IL7 missense variant in South Asians associated with lymphocyte count in vivo and IL-7 secretion levels in vitro. Fine-mapping prioritized variants annotated as functional and generated 95% credible sets that were 30% smaller when using the trans-ethnic as opposed to the EUR-only results. We explored the clinical significance and predictive value of trans-ethnic variants in multiple populations and compared genetic architecture and the effect of natural selection on these blood phenotypes between populations. Altogether, our results for hematological traits highlight the value of a more global representation of populations in genetic studies.

The Polygenic and Monogenic Basis of Blood Traits and Diseases

Blood cells play essential roles in human health, underpinning physiological processes such as immunity, oxygen transport, and clotting, which when perturbed cause a significant global health burden. Here we integrate data from UK Biobank and a large-scale international collaborative effort, including data for 563,085 European ancestry participants, and discover 5,106 new genetic variants independently associated with 29 blood cell phenotypes covering a range of variation impacting hematopoiesis. We holistically characterize the genetic architecture of hematopoiesis, assess the relevance of the omnigenic model to blood cell phenotypes, delineate relevant hematopoietic cell states influenced by regulatory genetic variants and gene networks, identify novel splice-altering variants mediating the associations, and assess the polygenic prediction potential for blood traits and clinical disorders at the interface of complex and Mendelian genetics. These results show the power of large-scale blood cell trait GWAS to interrogate clinically meaningful variants across a wide allelic spectrum of human variation.

The Polygenic and Monogenic Basis of Blood Traits and Diseases

Blood cells play essential roles in human health, underpinning physiological processes such as immunity, oxygen transport, and clotting, which when perturbed cause a significant global health burden. Here we integrate data from UK Biobank and a large-scale international collaborative effort, including data for 563,085 European ancestry participants, and discover 5,106 new genetic variants independently associated with 29 blood cell phenotypes covering a range of variation impacting hematopoiesis. We holistically characterize the genetic architecture of hematopoiesis, assess the relevance of the omnigenic model to blood cell phenotypes, delineate relevant hematopoietic cell states influenced by regulatory genetic variants and gene networks, identify novel splice-altering variants mediating the associations, and assess the polygenic prediction potential for blood traits and clinical disorders at the interface of complex and Mendelian genetics. These results show the power of large-scale blood cell trait GWAS to interrogate clinically meaningful variants across a wide allelic spectrum of human variation.

Analysis of change in patient-reported outcome measures with floor and ceiling effects using the multilevel Tobit model: a simulation study and an example from a National Joint Register using body mass index and the Oxford Hip Score

OBJECTIVES

This study has three objectives. (1) Investigate the association between body mass index (BMI) and the efficacy of primary hip replacement using a patient-reported outcome measure (PROMs) with a measurement floor and ceiling, (2) Explore the performance of different estimation methods to estimate change in PROMs score following surgery using a simulation study and real word data where data has measurement floors and ceilings and (3) Lastly, develop guidance for practising researchers on the analysis of PROMs in the presence of floor and ceiling effects.

DESIGN

Simulation study and prospective national medical device register.

SETTING

National Register of Joint Replacement and Medical Devices.

METHODS

Using a Monte Carlo simulation study and data from a national joint replacement register (162 513 patients with pre- and post-surgery PROMs), we investigate simple approaches for the analysis of outcomes with floor and ceiling effects that are measured at two occasions: linear and Tobit regression (baseline adjusted analysis of covariance, change-score analysis, post-score analysis) in addition to linear and multilevel Tobit models.

PRIMARY OUTCOME

The primary outcome of interest is change in PROMs from pre-surgery to 6 months post-surgery.

RESULTS

Analysis of data with floor and ceiling effects with models that fail to account for these features induce substantial bias. Single-level Tobit models only correct for floor or ceiling effects when the exposure of interest is not associated with the baseline score. In observational data scenarios, only multilevel Tobit models are capable of providing unbiased inferences.

CONCLUSIONS

Inferences from pre- post-studies that fail to account for floor and ceiling effects may induce spurious associations with substantial risk of bias. Multilevel Tobit models indicate the efficacy of total hip replacement is independent of BMI. Restricting access to total hip replacement based on a patients BMI can not be supported by the data.

Accelerating the Search for Interventions Aimed at Expanding the Health Span in Humans: The Role of Epidemiology

BACKGROUND

Extensive work in basic and clinical science suggests that biological mechanisms of aging are causally related to the development of disease and disability in late life. Modulation of the biological mechanisms of aging can extend both life span and health span in animal models, but translation to humans has been slow.

METHODS

Summary of workshop proceedings from the 2018-2019 Epidemiology of Aging Workshop hosted by the Intramural Research Program at the National Institute on Aging.

RESULTS

Epidemiologic studies play a vital role to progress in this field, particularly in evaluating new risk factors and measures of biologic aging that may influence health span, as well as developing relevant outcome measures that are robust and relevant for older individuals.

CONCLUSIONS

Appropriately designed epidemiological studies are needed to identify targets for intervention and to inform study design and sample size estimates for future clinical trials designed to promote health span.

A Platelet Function Modulator of Thrombin Activation Is Causally Linked to Cardiovascular Disease and Affects PAR4 Receptor Signaling

Dual antiplatelet therapy reduces ischemic events in cardiovascular disease, but it increases bleeding risk. Thrombin receptors PAR1 and PAR4 are drug targets, but the role of thrombin in platelet aggregation remains largely unexplored in large populations. We performed a genome-wide association study (GWAS) of platelet aggregation in response to full-length thrombin, followed by clinical association analyses, Mendelian randomization, and functional characterization including iPSC-derived megakaryocyte and platelet experiments. We identified a single sentinel variant in the GRK5 locus (rs10886430-G, p = 3.0 × 10^-42) associated with increased thrombin-induced platelet aggregation (β = 0.70, SE = 0.05). We show that disruption of platelet GRK5 expression by rs10886430-G is associated with enhanced platelet reactivity. The proposed mechanism of a GATA1-driven megakaryocyte enhancer is confirmed in allele-specific experiments. Utilizing further data, we demonstrate that the allelic effect is highly platelet- and thrombin-specific and not likely due to effects on thrombin levels. The variant is associated with increased risk of cardiovascular disease outcomes in UK BioBank, most strongly with pulmonary embolism. The variant associates with increased risk of stroke in the MEGASTROKE, UK BioBank, and FinnGen studies. Mendelian randomization analyses in independent samples support a causal role for rs10886430-G in increasing risk for stroke, pulmonary embolism, and venous thromboembolism through its effect on thrombin-induced platelet reactivity. We demonstrate that G protein-coupled receptor kinase 5 (GRK5) promotes platelet activation specifically via PAR4 receptor signaling. GRK5 inhibitors in development for the treatment of heart failure and cancer could have platelet off-target deleterious effects. Common variants in GRK5 may modify clinical outcomes with PAR4 inhibitors, and upregulation of GRK5 activity or signaling in platelets may have therapeutic benefits.

Education, intelligence and Alzheimer's disease: evidence from a multivariable two-sample Mendelian randomization study

OBJECTIVES

To examine whether educational attainment and intelligence have causal effects on risk of Alzheimer's disease (AD), independently of each other.

DESIGN

Two-sample univariable and multivariable Mendelian randomization (MR) to estimate the causal effects of education on intelligence and vice versa, and the total and independent causal effects of both education and intelligence on AD risk.

PARTICIPANTS

17 008 AD cases and 37 154 controls from the International Genomics of Alzheimer's Project (IGAP) consortium.

MAIN OUTCOME MEASURE

Odds ratio (OR) of AD per standardized deviation increase in years of schooling (SD = 3.6 years) and intelligence (SD = 15 points on intelligence test).

RESULTS

There was strong evidence of a causal, bidirectional relationship between intelligence and educational attainment, with the magnitude of effect being similar in both directions [OR for intelligence on education = 0.51 SD units, 95% confidence interval (CI): 0.49, 0.54; OR for education on intelligence = 0.57 SD units, 95% CI: 0.48, 0.66]. Similar overall effects were observed for both educational attainment and intelligence on AD risk in the univariable MR analysis; with each SD increase in years of schooling and intelligence, odds of AD were, on average, 37% (95% CI: 23-49%) and 35% (95% CI: 25-43%) lower, respectively. There was little evidence from the multivariable MR analysis that educational attainment affected AD risk once intelligence was taken into account (OR = 1.15, 95% CI: 0.68-1.93), but intelligence affected AD risk independently of educational attainment to a similar magnitude observed in the univariate analysis (OR = 0.69, 95% CI: 0.44-0.88).

CONCLUSIONS

There is robust evidence for an independent, causal effect of intelligence in lowering AD risk. The causal effect of educational attainment on AD risk is likely to be mediated by intelligence.

How does deprivation influence secondary care costs after hip fracture?

We studied the association between deprivation and healthcare costs after hip fracture. Hospital costs in the year following hip fracture were £1120 higher for those living in more deprived areas. Most of this difference was explained by pre-existing health inequalities which should be targeted to reduce this disparity.

INTRODUCTION

To quantify differences in hospital costs following hip fracture between those living in higher and lower deprivation areas of England, we investigate pre- and post-fracture variables that explain the association.

METHODS

We used English Hospital Episodes Statistics linked to the National Hip Fracture Database (April 2011-March 2015) and national mortality data to identify patients admitted with hip fracture aged 60+ years. Hospital care was costed using 2017/2018 national reference costs, by index of multiple deprivation quintile. Three generalised linear model regressions estimated associations between deprivation and costs and the pre- and post-fracture variables that mediate this relationship.

RESULTS

Patients from the most deprived areas had higher hospital costs in the year post-fracture (£1,120; 95% CI £993 to £1,247) than those from the least deprived areas. If all patients could have incurred similar costs to those in the least deprived quintile, this would equate to an annual reduction in expenditure of £28.8 million. Pre-fracture characteristics, particularly comorbidities and anaesthetic risk grade, accounted for approximately 50% of the association between deprivation and costs. No evidence was found that post-fracture variables, such as transfer to a residential or nursing home, contributed to the association between deprivation and costs.

CONCLUSIONS

Socioeconomic inequalities are associated with substantial costs for the NHS after hip fracture. We did not identify post-fracture targets for intervention to reduce the impact of inequalities on post-fracture costs. The case for interventions to reduce comorbid conditions, improve health-related behaviours and prevent falls in deprived areas is clear but challenging to implement.

Relative contribution of diet and physical activity to increased adiposity among rural to urban migrants in India: A cross-sectional study

BACKGROUND

In common with many other low- and middle-income countries (LMICs), rural to urban migrants in India are at increased risk of obesity, but it is unclear whether this is due to increased energy intake, reduced energy expenditure, or both. Knowing this and the relative contribution of specific dietary and physical activity behaviours to greater adiposity among urban migrants could inform policies for control of the obesity epidemic in India and other urbanising LMICs. In the Indian Migration Study, we previously found that urban migrants had greater prevalence of obesity and diabetes compared with their nonmigrant rural-dwelling siblings. In this study, we investigated the relative contribution of energy intake and expenditure and specific diet and activity behaviours to greater adiposity among urban migrants in India.

METHODS AND FINDINGS

The Indian Migration Study was conducted between 2005 and 2007. Factory workers and their spouses from four cities in north, central, and south of India, together with their rural-dwelling siblings, were surveyed. Self-reported data on diet and physical activity was collected using validated questionnaires, and adiposity was estimated from thickness of skinfolds. The association of differences in dietary intake, physical activity, and adiposity between siblings was examined using multivariable linear regression. Data on 2,464 participants (median age 43 years) comprised of 1,232 sibling pairs (urban migrant and their rural-dwelling sibling) of the same sex (31% female) were analysed. Compared with the rural siblings, urban migrants had 18% greater adiposity, 12% (360 calories/day) more energy intake, and 18% (11 kilojoules/kg/day) less energy expenditure (P < 0.001 for all). Energy intake and expenditure were independently associated with increased adiposity of urban siblings, accounting for 4% and 6.5% of adiposity difference between siblings, respectively. Difference in dietary fat/oil (10 g/day), time spent engaged in moderate or vigorous activity (69 minutes/day), and watching television (30 minutes/day) were associated with difference in adiposity between siblings, but no clear association was observed for intake of fruits and vegetables, sugary foods and sweets, cereals, animal and dairy products, and sedentary time. The limitations of this study include a cross-sectional design, systematic differences in premigration characteristics of migrants and nonmigrants, low response rate, and measurement error in estimating diet and activity from questionnaires.

CONCLUSIONS

We found that increased energy intake and reduced energy expenditure contributed equally to greater adiposity among urban migrants in India. Policies aimed at controlling the rising prevalence of obesity in India and potentially other urbanising LMICs need to be multicomponent, target both energy intake and expenditure, and focus particularly on behaviours such as dietary fat/oil intake, time spent on watching television, and time spent engaged in moderate or vigorous intensity physical activity.

Effect of supplemental nutrition in pregnancy on offspring's risk of cardiovascular disease in young adulthood: Long-term follow-up of a cluster trial from India

BACKGROUND

Undernutrition during intrauterine life and early childhood is hypothesised to increase the risk of cardiovascular disease (Developmental Origins of Health and Disease Hypothesis), but experimental evidence from humans is limited. This hypothesis has major implications for control of the cardiovascular disease epidemic in South Asia (home to a quarter of world's population), where a quarter of newborns have low birth weight. We investigated whether, in an area with prevalent undernutrition, supplemental nutrition offered to pregnant women and their offspring below the age of 6 years was associated with a lower risk of cardiovascular disease in the offspring when they were young adults.

METHODS AND FINDINGS

The Hyderabad Nutrition Trial was a community-based nonrandomised controlled intervention trial conducted in 29 villages near Hyderabad, India (1987-1990). Protein-calorie food supplement was offered daily to pregnant and lactating women (2.09 MJ energy and 20-25 g protein) and their offspring (1.25 MJ energy and 8-10 g protein) until the age of six years in the 15 intervention villages, but not in the 14 control villages. A total of 1,826 participants (949 from the intervention villages and 877 from the control villages, representing 70% of the cohort) at a mean age of 21.6 years (62% males) were examined between 2009 and 2012. The mean body mass index (BMI) of the participants was 20 kg/m2 and the mean systolic blood pressure was 115 mm Hg. The age, sex, socioeconomic position, and urbanisation-adjusted effects of intervention (beta coefficients and 95% confidence intervals) on outcomes were as follows: carotid intima-media thickness, 0.01 mm (-0.01 to 0.03), p = 0.36; arterial stiffness (augmentation index), -1.1% (-2.5 to 0.3), p = 0.097; systolic blood pressure, 0.5 mm Hg (-0.6 to 1.6), p = 0.36; BMI, -0.13 kg/m2 (-0.75 to 0.09), p = 0.093; low-density lipoprotein (LDL) cholesterol, 0.06 mmol/L (-0.07 to 0.2), p = 0.37; and fasting insulin (log), -0.06 mU/L (-0.19 to 0.07), p = 0.43. The limitations of this study include nonrandomised allocation of intervention and lack of data on compliance, and potential for selection bias due to incomplete follow-up.

CONCLUSIONS

Our results showed that in an area with prevalent undernutrition, protein-calorie food supplements offered to pregnant women and their offspring below the age of 6 years were not associated with lower levels of cardiovascular risk factors among offspring when they were young adults. Our findings, coupled with evidence from other intervention studies to date, suggest that policy makers should attach limited value to cardiovascular health benefits of maternal and child protein-calorie food supplementation programmes.

P1660ACCESS TO KIDNEY TRANSPLANTATION IN THE UK CHINESE POPULATION: A UK RENAL REGISTRY ANALYSIS

Background and Aims

Previous UK Renal Registry (UKRR) analyses and the Access to Transplantation and Transplant Outcome Measures (ATTOM) study have shown ethnic disparity in access to kidney transplants in the UK, but access to transplantation for the UK Chinese population has not been investigated

In this UKRR analysis, we compared the likelihood of kidney transplantation between the UK White and UK Chinese renal populations, aiming to investigate whether there was evidence of ethnic disparity in access to kidney transplantation for this specific ethnic group.

Method

Data on all adult patients &gt;=18 years who started renal replacement therapy (RRT) between 1/1/97 and 31/12/16 were extracted from the UKRR. Patients with ethnicity recorded as anything other than “Chinese” or “White” were excluded from analysis. Patients with ethnicity data missing were also excluded. Patients aged &gt;= 75 years at the start of RRT were excluded because of the high prevalence of comorbidity which decreases the likelihood of transplantation and the very small proportion of patients receiving a kidney transplant in the UK in this age group. Socioeconomic status (SES) was measured using country-specific Index of Multiple Deprivation (IMD) quintiles derived from patient postcodes (1= most deprived, 5= least deprived).

The independent variable of interest was Chinese ethnicity (Chinese vs White). Multivariable logistic regression models were used to investigate the relationship between Chinese ethnicity and being listed on the deceased donor transplant waiting list i) at start of RRT ii) 2 years after start of RRT iii) pre-emptive kidney transplantation, iv) kidney transplantation at 3 years after start of RRT, and v) living-donor kidney transplantation. The models were run unadjusted and then adjusted for the confounders, specified a priori, age, sex, primary renal disease and SES. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using robust standard errors to account for clustering by renal centre.

Results

The dataset comprised of 92,857 incident RRT patients. 0.5% (n=501) were of Chinese ethnicity, 76% (n=70,575) were White. The findings of the multivariable logistic regression analyses are presented in Table 1. Even after adjustment for potential confounders UK Chinese patients had lower odds of being waitlisted at the start of RRT (OR 0.71, [95% CI 0.54-0.94]) but were more likely to be waitlisted at 2 years (OR 1.28, [95% CI 1.02-1.61]) compared to White patients. UK Chinese individuals were also less likely to receive a pre-emptive kidney transplant (OR 0.47, [95% CI 0.29-0.78]), less likely to be transplanted within 3 years of starting RRT (OR 0.69, [95% CI 0.52-0.92]) or have a living-donor kidney transplant(LDKT) (OR 0.39, [95% CI 0.26-0.59]) compared to White patients.

Conclusion

This is the first study that has shown that UK Chinese renal patients are less likely to have the opportunity to receive a living or deceased kidney transplant. Future research needs to test whether later presentation or more rapid progression of renal disease could explain these observations. The higher odds of transplant listing at 2 years suggests fitness for transplantation is not a significant barrier. The reasons why this ethnic group are less likely to receive a LDKT is also not well understood. Understanding whether these disparities reflect modifiable policy, health system or donor/recipient level barriers will help ensure equitable access to transplantation.

The Dementias Platform UK (DPUK) Data Portal

The Dementias Platform UK Data Portal is a data repository facilitating access to data for 3 370 929 individuals in 42 cohorts. The Data Portal is an end-to-end data management solution providing a secure, fully auditable, remote access environment for the analysis of cohort data. All projects utilising the data are by default collaborations with the cohort research teams generating the data. The Data Portal uses UK Secure eResearch Platform infrastructure to provide three core utilities: data discovery, access, and analysis. These are delivered using a 7 layered architecture comprising: data ingestion, data curation, platform interoperability, data discovery, access brokerage, data analysis and knowledge preservation. Automated, streamlined, and standardised procedures reduce the administrative burden for all stakeholders, particularly for requests involving multiple independent datasets, where a single request may be forwarded to multiple data controllers. Researchers are provided with their own secure 'lab' using VMware which is accessed using two factor authentication. Over the last 2 years, 160 project proposals involving 579 individual cohort data access requests were received. These were received from 268 applicants spanning 72 institutions (56 academic, 13 commercial, 3 government) in 16 countries with 84 requests involving multiple cohorts. Projects are varied including multi-modal, machine learning, and Mendelian randomisation analyses. Data access is usually free at point of use although a small number of cohorts require a data access fee.

P0772CLINICAL CHARACTERISTICS OF THE UK CHINESE POPULATION WITH KIDNEY FAILURE: A UK RENAL REGISTRY ANALYSIS

Background and Aims

Data from the UK Renal Registry (UKRR) has shown that 0.5% of those in the UK with kidney failure are of Chinese ethnicity. The UK Chinese population is growing. Ethnic differences in cause of renal disease and dialysis rates have been described in UK individuals of White, South Asian, and Black ethnicity. However, the clinical demographics of the UK Chinese population with renal disease have not previously been investigated.

The China Kidney Disease Network and the Hong Kong Renal Registry have reported the main cause of chronic kidney disease in their populations is diabetes, but the causes of renal disease in other Chinese diaspora have not been well described.

We investigated the clinical characteristics of the UK Chinese population on renal replacement therapy (RRT) as compared with the UK White RRT population in this UKRR analysis.

Method

Data on all adult patients &gt;=18 years who started RRT between 1/1/97 and 31/12/16 were extracted from the UKRR. Patients with ethnicity recorded as anything other than “Chinese” or “White” were excluded from analysis. Patients with ethnicity data missing were also excluded.

Socioeconomic status was measured using country-specific Index of Multiple Deprivation (IMD) quintiles derived from patients’ postcodes (1= most deprived, 5= least deprived). The Chi-square (*) and Mann-Whitney U (**) tests were used to compare baseline characteristics between Chinese and White ethnic groups.

Results

The dataset comprised of 92,857 incident RRT patients, of which 0.5% (n=501) were of Chinese ethnicity and 76% (n=70,575) were White. Clinical characteristics of the UK Chinese population as compared to the UK White population are presented in Table 1.

UK Chinese patients were younger at start of RRT than white patients (61.4 years vs 65.6 years, p&lt;0.001**). Any difference in the proportion of male patients (60.7% vs 63.0%, p=0.29*) or socioeconomic status (p=0.75*) between the two groups was consistent with chance.

There were marked differences in the causes of renal disease: UK Chinese patients had more diabetic renal disease (29% versus 20%, p&lt;0.001*) and glomerulonephritis that white patients (21% vs 13%, p&lt;0.001*) There was modest evidence that more UK Chinese patients started RRT on peritoneal dialysis (PD) compared to the White population (26% vs 23%, p=0.01*)

Conclusion

We found evidence that the UK Chinese RRT population differs from the UK White RRT population. To our knowledge, this is the first study describing renal disease in the UK Chinese population, and one of the first to describe disease in the Chinese diaspora.

Our finding of a greater burden of diabetes in the UK Chinese RRT population compared to the White RRT population may reflect the high prevalence of diabetes in the UK Chinese, as in mainland China and Hong Kong. Further investigation is needed to understand the causes behind the higher burden of glomerulonephritis in the UK Chinese population.

The increased rates of PD in UK Chinese patients may be associated with lower average Body Mass Index (BMI) in the Chinese population. The quantity of missing BMI data in the UKRR dataset prevented investigation of this association. Hong Kong has had a successful “PD first” policy for &gt;30 years. Familiarity with this as a mode of dialysis may have led to higher rates of PD in the UK Chinese population. Studies from Hong Kong have also suggested that lower dialysis volumes are required for Chinese PD patients, and that high transporter status is less common in their population. It would be beneficial to elucidate whether this is also the case in UK Chinese patients.

P1635INVESTIGATING REASONS FOR ETHNIC INEQUITY IN LIVING-DONOR KIDNEY TRANSPLANTATION IN THE UK: A MIXED METHODS ANALYSIS OF A MULTICENTRE QUESTIONNAIRE-BASED STUDY

Background and Aims

A living-donor kidney transplant (LDKT) is one of the best treatments for kidney failure, yet in the UK there is evidence of ethnic inequity in access. We designed this questionnaire-based mixed-methods study to investigate the patient-reported reasons that family members of Black, Asian and Minority Ethnic group (BAME) individuals were not able to become living kidney donors.

Method

This questionnaire-based case-control study included 14 UK hospitals. Participants were adults transplanted between 1/4/13-31/3/17. Participants provided data on all relatives aged &gt;18 years who could have been potential living kidney donors. Participants were asked for the reasons why relatives could not donate: individuals were asked to tick all options that applied from a list of reasons (Age; Health; Weight; Location; Financial/Cost; Job; Blood group; No-one to care for them after donation), and a box was provided for free-text entries following the option of ‘Other – please give details’. Multivariable logistic regression was used to analyse the association between the likelihood of selecting each reason for non-donation and the participant’s ethnicity (binary variable White versus BAME). 56/171 BAME respondents provided free text responses and all were analysed. Qualitative responses were analysed using thematic analysis.

Results

1,240 questionnaires were returned from 3,103 patients (40% response). There was strong evidence that after adjustment for potential confounders sex, age and socioeconomic position, BAME individuals were more likely than White respondents to indicate that family members lived too far away to donate (adjusted odds ratio (aOR) 3.14 [95% CI 2.10-4.70]), were prevented from donating by financial concerns (aOR 2.25 [95% CI 1.49-3.39]), were not able to take time off work (aOR 2.05 [95% CI 1.36-3.09]), and were not the right blood group (aOR 1.47 [95% CI 1.12-1.94]). Four qualitative themes were identified from free-text responses from BAME participants: i) Burden of disease within the family ii) ‘Unorthodox’ religious beliefs iii) Specific geographical concerns (healthcare provision, visa difficulties) iv) Knowledge handling. The theme ‘Knowledge Handling’ incorporated three subthemes: a) Need for more detailed knowledge, b) Protected disclosure of health status, and c) Recipient assumptions about potential donor knowledge.

Conclusion

We have identified multiple barriers to living kidney donation in the UK BAME population, which should be further investigated and addressed. BAME transplant recipients were more likely to report that potential donors were not the right blood group to donate: work should be undertaken to ascertain if this reflects true ABO-incompatibility or perceived incompatibility. Potential donors living outside the UK is a major barrier, related to difficulties with accessing visa and concerns about a specific country’s healthcare system’s capacity for longer-term post-donation care. The financial barriers reported may disproportionately affect overseas donors who, although entitled to reimbursement for travel, accommodation and visa costs, may incur large “up-front” costs which may be prohibitive. No respondents reported that a major religion’s position on living donation was a barrier to donation. However, there were several references to family members holding beliefs that were described as ‘distorted’ religious beliefs: this highlights the need to understand the beliefs of potential donors who belong to non-mainstream religions, which may be out of the remit of denominational faith leaders.

Genetic analysis of Mendelian mutations in a large UK population-based Parkinson's disease study

Our objective was to define the prevalence and clinical features of genetic Parkinson’s disease in a large UK population-based cohort, the largest multicentre prospective clinico-genetic incident study in the world. We collected demographic data, Movement Disorder Society Unified Parkinson’s Disease Rating Scale scores, and Montreal Cognitive Assessment scores. We analysed mutations in PRKN (parkin), PINK1, LRRK2 and SNCA in relation to age at symptom onset, family history and clinical features. Of the 2262 participants recruited to the Tracking Parkinson’s study, 424 had young-onset Parkinson’s disease (age at onset ≤ 50) and 1799 had late onset Parkinson’s disease. A range of methods were used to genotype 2005 patients: 302 young-onset patients were fully genotyped with multiplex ligation-dependent probe amplification and either Sanger and/or exome sequencing; and 1701 late-onset patients were genotyped with the LRRK2 ‘Kompetitive’ allele-specific polymerase chain reaction assay and/or exome sequencing (two patients had missing age at onset). We identified 29 (1.4%) patients carrying pathogenic mutations. Eighteen patients carried the G2019S or R1441C mutations in LRRK2, and one patient carried a heterozygous duplication in SNCA. In PRKN, we identified patients carrying deletions of exons 1, 4 and 5, and P113Xfs, R275W, G430D and R33X. In PINK1, two patients carried deletions in exon 1 and 5, and the W90Xfs point mutation. Eighteen per cent of patients with age at onset ≤30 and 7.4% of patients from large dominant families carried pathogenic Mendelian gene mutations. Of all young-onset patients, 10 (3.3%) carried biallelic mutations in PRKN or PINK1. Across the whole cohort, 18 patients (0.9%) carried pathogenic LRRK2 mutations and one (0.05%) carried an SNCA duplication. There is a significant burden of LRRK2 G2019S in patients with both apparently sporadic and familial disease. In young-onset patients, dominant and recessive mutations were equally common. There were no differences in clinical features between LRRK2 carriers and non-carriers. However, we did find that PRKN and PINK1 mutation carriers have distinctive clinical features compared to young-onset non-carriers, with more postural symptoms at diagnosis and less cognitive impairment, after adjusting for age and disease duration. This supports the idea that there is a distinct clinical profile of PRKN and PINK1-related Parkinson’s disease. We estimate that there are approaching 1000 patients with a known genetic aetiology in the UK Parkinson’s disease population. A small but significant number of patients carry causal variants in LRRK2, SNCA, PRKN and PINK1 that could potentially be targeted by new therapies, such as LRRK2 inhibitors.

Testing Shortened Versions of Smell Tests to Screen for Hyposmia in Parkinson's Disease

Background

Hyposmia is an early feature in neurodegenerative diseases, most notably Parkinson's disease (PD). Using abbreviated smell tests could provide a cost-effective means for large-scale hyposmia screening. It is unclear whether short smell tests can effectively detect hyposmia in patient populations.

Objectives

To test the ability of short smell combinations to "prescreen" for probable hyposmia in people with PD and target administration of more extensive tests, such as the University of Pennsylvania Smell Identification Test.

Methods

We assessed the screening performance of a short 4-smell combination previously derived from use of the 40-item University of Pennsylvania Smell Identification Test in healthy older people and its ability to detect hyposmia in a large cohort of PD patients.

Results

The novel 4-smell combination included menthol, clove, onion, and orange and had a sensitivity of 87.1% (95% confidence interval, 84.9%-89.2%) and specificity of 69.7% (63.3%-75.5%) for detecting hyposmia in patients with PD. A different (also novel) 4-item combination developed using a data-driven approach in PD patients only achieved 81.3% (78.2%-84.4%) sensitivity for equivalent specificity.

Conclusions

A short 4-smell combination derived from a healthy population demonstrated high sensitivity to detect those with hyposmia and PD.

Oral Bisphosphonate Use and All-Cause Mortality in Patients With Moderate-Severe (Grade 3B-5D) Chronic Kidney Disease: A Population-Based Cohort Study

Oral bisphosphonates (oBPs) have been associated with reduced fractures and mortality. However, their risks and benefits are unclear in patients with moderate-severe CKD. This study examined the association between oBPs and all-cause mortality in G3B-5D CKD. This is a population-based cohort study including all subjects with an estimated glomerular filtration rate (eGFR) <45/mL/min/1.73 m² (G3B: eGFR <45/mL/min/1.73 m² G4: eGFR 15-29/mL/min/1.73 m² G5: eGFR <15/mL/min/1.73 m² G5D: hemodialysis) aged 40+ years from the UK Clinical Practice Research Datalink (CPRD) and the Catalan Information System for Research in Primary Care (SIDIAP). Previous and current users of other anti-osteoporosis drugs were excluded. oBP use was modeled as a time-varying exposure to avoid immortal time bias. Treatment episodes in oBP users were created by concatenating prescriptions until patients switched or stopped therapy or were censored or died. A washout period of 180 days was added to (date of last prescription +180 days). Propensity scores (PSs) were calculated using prespecified predictors of mortality including age, gender, baseline eGFR, socioeconomic status, comorbidities, previous fracture, co-medications, and number of hospital admissions in the previous year. Cox models were used for PS adjustment before and after PS trimming (the first and last quintiles). In the CPRD, of 19,351 oBP users and 210,954 non-oBP users, 5234 (27%) and 85,105 (40%) deaths were recorded over 45,690 and 915,867 person-years of follow-up, respectively. oBP users had 8% lower mortality risk compared to non-oBP users (hazard ratio [HR] 0.92; 95% CI, 0.89 to 0.95). Following PS trimming, this became nonsignificant (HR 0.98; 95% CI, 0.94 to 1.04). In the SIDIAP, of 4146 oBP users and 86,127 non-oBP users, 1330 (32%) and 36,513 (42%) died, respectively. oBPs were not associated with mortality in PS adjustment and trimming (HR 1.04; 95% CI, 0.99 to 1.1 and HR 0.95; 95% CI, 0.89 to 1.01). In this observational, patient-based cohort study, oBPs were not associated with increased mortality among patients with moderate-severe CKD. However, further studies are needed on other effects of oBPs in CKD patients. © 2020 American Society for Bone and Mineral Research.

Circulating Fatty Acids and Risk of Coronary Heart Disease and Stroke: Individual Participant Data Meta-Analysis in Up to 16 126 Participants

Background We aimed at investigating the association of circulating fatty acids with coronary heart disease (CHD) and stroke risk. Methods and Results We conducted an individual-participant data meta-analysis of 5 UK-based cohorts and 1 matched case-control study. Fatty acids (ie, omega-3 docosahexaenoic acid, omega-6 linoleic acid, monounsaturated and saturated fatty acids) were measured at baseline using an automated high-throughput serum nuclear magnetic resonance metabolomics platform. Data from 3022 incident CHD cases (13 104 controls) and 1606 incident stroke cases (13 369 controls) were included. Logistic regression was used to model the relation between fatty acids and odds of CHD and stroke, adjusting for demographic and lifestyle variables only (ie, minimally adjusted model) or with further adjustment for other fatty acids (ie, fully adjusted model). Although circulating docosahexaenoic acid, but not linoleic acid, was related to lower CHD risk in the fully adjusted model (odds ratio, 0.85; 95% CI, 0.76-0.95 per standard unit of docosahexaenoic acid), there was evidence of high between-study heterogeneity and effect modification by study design. Stroke risk was consistently lower with increasing circulating linoleic acid (odds ratio for fully adjusted model, 0.82; 95% CI, 0.75-0.90). Circulating monounsaturated fatty acids were associated with higher CHD risk across all models and with stroke risk in the fully adjusted model (odds ratio, 1.22; 95% CI, 1.03-1.44). Saturated fatty acids were not related to increased CHD risk in the fully adjusted model (odds ratio, 0.94; 95% CI, 0.82-1.09), or stroke risk. Conclusions We found consistent evidence that linoleic acid was associated with decreased risk of stroke and that monounsaturated fatty acids were associated with increased risk of CHD. The different pattern between CHD and stroke in terms of fatty acids risk profile suggests future studies should be cautious about using composite events. Different study designs are needed to assess which, if any, of the associations observed is causal.

Systemic Inflammation and Cardio-Renal Organ Damage Biomarkers in Middle Age Are Associated With Physical Capability Up to 9 Years Later

Supplemental Digital Content is available in the text.

Background:

Physical capability, a key component of healthy aging, is associated with cardiovascular and other risk factors across life. We investigated whether midlife biomarkers of heart and kidney damage capturing the cumulative impact of long-term adverse exposures were associated with the level and decline in physical capability over 9 years of follow-up, taking account of systemic inflammatory biomarkers and conventional cardiovascular risk factors.

Methods:

We used data on 1736 men and women from the oldest British birth cohort study with walking speed, chair rise speed, balance time, and grip strength assessed at ages 60 to 64 and 69 years. We tested associations between logged and standardized measures of cystatin C, NT-proBNP (N-terminal pro-B-type natriuretic peptide), interleukin (IL)-6, and E-selectin at age 60 to 64 years with performance at age 69 years, adjusting for sex, height, and body mass index; then for performance at age 60 to 64 years. These biomarkers were mutually adjusted, and additionally adjusted for cardiovascular risk factors (pulse pressure, total/high density lipoprotein cholesterol, glycosylated hemoglobin), diabetes mellitus, cardiovascular and kidney disease, smoking status, and lifetime socioeconomic position.

Results:

Cystatin C, NT-proBNP, and IL-6 (but not E-selectin) were inversely associated with all outcomes, adjusted for sex, height, and body mass index. For example, a 1-SD increase in logged NT-proBNP was associated with weaker grip (−0.63 kg, 95% CI, −0.99 to −0.28); the equivalent association for cystatin C was −0.60 kg (95% CI, −0.94 to −0.25) and for IL-6 was −0.76 kg (95% CI, −1.11 to −0.41). Most associations remained, albeit attenuated, after adjustment for previous performance and mutual adjustment of the biomarkers. NT-proBNP and IL-6 (but not cystatin C) were more strongly associated with the outcomes than many of the conventional risk factors after mutual adjustment.

Conclusions:

Higher levels of NT-proBNP may identify those in midlife at risk of accelerated physical decline. Before considering the use of NT-proBNP for risk stratification, further research should untangle whether these associations exist because the biomarker is an integrated measure of cumulative exposures to relevant stressors across life, or whether it is marking additional risk pathways. Randomized trials to reduce the rate of decline in physical capability or delay incident disability could benefit from including middle-aged adults and adding NT-proBNP and IL-6 as intermediate outcomes.

Freezing of Gait in People with Parkinson's Disease: Nature, Occurrence, and Risk Factors

BACKGROUND

Freezing of gait (FOG) is a common symptom of Parkinson's disease (PD) which can result in falls and fall related injuries, poor quality of life and reduced functional independence. It is a heterogeneous phenomenon that is difficult to quantify and eludes a unified pathophysiological framework.

OBJECTIVE

Our aim was to document the occurrence and nature of freezing, cognitive stops and stumbles in people with PD during walks with varying cognitive loads and conditions designed to elicit FOG.

METHODS

130 people with PD walked under four conditions (normal walking, walking plus easy and hard dual-tasks, and a FOG elicitation condition. Video and accelerometry recordings were examined to document freezes and other gait disruptions.

RESULTS

Participants experienced 391 freezes, 97 cognitive stops and 73 stumbles in the trial walks; with total gait disruptions increasing with task complexity. Most freezes in the FOG elicitation condition occurred during turning and approach destination. People who experienced freezing during the walks were more likely to have Postural Instability and Gait Difficulty (PIGD) subtype, longer disease duration and more severe UPDRS part II and part III sub-scores than people who did not freeze. They also took higher doses of levodopa, reported freezing in the past month, more prior falls, had poorer executive function, poorer proprioception, slower reaction time, poorer standing and leaning balance, more depressive symptoms, lower quality of life and greater fear of falling. PD disease duration, reduced controlled leaning balance and poor proprioception were identified as independent and significant determinants of freezing in logistic regression analysis.

CONCLUSION

The multiple motor and cognitive factors identified as being associated with freezing, including poor proprioception and impaired controlled leaning balance provide new insights into this debilitating PD symptom and may contribute to potential new targets for rehabilitation.

Alendronate use and bone mineral density gains in women with moderate-severe (stages 3B-5) chronic kidney disease: an open cohort multivariable and propensity score analysis from Funen, Denmark

Bisphosphonates are contraindicated in moderate-to-severe chronic kidney disease patients. However, they are used to prevent fragility fractures in patients with impaired kidney function, despite a lack of evidence on their effects on bone density in these patients. We demonstrated that Alendronate had a positive effect on bone in these patients.

PURPOSE

This study aimed to assess the association between alendronate use and bone mineral density (BMD) change in subjects with moderate-severe chronic kidney disease (CKD).

METHODS

We created a cohort of CKD stage 3B-5 patients by linking all DXA-based measurements in the Funen area, Denmark, to biochemistry, national health registries and filled prescriptions. Exposure was dispensation of alendronate and the outcome was annualized percentage change in BMD at the femoral neck, total hip and lumbar spine. Individuals were followed from first BMD to the latest of subsequent DXA measurements. Alendronate non-users were identified using incidence density sampling and matched groups were created using propensity scores. Linear regression was used to estimate average differences in the annualized BMD.

RESULTS

Use of alendronate was rare in this group of patients: propensity score matching (PSM) resulted in 71 alendronate users and 142 non-users with stage 3B-5 CKD (as in the 1 year before DXA). Whilst alendronate users gained an average 1.07% femoral neck BMD per year, non-users lost an average of 1.59% per annum. The PSM mean differences in annualized BMD were + 2.65% (1.32%, 3.99%), + 3.01% (1.74%, 4.28%) and + 2.12% (0.98%, 3.25%) at the femoral neck, total hip and spine BMD, respectively, all in favour of alendronate users.

CONCLUSION

In a real-world cohort of women with stage 3B-5 CKD, use of alendronate appears associated with a significant improvement of 2-3% per year in the femoral neck, total hip and spine BMD. More data are needed on the anti-fracture effectiveness and safety of bisphosphonate therapy in moderate-severe CKD.

Estimating the risk of acute kidney injury associated with use of diuretics and renin angiotensin aldosterone system inhibitors: A population based cohort study using the clinical practice research datalink

Background

The risk of acute kidney injury (AKI) attributable to renin angiotensin aldosterone (RAAS) inhibitors and diuretics remains unclear.

Methods

We conducted a prospective cohort study using the Clinical Practice Research Datalink (2008–2015) linked to Hospital Episode Statistics – Admitted Patient Care and Office for National Statistics mortality data. Patients were included if they had one or more chronic diagnoses requiring medication. Exposed patients had a first ever prescription for RAAS inhibitors/diuretics during the study period. AKI risk associated with exposure was determined by multivariable Cox regression, propensity score-adjusted Cox regression and a prior event rate ratio (PERR) analysis.

Results

One hundred forty thousand nine hundred fifty-two individuals were included. Increased AKI risk in the exposed group was demonstrated in both the multivariable and propensity score-adjusted cox regressions (HR 1.23 (95% CI 1.04–1.45) and HR 1.24 (1.05–1.47) respectively). The PERR analysis provided a similar overall hazard ratio with a wider confidence interval (HR 1.29 (0.94–1.63)). The increased AKI risk in the exposed group was present only in those receiving two or more antihypertensives. Absolute AKI risk was small.

Conclusions

RAAS inhibitors/diuretics result in an increased risk of AKI. The absolute increase in AKI risk is small, however, and needs to be considered in the context of any potential benefits.

Admission patterns and survival from status epilepticus in critical care in the UK: an analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database

BACKGROUND AND PURPOSE

Factors influencing the outcome after the critical care unit (CCU) for patients with status epilepticus (SE) are poorly understood. Survival for these patients was examined to establish (i) whether the risk of mortality has changed over time and (ii) whether admission to different unit types affects mortality risk over and above other risk factors.

METHODS

The Intensive Care National Audit and Research Centre database and the Case Mix Programme database (January 2001 to December 2016) were analysed. Units were defined as neuro-CCU (NCCU), general CCU with 24-h neurological support (GCCU-N) or general CCU with limited neurological support (GCCU-L).

RESULTS

There were 35 595 CCU cases of SE with a 3-fold increase over time (4739 in 2001-2004 to 14 166 in 2013-2016). More recent admissions were older and were more often unsedated on admission. Mortality declined for all units although this was more marked for NCCUs (8.1% in 2001-2004 to 4.4% in 2013-2016 compared to 5.1% and 4.1% for GCCU-L). Acute hospital mortality was two to three times higher than CCU mortality although this has also declined with time. GCCU-L appeared to have lower mortality than NCCUs (odds ratio 0.84, 95% confidence interval 0.72, 0.98) but after post hoc adjustment for case mix there were no differences. Older age and markers of seriousness of morbidity were all associated with increased mortality risk.

CONCLUSIONS

The number of patients admitted to a CCU for SE is rising but critical care and acute hospital mortality is decreasing. Patients treated in an NCCU have higher mortality but this is explicable by more severe underlying disease.

Blood biomarkers with Parkinson's disease clusters and prognosis: The oxford discovery cohort

Background

Predicting prognosis in Parkinson's disease (PD) has important implications for individual prognostication and clinical trials design and targeting novel treatments. Blood biomarkers could help in this endeavor.

Methods

We identified 4 blood biomarkers that might predict prognosis: apolipoprotein A1, C‐reactive protein, uric acid and vitamin D. These biomarkers were measured in baseline serum from 624 Parkinson's disease subjects (median disease duration, 1.0 years; interquartile range, 0.5–2.0) from the Oxford Discovery prospective cohort. We compared these biomarkers against PD subtypes derived from clinical features in the baseline cohort using data‐driven approaches. We used multilevel models with MDS‐UPDRS parts I, II, and III and Montreal Cognitive Assessment as outcomes to test whether the biomarkers predicted subsequent progression in motor and nonmotor domains. We compared the biomarkers against age of PD onset and age at diagnosis. The q value, a false‐discovery rate alternative to P values, was calculated as an adjustment for multiple comparisons.

Results

Apolipoprotein A1 and C‐reactive protein levels differed across our PD subtypes, with severe motor disease phenotype, poor psychological well‐being, and poor sleep subtype having reduced apolipoprotein A1 and higher C‐reactive protein levels. Reduced apolipoprotein A1, higher C‐reactive protein, and reduced vitamin D were associated with worse baseline activities of daily living (MDS‐UPDRS II).

Conclusion

Baseline clinical subtyping identified a pro‐inflammatory biomarker profile significantly associated with a severe motor/nonmotor disease phenotype, lending biological validity to subtyping approaches. No blood biomarker predicted motor or nonmotor prognosis. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.

Phenome-wide association analysis of LDL-cholesterol lowering genetic variants in PCSK9

BACKGROUND

We characterised the phenotypic consequence of genetic variation at the PCSK9 locus and compared findings with recent trials of pharmacological inhibitors of PCSK9.

METHODS

Published and individual participant level data (300,000+ participants) were combined to construct a weighted PCSK9 gene-centric score (GS). Seventeen randomized placebo controlled PCSK9 inhibitor trials were included, providing data on 79,578 participants. Results were scaled to a one mmol/L lower LDL-C concentration.

RESULTS

The PCSK9 GS (comprising 4 SNPs) associations with plasma lipid and apolipoprotein levels were consistent in direction with treatment effects. The GS odds ratio (OR) for myocardial infarction (MI) was 0.53 (95% CI 0.42; 0.68), compared to a PCSK9 inhibitor effect of 0.90 (95% CI 0.86; 0.93). For ischemic stroke ORs were 0.84 (95% CI 0.57; 1.22) for the GS, compared to 0.85 (95% CI 0.78; 0.93) in the drug trials. ORs with type 2 diabetes mellitus (T2DM) were 1.29 (95% CI 1.11; 1.50) for the GS, as compared to 1.00 (95% CI 0.96; 1.04) for incident T2DM in PCSK9 inhibitor trials. No genetic associations were observed for cancer, heart failure, atrial fibrillation, chronic obstructive pulmonary disease, or Alzheimer's disease - outcomes for which large-scale trial data were unavailable.

CONCLUSIONS

Genetic variation at the PCSK9 locus recapitulates the effects of therapeutic inhibition of PCSK9 on major blood lipid fractions and MI. While indicating an increased risk of T2DM, no other possible safety concerns were shown; although precision was moderate.

World Health Organization cardiovascular disease risk charts: revised models to estimate risk in 21 global regions

BACKGROUND

To help adapt cardiovascular disease risk prediction approaches to low-income and middle-income countries, WHO has convened an effort to develop, evaluate, and illustrate revised risk models. Here, we report the derivation, validation, and illustration of the revised WHO cardiovascular disease risk prediction charts that have been adapted to the circumstances of 21 global regions.

METHODS

In this model revision initiative, we derived 10-year risk prediction models for fatal and non-fatal cardiovascular disease (ie, myocardial infarction and stroke) using individual participant data from the Emerging Risk Factors Collaboration. Models included information on age, smoking status, systolic blood pressure, history of diabetes, and total cholesterol. For derivation, we included participants aged 40-80 years without a known baseline history of cardiovascular disease, who were followed up until the first myocardial infarction, fatal coronary heart disease, or stroke event. We recalibrated models using age-specific and sex-specific incidences and risk factor values available from 21 global regions. For external validation, we analysed individual participant data from studies distinct from those used in model derivation. We illustrated models by analysing data on a further 123 743 individuals from surveys in 79 countries collected with the WHO STEPwise Approach to Surveillance.

FINDINGS

Our risk model derivation involved 376 177 individuals from 85 cohorts, and 19 333 incident cardiovascular events recorded during 10 years of follow-up. The derived risk prediction models discriminated well in external validation cohorts (19 cohorts, 1 096 061 individuals, 25 950 cardiovascular disease events), with Harrell's C indices ranging from 0·685 (95% CI 0·629-0·741) to 0·833 (0·783-0·882). For a given risk factor profile, we found substantial variation across global regions in the estimated 10-year predicted risk. For example, estimated cardiovascular disease risk for a 60-year-old male smoker without diabetes and with systolic blood pressure of 140 mm Hg and total cholesterol of 5 mmol/L ranged from 11% in Andean Latin America to 30% in central Asia. When applied to data from 79 countries (mostly low-income and middle-income countries), the proportion of individuals aged 40-64 years estimated to be at greater than 20% risk ranged from less than 1% in Uganda to more than 16% in Egypt.

INTERPRETATION

We have derived, calibrated, and validated new WHO risk prediction models to estimate cardiovascular disease risk in 21 Global Burden of Disease regions. The widespread use of these models could enhance the accuracy, practicability, and sustainability of efforts to reduce the burden of cardiovascular disease worldwide.

FUNDING

World Health Organization, British Heart Foundation (BHF), BHF Cambridge Centre for Research Excellence, UK Medical Research Council, and National Institute for Health Research.

Mid-life social participation and physical performance at age 60-64: evidence from the 1946 British Birth Cohort Study

BACKGROUND

Previous studies linking social activity and disability have been limited by focussing on self-reported physical performance in older adults (>65). We examined whether social participation in mid-life is associated with objective and subjective measures of physical performance in older age.

METHODS

Participants of the Medical Research Council National Survey of Health and Development reported their involvement in social activities at ages 43 and 60-64 years; frequency of such involvement was classified into thirds. Physical performance was measured at age 60-64 using: grip strength; standing balance; chair rises; timed get-up-and-go; self-reported physical function from the Short Form-36. Multivariable regression was used to examine longitudinal associations between social participation and each physical performance measure. We also investigated whether change in social participation between 43 and 60-64 was associated with each outcome.

RESULTS

In fully adjusted models, higher frequency of social participation at 43 was associated with faster chair rise (1.42 repetitions/min, 95% CI 0.45-2.39) and timed get-up-and-go speed (2.47 cm/s, 95% CI 0.27-4.67) and lower likelihood of self-report limitations (OR of low physical function 0.67, 95% CI 0.50-0.91) at 60-64 compared with low frequency. Better performance in objectively measured outcomes was observed only if higher social participation persisted over time whereas lower odds of self-reported limitations were found in all groups when compared to those with persistently low participation (ORs 0.43-0.56, all P≤0.02).

CONCLUSION

Our findings suggest that associations between higher levels of social participation in mid-life and better physical performance exist only if this social participation persists through to older age.

Trends in multimorbidity, complex multimorbidity and multiple functional limitations in the ageing population of England, 2002-2015

This study aimed to estimate the prevalence of three measures of multimorbidity among people aged 50 years or older in England. Beside the basic measure of two or more diseases within a person, we added a measure of three or more affected body systems (complex multimorbidity) and a measure of 10 or more functional limitations. We found that the three health outcomes became more prevalent between 2002 and 2015. They were more common among females than males and were becoming more common among younger age groups. While in 2002, the prevalence of basic multimorbidity overcame 50% from the 70–74 age group upwards, in 2015 it crossed the same threshold in the 65–69 age group. The distribution of multimorbidity and multiple functional limitations were stratified by the amount of household wealth. Multiple functional limitations reflected the largest differences between the most and the least affluent groups (5.9-fold in 2014/2015), followed by the measure of complex multimorbidity (2.8-fold in 2014/2015) and basic multimorbidity (1.9-fold) in 2014/2015.While age acted as a levelling factor for the wealth differences in basic multimorbidity, it had no such effect on the two other outcomes. Our study observed social polarization among multimorbid ageing population in England where complex multimorbidity and multiple functional limitations increase faster and reflect stronger inequality than basic multimorbidity.

The usefulness of symptoms alone or combined for general practitioners in considering the diagnosis of a brain tumour: a case-control study using the clinical practice research database (CPRD) (2000-2014)

OBJECTIVES

To evaluate the utility of different symptoms, alone or combined, presented to primary care for an adult brain tumour diagnosis.

DESIGN AND SETTING

Matched case-control study, using the data from Clinical Practice Research Datalink (2000-2014) from primary care consultations in the UK.

METHOD

All presentations within 6 months of the index diagnosis date (cases) or equivalent (controls) were coded into 32 symptom groups. Sensitivity, specificity, positive predictive values (PPVs) and positive likelihood ratios were calculated for symptoms and combinations of symptoms with headache and cognitive features. Diagnostic odds ratios were calculated using conditional logistic regression, adjusted for age group, sex and Charlson comorbidity. Stratified analyses were performed for age group, sex and whether the tumour was of primary or secondary origin.

RESULTS

We included 8,184 cases and 28,110 controls. Seizure had the highest PPV of 1.6% (95% CI 1.4% to 1.7%) followed by weakness 1.5% (1.3 to 1.7) and confusion 1.4% (1.3 to 1.5). Combining headache with other symptoms increased the PPV. For example, headache plus combined cognitive symptoms PPV 7.2% (6.0 to 8.6); plus weakness 4.4% (3.2 to 6.2), compared with headache alone PPV 0.1%. The diagnostic ORs were generally larger for patients <70 years; this was most marked for confusion, seizure and visual symptoms.

CONCLUSION

We found seizure, weakness and confusion had relatively higher predictive values than many other symptoms. Headache on its own was a weak predictor but this was enhanced when combined with other symptoms especially in younger patients. Clinicians need to actively search for other neurological symptoms such as cognitive problems.

The clinical epidemiology of young adults starting renal replacement therapy in the UK: presentation, management and survival using 15 years of UK Renal Registry data

Background

Clinical epidemiology data for young adults on renal replacement therapy (RRT) are lacking. While mostly transplanted, they have an increased risk of graft loss during young adulthood.

Methods

We combined the UK Renal Registry paediatric and adult databases to describe patient characteristics, transplantation and survival for young adults. We grouped patients 11–30 years of age starting RRT from 1999 to 2008 by age band and examined their course during 5 years of follow-up.

Results

The cohort (n = 3370) was 58% male, 79% white and 29% had glomerulonephritis. Half (52%) started RRT on haemodialysis (HD). Most (78%) were transplanted (18% pre-emptive, 61% as second modality); 11% were not listed for transplant. Transplant timing varied by age group. The deceased:living donor kidney transplant ratio was 2:1 for 11–<16 year olds and 1:1 otherwise. Median deceased donor transplant waiting times ranged from 6 months if <16 years of age to 17 months if ≥21 years. Overall 8% died, with being on dialysis and not transplant listed versus transplanted {hazard ratio [HR] 16.6 [95% confidence interval (CI) 10.8–25.4], P < 0.0001} and diabetes versus glomerulonephritis [HR 4.03 (95% CI 2.71–6.01), P < 0.0001] increasing mortality risk.

Conclusions

This study highlights the frequent use of HD and the importance of transplant listing and diabetes for young adults. More than half the young adults in our cohort started renal replacement therapy on HD. One in 10 young adults were not listed for transplant by 5 years and were ∼20 times more likely to die than those who were transplanted. Diabetes as a primary renal disease was common among young adults and associated with increased mortality. Overall, almost 1 in 10 young adults had died by 5 years from the start of RRT.

Predicting motor, cognitive & functional impairment in Parkinson's

OBJECTIVE

We recently demonstrated that 998 features derived from a simple 7-minute smartphone test could distinguish between controls, people with Parkinson's and people with idiopathic Rapid Eye Movement sleep behavior disorder, with mean sensitivity/specificity values of 84.6-91.9%. Here, we investigate whether the same smartphone features can be used to predict future clinically relevant outcomes in early Parkinson's.

METHODS

A total of 237 participants with Parkinson's (mean (SD) disease duration 3.5 (2.2) years) in the Oxford Discovery cohort performed smartphone tests in clinic and at home. Each test assessed voice, balance, gait, reaction time, dexterity, rest, and postural tremor. In addition, standard motor, cognitive and functional assessments and questionnaires were administered in clinic. Machine learning algorithms were trained to predict the onset of clinical outcomes provided at the next 18-month follow-up visit using baseline smartphone recordings alone. The accuracy of model predictions was assessed using 10-fold and subject-wise cross validation schemes.

RESULTS

Baseline smartphone tests predicted the new onset of falls, freezing, postural instability, cognitive impairment, and functional impairment at 18 months. For all outcome predictions AUC values were greater than 0.90 for 10-fold cross validation using all smartphone features. Using only the 30 most salient features, AUC values greater than 0.75 were obtained.

INTERPRETATION

We demonstrate the ability to predict key future clinical outcomes using a simple smartphone test. This work has the potential to introduce individualized predictions to routine care, helping to target interventions to those most likely to benefit, with the aim of improving their outcome.

Impulse control disorders in Parkinson disease and RBD: A longitudinal study of severity

Objective

To describe the prevalence, natural history, and risk factors for impulse control behaviors (ICBs) among people with Parkinson disease (PD), those with REM sleep behavior disorder (RBD), and controls.

Methods

Participants with early PD (within 3.5 years of diagnosis), those with RBD, and controls were clinically phenotyped and screened for ICBs longitudinally (with the Questionnaire for Impulsivity in Parkinson's Disease). ICB-positive individuals were invited for a semistructured interview, repeated 1 year later. The severity of the ICB was assessed with the Parkinson's Impulse Control Scale. Multiple imputation and regression models were used to estimate ICB prevalence and associations.

Results

Data from 921 cases of PD at baseline, 768 cases at 18 months, and 531 cases at 36 months were included, with 21% to 25% screening positive for ICBs at each visit. Interviews of ICB screen–positive individuals revealed that 10% met formal criteria for impulse control disorders (ICD), while 33% had subsyndromal ICD (ICB symptoms without reaching the formal diagnostic criteria for ICD). When these data were combined through the use of multiple imputation, the prevalence of PD-ICB was estimated at 19.1% (95% confidence interval 10.1–28.2). On follow-up, 24% of cases of subsyndromal ICD had developed full symptoms of an ICD. PD-ICD was associated with dopamine agonist use, motor complications, and apathy but not PD-RBD. ICD prevalence in the RBD group (1%) was similar to that in controls (0.7%).

Conclusions

ICBs occur in 19.1% of patients with early PD, many persisting or worsening over time. RBD is not associated with increased ICD risk. Psychosocial drivers, including mood and support networks, affect severity.

Smoking does not accelerate leucocyte telomere attrition: a meta-analysis of 18 longitudinal cohorts

Smoking is associated with shorter leucocyte telomere length (LTL), a biomarker of increased morbidity and reduced longevity. This association is widely interpreted as evidence that smoking causes accelerated LTL attrition in adulthood, but the evidence for this is inconsistent. We analysed the association between smoking and LTL dynamics in 18 longitudinal cohorts. The dataset included data from 12 579 adults (4678 current smokers and 7901 non-smokers) over a mean follow-up interval of 8.6 years. Meta-analysis confirmed a cross-sectional difference in LTL between smokers and non-smokers, with mean LTL 84.61 bp shorter in smokers (95% CI: 22.62 to 146.61). However, LTL attrition was only 0.51 bp yr-1 faster in smokers than in non-smokers (95% CI: -2.09 to 1.08), a difference that equates to only 1.32% of the estimated age-related loss of 38.33 bp yr-1. Assuming a linear effect of smoking, 167 years of smoking would be required to generate the observed cross-sectional difference in LTL. Therefore, the difference in LTL between smokers and non-smokers is extremely unlikely to be explained by a linear, causal effect of smoking. Selective adoption, whereby individuals with short telomeres are more likely to start smoking, needs to be considered as a more plausible explanation for the observed pattern of telomere dynamics.

The Consortium of Metabolomics Studies (COMETS): Metabolomics in 47 Prospective Cohort Studies

The Consortium of Metabolomics Studies (COMETS) was established in 2014 to facilitate large-scale collaborative research on the human metabolome and its relationship with disease etiology, diagnosis, and prognosis. COMETS comprises 47 cohorts from Asia, Europe, North America, and South America that together include more than 136,000 participants with blood metabolomics data on samples collected from 1985 to 2017. Metabolomics data were provided by 17 different platforms, with the most frequently used labs being Metabolon, Inc. (14 cohorts), the Broad Institute (15 cohorts), and Nightingale Health (11 cohorts). Participants have been followed for a median of 23 years for health outcomes including death, cancer, cardiovascular disease, diabetes, and others; many of the studies are ongoing. Available exposure-related data include common clinical measurements and behavioral factors, as well as genome-wide genotype data. Two feasibility studies were conducted to evaluate the comparability of metabolomics platforms used by COMETS cohorts. The first study showed that the overlap between any 2 different laboratories ranged from 6 to 121 metabolites at 5 leading laboratories. The second study showed that the median Spearman correlation comparing 111 overlapping metabolites captured by Metabolon and the Broad Institute was 0.79 (interquartile range, 0.56-0.89).

Social determinants of multimorbidity and multiple functional limitations among the ageing population of England, 2002-2015

This study explores longitudinal relationships between material, psycho-social and behavioural social determinants of health and multimorbidity of people aged 50 years or older in England. We used data from the English Longitudinal Study of Ageing collected biannually between 2002 and 2015. Apart from the basic measure of multimorbidity (two or more diseases within a person) we constructed two distinct measures of health in order to take into account the biology of ageing (complex multimorbidity and multiple functional limitations).

We found that the likelihood of multimorbidity and multiple functional limitations was consistently associated with the levels of household wealth, sense of control over one's life, physical activity and loneliness. Larger health inequalities were observed when health was measured as complex multimorbidity and multiple functional limitations than basic multimorbidity. Compared to the population group with the highest wealth, those with the lowest wealth had 47% higher odds of basic multimorbidity (95% C.I. 1.34-1.61), 73% higher odds of complex multimorbidity (95% C.I. 1.52-1.96) and 90% higher odds of having 10 or more functional limitations (95% C.I. 1.59-2.26). We did not find a dose-response relationship between alcohol consumption, smoking and multimorbidity but rather evidence of people in ill health actively moderating their health behaviour.

We suggest that materialist models of multimorbidity and functional limitation at older age can not, on their own, explain the health inequalities as the behavioural and psycho-social factors play an important role. Policies aiming to reduce the risk of multimorbidity and functional limitation should address the issue at these three levels simultaneously, using the existing national infrastructure of General Practices.

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Multimorbidity and functional limitation were associated with household wealth, sense of control over life, physical activity, loneliness.

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We observed larger health inequalities for complex multimorbidity and multiple functional limitation than basic multimorbidity.

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Materialist models of multimorbidity do not explain inequalities.

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Behavioural and psycho-social factors play an important role.

Establishing a tele-clinic service for kidney transplant recipients through a patient-codesigned quality improvement project

Kidney transplant patients in our regional centre travel long distances to attend routine hospital follow-up appointments. Patients incur travel costs and productivity losses as well as adverse environmental impacts. A significant proportion of these patients, who may not require physical examination, could potentially be managed through telephone consultations (tele-clinic). We adopted a Quality Improvement approach with iterative Plan-Do-Study-Act (PDSA) cycles to test the introduction of a tele-clinic service. We codesigned the service with patients and developed a prototype delivery model that we then tested over two PDSA improvement ramps containing multiple PDSA cycles to embed the model into routine service delivery. Nineteen tele-clinics were held involving 168 kidney transplant patients (202 tele-consultations). 2.9% of tele-clinic patients did not attend compared with 6.9% for face-to-face appointments. Improving both blood test quality and availability for the tele-clinic was a major focus of activity during the project. Blood test quality for tele-clinics improved from 25% to 90.9%. 97.9% of survey respondents were satisfied overall with their tele-clinic, and 96.9% of the patients would recommend this to other patients. The tele-clinic saved 3527 miles of motorised travel in total. This equates to a saving of 1035 kgCO2. There were no unplanned admissions within 30 days of the tele-clinic appointment. The service provided an immediate saving of £6060 for commissioners due to reduced tele-clinic tariff negotiated locally (£30 less than face-to-face tariff). The project has shown that tele-clinics for kidney transplant patients are deliverable and well received by patients with a positive environmental impact and modest financial savings. It has the potential to be rolled out to other renal centres if a national tele-clinic tariff can be negotiated, and an integrated, appropriately reimbursed community phlebotomy system can be developed to facilitate remote monitoring of patients.

A life fulfilled: positively influencing physical activity in older adults - a systematic review and meta-ethnography

BACKGROUND

Increasing physical activity in older adults remains a key public health priority in countries with a high burden of non-communicable disease, yet current interventions have failed to substantially increase population uptake with UK data suggesting that only half of 65-74 year olds report meeting recommended levels. The aim of this study was to conduct a systematic and inductive qualitative synthesis of the large body of qualitative research describing what influences physical activity at this age, and older adults' experiences of physical activity.

METHODS

A qualitative meta-ethnography was chosen as the study design as this inductive approach can provide novel insights and generate new theory about physical activity and ageing. Papers were identified by searching electronic databases and key citations. Peer-reviewed primary qualitative studies and systematic reviews were included if they met the following inclusion criteria: community-dwelling participants aged 60 years or older or in the retirement transition period; reporting on leisure-time physical activity; utilising a rigorous qualitative methodology. A line of argument approach was employed to generate a theory about how older adults think and feel about physical activity.

RESULTS

Thirty-nine papers met the inclusion criteria and were synthesised. The emergent theory suggested transition to older age can challenge people's sense of self and their role in life. Physical activity can help in regaining feelings of purpose, of being needed in collective group activity, and by creating habitual routine and structure to the day. In overcoming real and perceived barriers, and by taking up or sustaining physical activities, older adults can further build self-esteem all of which contributes to a fulfilling older age.

CONCLUSION

Current failures to increase population levels of physical activity in older adults may be explained by an approach overly focused on the health benefits of activity. Insights from this study suggest we need to reframe our approach to consider the wider set of goals and aspirations which are of greater personal importance to older adults, and future interventions should focus on how physical activity can contribute to life satisfaction, sense of purpose, and sense of role fulfilment in older age.

TRIAL REGISTRATION

Registered prospectively on PROSPERO on 29th March 2013: CRD42013003796 .

A pilot randomised controlled trial of physical activity facilitation for older adults: feasibility study findings

Background

More people are living longer lives leading to a growth in the population of older adults, many of whom have comorbidities and low levels of physical function. Physical activity in later life can prevent or delay age-related disability. Identifying a cost-effective means of increasing physical activity in older adults therefore remains an important public health priority.

Physical Activity Facilitation (PAF) is an intervention shown to increase physical activity in adults with depression. The PAF model was modified for a population of older adults at risk of disability. This study aimed to assess the feasibility of undertaking a definitive RCT of the PAF intervention in the target population.

Methods

A pilot randomised controlled trial (RCT) was delivered through primary care. Patients at risk of disability and who were not meeting recommended levels of physical activity were recruited through postal invitation and direct approach in the practice waiting room. Those meeting eligibility criteria were enrolled and randomised at a 2:1 ratio to the PAF intervention and control. Behaviour change techniques were used by facilitators with participants over the telephone and face-to-face for 6 months. Outcome measures including physical function, physical activity, depression, social support, and quality of life were collected at baseline and at 6 months.

Results

A high proportion of patients responded to the initial invitation (68%), yet many were ineligible due to high levels of self-reported physical activity and baseline physical function. Fifty-one participants were recruited to the trial, with an average age of 74 years (range 65–89), and there were high rates of adherence and retention to the study (94% follow-up at 6 months). The majority of outcome data collected from participants was complete; however, the validated scale used to measure self-reported physical activity was associated with high levels of missing data.

Conclusions

The findings of this pilot RCT suggest that it is feasible to deliver a definitive RCT of the PAF intervention in this population. Further work is required to improve the efficiency of recruitment and to minimise missing data from self-reported physical activity measures.

Trial registration

Current controlled trials ISRCTN80470273. Registered 25 October 2013.

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0414-9) contains supplementary material, which is available to authorized users.

Dysregulation of the hypothalamic pituitary adrenal (HPA) axis and cognitive capability at older ages: individual participant meta-analysis of five cohorts

Evidence on the association between functioning of the hypothalamic pituitary adrenal (HPA) axis and cognitive capability at older ages is mixed. We undertook a systematic review (until October 2016) and individual participant data (IPD) meta-analysis to test if dysregulation of the HPA axis is associated with worse cognitive capability. Five cohort studies were included in the IPD meta-analysis of diurnal cortisol patterns with crystallised and fluid cognitive ability. Higher night time cortisol was associated with worse fluid ability (standardised coefficient per SD increase −0.063, 95% CI −0.124, −0.002, P = 0.04; I² = 79.9%; age and gender adjusted). A larger diurnal drop was associated with better fluid ability (standardised coefficient per SD increase 0.037, 95% CI 0.008, 0.065, P = 0.01; I² = 49.2%; age and gender adjusted). A bigger cortisol awakening response (CAR) was weakly associated with better fluid (P = 0.09; I² = 0.0%; age and gender adjusted) and crystallised (P = 0.10; I² = 0.0%; age and gender adjusted) ability. There is weak evidence that a greater diurnal decline of the HPA axis and a larger CAR are associated with improvements in cognition at older ages. As associations are cross-sectional, we cannot rule out reverse causation.

Genetic meta-analysis of diagnosed Alzheimer's disease identifies new risk loci and implicates Aβ, tau, immunity and lipid processing

Risk for late-onset Alzheimer's disease (LOAD), the most prevalent dementia, is partially driven by genetics. To identify LOAD risk loci, we performed a large genome-wide association meta-analysis of clinically diagnosed LOAD (94,437 individuals). We confirm 20 previous LOAD risk loci and identify five new genome-wide loci (IQCK, ACE, ADAM10, ADAMTS1, and WWOX), two of which (ADAM10, ACE) were identified in a recent genome-wide association (GWAS)-by-familial-proxy of Alzheimer's or dementia. Fine-mapping of the human leukocyte antigen (HLA) region confirms the neurological and immune-mediated disease haplotype HLA-DR15 as a risk factor for LOAD. Pathway analysis implicates immunity, lipid metabolism, tau binding proteins, and amyloid precursor protein (APP) metabolism, showing that genetic variants affecting APP and Aβ processing are associated not only with early-onset autosomal dominant Alzheimer's disease but also with LOAD. Analyses of risk genes and pathways show enrichment for rare variants (P = 1.32 × 10-7), indicating that additional rare variants remain to be identified. We also identify important genetic correlations between LOAD and traits such as family history of dementia and education.

Assessing the long-term effectiveness of interferon-beta and glatiramer acetate in multiple sclerosis: final 10-year results from the UK multiple sclerosis risk-sharing scheme

BACKGROUND

Because multiple sclerosis (MS) is a chronic disease causing disability over decades, it is crucial to know if the short-term effects of disease-modifying therapies reported in randomised controlled trials reduce long-term disability. This 10-year prospective observational study of disability outcomes (Expanded Disability Status Scale (EDSS) and utility) was set up, in conjunction with a risk-sharing agreement between payers and producers, to investigate this issue.

METHODS

The outcomes of the UK treated patients were compared with a modelled untreated control based on the British Columbia MS data set to assess the long-term effectiveness of these treatments. Two complementary analysis models were used: a multilevel model (MLM) and a continuous Markov model.

RESULTS

4862 patients with MS were eligible for the primary analysis (mean and median follow-up times 8.7 and 10 years). EDSS worsening was reduced by 28% (MLM), 7% (Markov) and 24% time-adjusted Markov in the total cohort, and by 31% (MLM) and 14% (Markov) for relapsing remitting patients. The utility worsening was reduced by 23%-24% in the total cohort and by 24%-31% in the RR patients depending on the model used. All sensitivity analyses showed a treatment effect. There was a 4-year (CI 2.7 to 5.3) delay to EDSS 6.0. An apparent waning of treatment effect with time was seen. Subgroup analyses suggested better treatment effects in those treated earlier and with lower EDSS scores.

CONCLUSIONS

This study supports a beneficial effect on long-term disability with first-line MS disease-modifying treatments, which is clinically meaningful. However the waning effect noted requires further study.

Equalization of four cardiovascular risk algorithms after systematic recalibration: individual-participant meta-analysis of 86 prospective studies

AIMS

There is debate about the optimum algorithm for cardiovascular disease (CVD) risk estimation. We conducted head-to-head comparisons of four algorithms recommended by primary prevention guidelines, before and after 'recalibration', a method that adapts risk algorithms to take account of differences in the risk characteristics of the populations being studied.

METHODS AND RESULTS

Using individual-participant data on 360 737 participants without CVD at baseline in 86 prospective studies from 22 countries, we compared the Framingham risk score (FRS), Systematic COronary Risk Evaluation (SCORE), pooled cohort equations (PCE), and Reynolds risk score (RRS). We calculated measures of risk discrimination and calibration, and modelled clinical implications of initiating statin therapy in people judged to be at 'high' 10 year CVD risk. Original risk algorithms were recalibrated using the risk factor profile and CVD incidence of target populations. The four algorithms had similar risk discrimination. Before recalibration, FRS, SCORE, and PCE over-predicted CVD risk on average by 10%, 52%, and 41%, respectively, whereas RRS under-predicted by 10%. Original versions of algorithms classified 29-39% of individuals aged ≥40 years as high risk. By contrast, recalibration reduced this proportion to 22-24% for every algorithm. We estimated that to prevent one CVD event, it would be necessary to initiate statin therapy in 44-51 such individuals using original algorithms, in contrast to 37-39 individuals with recalibrated algorithms.

CONCLUSION

Before recalibration, the clinical performance of four widely used CVD risk algorithms varied substantially. By contrast, simple recalibration nearly equalized their performance and improved modelled targeting of preventive action to clinical need.