Kidney Transplantation Significantly Improves Patient and Graft Survival Irrespective of BMI: A Cohort Study

Obesity and end-stage renal disease (ESRD) are on the increase worldwide. Kidney transplantation is the treatment of choice for ESRD. However, obesity is considered a contraindication for transplantation. We investigated the effect of BMI on mortality in transplanted and patients remaining on the waiting list in the United Kingdom. We analyzed the UK Renal Registry (RR) and the National Health Service Blood and Transplant (NHSBT) Organ Donation and Transplantation data for patients listed from January 1, 2004 to December 31, 2010, with follow-up until December 31, 2011. Seventeen thousand six hundred eighty-one patients were listed during the study period, with BMI recorded for 13 526 (77%). One- and five-year patient survival was significantly better in all BMI bands (<18.5, 18.5-<25, 25-<30, 30-<35, 35-<40, and 40+kg/m(2) ) in the transplant group when compared to those who remained on the waiting list (p < 0.0001). The analyses were repeated excluding live donor transplants and the results were essentially the same. On analyses of patient survival with BMI as a continuous variable or using 5 kg weight bands, there was no cut-off observed in the higher BMI patients where there would be no benefit to transplantation. For transplanted patients (N = 8088), there was no difference in patient or graft survival between the defined BMI bands. Thus, irrespective of BMI, patient survival is improved if transplanted.

What factors influence concordance with medications? Findings from the U.K. Asian Diabetes study

AIMS

To investigate concordance with medication, as assessed at baseline and at 1- and 2-year follow-up, and to examine factors associated with non-concordance in a UK-resident South-Asian population.

METHODS

Data from the UK Asian Diabetes Study were analysed. Concordance with medications was assessed and recorded at three time points during the study. Multiple logistic regression was used to investigate the factors associated with non-concordance; the associations of baseline factors with year 1 concordance and baseline plus year 1 factors with year 2 concordance.

RESULTS

Data for 403 patients from seven practices participating in the UK Asian Diabetes Study were analysed. The numbers of patients who were non-concordant were: 63 (16%) at baseline; 101 (25%) at year 1; and 122 (30%) at year 2. The baseline-measured variables that were significantly associated with year 1 non-concordance included diabetes duration, history of cardiovascular disease, components of the EuroQol quality of life questionnaire, the EQ-5D score, and number of medications prescribed. In multivariable analyses, the most important determinant of year 1 non-concordance was baseline non-concordance: odds ratio 13.6 (95% confidence limits 4.7, 39.9). Number of medications prescribed for blood pressure control was also significant: odds ratio 1.8 (95% confidence limits 1.4, 2.4). Similar results were observed for year 2 non-concordance.

CONCLUSIONS

Non-concordance with medications was common and more likely in people prescribed more medications. The current target-driven management of risk factor levels may lead to increasing numbers and doses of medications. Considering the high cost of medications and the implications of poor health behaviours on morbidity and mortality, further investigation of prescribing behaviours and the factors affecting patient concordance are required.

Enhanced diabetes care to patients of south Asian ethnic origin (the United Kingdom Asian Diabetes Study): a cluster randomised controlled trial

BACKGROUND

Delivery of high-quality, evidence-based health care to deprived sectors of the community is a major goal for society. We investigated the effectiveness of a culturally sensitive, enhanced care package in UK general practices for improvement of cardiovascular risk factors in patients of south Asian origin with type 2 diabetes.

METHODS

In this cluster randomised controlled trial, 21 inner-city practices in the UK were assigned by simple randomisation to intervention (enhanced care including additional time with practice nurse and support from a link worker and diabetes-specialist nurse [nine practices; n=868]) or control (standard care [12 practices; n=618]) groups. All adult patients of south Asian origin with type 2 diabetes were eligible. Prescribing algorithms with clearly defined targets were provided for all practices. Primary outcomes were changes in blood pressure, total cholesterol, and glycaemic control (haemoglobin A1c) after 2 years. Analysis was by intention to treat. This trial is registered, number ISRCTN 38297969.

FINDINGS

We recorded significant differences between treatment groups in diastolic blood pressure (1.91 [95% CI -2.88 to -0.94] mm Hg, p=0.0001) and mean arterial pressure (1.36 [-2.49 to -0.23] mm Hg, p=0.0180), after adjustment for confounders and clustering. We noted no significant differences between groups for total cholesterol (0.03 [-0.04 to 0.11] mmol/L), systolic blood pressure (-0.33 [-2.41 to 1.75] mm Hg), or HbA1c (-0.15% [-0.33 to 0.03]). Economic analysis suggests that the nurse-led intervention was not cost effective (incremental cost-effectiveness ratio pound28 933 per QALY gained). Across the whole study population over the 2 years of the trial, systolic blood pressure, diastolic blood pressure, and cholesterol decreased significantly by 4.9 (95% CI 4.0-5.9) mm Hg, 3.8 (3.2-4.4) mm Hg, and 0.45 (0.40-0.51) mmol/L, respectively, and we recorded a small and non-significant increase for haemoglobin A1c (0.04% [-0.04 to 0.13]), p=0.290).

INTERPRETATION

We recorded additional, although small, benefits from our culturally tailored care package that were greater than the secular changes achieved in the UK in recent years. Stricter targets in general practice and further measures to motivate patients are needed to achieve best possible health-care outcomes in south Asian patients with diabetes.

Type 2 diabetes and cardiovascular risk in the UK south Asian community

A popular hypothesis for the greater prevalence of type 2 diabetes and cardiovascular disease in UK south Asians is that they have an increased susceptibility of developing insulin resistance in response to certain environmental factors, including obesity and adoption of a sedentary lifestyle. Insulin resistance is postulated as a central feature of the metabolic syndrome, culminating in type 2 diabetes, atherosclerotic vascular disease and CHD; a pathway potentially accelerated by migration/urbanisation. We describe and compare the prevalence of type 2 diabetes, cardiovascular disease and their associated risk factors in UK south Asian and white Caucasian populations to determine possible reasons for the increased preponderance of these diseases in south Asians, and highlight key evidence for optimal risk factor management. Finally, we describe a UK community-based programme that attempts to reduce the morbidity and mortality from type 2 diabetes and cardiovascular disease in south Asians through a new approach to management.

Evaluation of delivery of enhanced diabetes care to patients of South Asian ethnicity: the United Kingdom Asian Diabetes Study (UKADS)

AIMS

We tested the hypothesis that enhanced care for diabetes, tailored to the needs of the South Asian community with Type 2 diabetes, would improve risk factors for diabetic vascular complications and ultimately reduce morbidity and mortality.

PATIENTS AND METHODS

The study was a cluster randomized controlled trial (RCT) with general practice the unit of randomization. Six West Midlands general practices with a high proportion of South Asian patients were randomized to 'enhanced care' using Asian link workers and extra community diabetes specialist nurse sessions (intervention) or continued standard practice care (control).

RESULTS

Of 401 patients recruited to the study, 361 (90%), comprising 178 from Coventry and 183 from Birmingham were eligible and included in the analyses. The mean age at baseline (standard deviation, SD) was 58.9 (11.7 years) with median (interquartile range; IQR) duration of diabetes 6.5 (3-11) years. At one year follow-up there was a significant difference in reduction of systolic (4.6 mmHg, P = 0.035) and diastolic blood pressure (3.4 mmHg, P = 0.003) and total cholesterol (0.4 mmol/l, P = 0.005), comparing the intervention and control groups. After adjusting for baseline measurement and age, only differential reduction in diastolic blood pressure remained significant. There was no significant change in HbA(1c) and no difference between the groups.

CONCLUSIONS

Using link workers and extra community diabetes specialist nurse input together with treatment protocols in primary care might prove a useful strategy in working towards NSF targets for diabetes management. In this study, small reductions in blood pressure and cholesterol were achieved. Improvement in glycaemic control may require longer and possibly different strategies. Further research is required to evaluate fully the effectiveness, including the costs and longer term sustainability of culturally sensitive initiatives.

The epidemiology of Type 1 diabetes mellitus is not the same in young adults as in children

AIMS/HYPOTHESIS

This prospective study examined the epidemiology of Type 1 diabetes in young adults in Europe.

METHODS

We ascertained incident cases of Type 1 diabetes in the 15 to 29 years (both inclusive) age group throughout Europe over a period of 2 years. Diabetes registries in nine countries, in which incidence rates for Type 1 diabetes in the 0 to 14 age group were available, took part. Incidence rates were estimated per 100000 person years and standardised for sex and age. Cumulative incidences per 1000 from birth to age 30 were estimated. Heterogeneity between centres was tested with a Poisson regression model.

RESULTS

A total of 2112 diabetes cases were ascertained in 1996 and 1997, of which 61.4% were considered to be Type 1 diabetes. Completeness of ascertainment varied from 70 to 90%. Standardised incidence varied from 4.8 per 100000 person years to 13.4 per 100000 person years. The male-female ratio was estimated to be one or more, and in the 25 to 29 age group 1.5 or more in all countries. Cumulative incidences for males and females indicate that the former exceeds the latter from age 24. In the two centres with highest childhood incidence, this applied already from 14 years of age.

CONCLUSIONS/INTERPRETATION

The incidence of Type 1 diabetes in adults is lower than in children and the range of incidence is also reduced, with a less than threefold variation in adults, against an eightfold variation in children. There is a male excess in incidence, especially in the age group 25 to 29 years.

Acute rejection after renal transplantation is reduced by approximately 50% by prior therapeutic blood transfusions, even in tacrolimus-treated patients

BACKGROUND

The authors investigated the relationship between therapeutic blood transfusion before renal transplantation and rejection rates in cyclosporine- and tacrolimus-treated patients.

METHODS

In one center, 265 consecutive recipients were studied. Protocol induction was with azathioprine, prednisolone, and cyclosporine or tacrolimus; 37% had biopsy-proven acute rejection in the first 6 months and 46% had received zero to two units of blood before transplantation.

RESULTS

Lower risk of rejection was associated with tacrolimus induction (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.29-0.95; P=0.049), prior transfusion of three or more units of blood (OR, 0.54; 95% CI, 0.33-0.90; P=0.024), and older age at transplantation (mean, 44.23 +/- 12.56 [+/- SD] years vs. 38.96 +/- 12.37 years; P=0.001). Multiple logistic regression modeling showed the effect of three or more prior transfusions on acute rejection was as follows: OR, 0.49; 95% CI, 0.29 to 0.83; P=0.008.

CONCLUSIONS

Induction immunosuppression should take account of the higher risk of rejection in patients coming to transplantation who have previously received zero to two units of blood.

What is the prevalence of visual impairment in the general and diabetic populations: are there ethnic and gender differences?

AIMS

To estimate the prevalence of blindness and partial sight in the general and diabetic populations and to measure the impact of ethnicity and gender on these rates.

METHODS

Data on visual impairment in the population to be studied was obtained from the Royal Leicestershire Rutland and Wycliffe Society for the Blind (RLRWSB). Using the validated technique of capture-mark-recapture (CMR), a census day was set and data from four sources collected: hospital admissions data, GP returns, wards, and mass media. Computer cross-linkage to Leicestershire Health Authority data ensured patients were alive and resident in Leicestershire at the census date. Estimates of diabetes, ethnicity and gender prevalence were calculated using the 1991 census.

RESULTS

CMR calculations revealed that there was under ascertainment of visual impairment in the RLRWSB data. The CMR calculations with direct age standardization estimate the prevalence of blindness and partial sight in the general and diabetic populations to be 51.8/10 000 (CI 50.6-53.0) and 148.8/10 000 (CI 122.1-175.5), respectively. In the diabetic population there was a higher proportion of visually impaired females than males (P < 0.05), with no overall ethnic differences; however, rates were lower than expected in female Indo-Asians. In the general population there was a higher proportion of visually impaired Indo-Asian people (P < 0.01).

CONCLUSIONS

Our study has shown the prevalence of visual impairment in both the general and diabetic populations and has demonstrated both ethnic and gender differences. CMR allows the calculation of prevalence of blindness and partial sight from existing data. When comparing the prevalence of visual impairment, whether from diabetes or other causes, it is important to know the gender and ethnicity of the 'at risk' population, as well as the rates in the background population.

Comparative incidence of Type I diabetes in children aged under 15 years from South Asian and White or Other ethnic backgrounds in Leicestershire, UK, 1989 to 1998

AIMS/HYPOTHESIS

Estimates of incidence of Type I (insulin-dependent) diabetes mellitus in childhood populations vary around the world. This study aimed to estimate and compare the incidence of Type I diabetes in Leicestershire of children of South Asian and White or Other ethnic backgrounds.

METHODS

All new cases of childhood-onset Type I diabetes diagnosed before 15 years of age in Leicestershire during the period 1989-98 were studied. Population data for Leicestershire from the 1991 census was used. Ethnicity was assigned to all children in the study according to their surnames. Incidence rates (95%-Confidence limits) for the South Asian and white or other ethnic group were estimated and compared.

RESULTS

Over the 10-year period, 46 South Asian children and 263 children who were white or from another ethnic group fulfilled the criteria for inclusion in the study. Crude incidence rates per 100,000 person-years were 19.2 (12.0, 29.1) girls and 20.3 (13.0, 30.3) boys for South Asians and 17.7 (14.8, 21.1) girls and 17.7 (14.8, 20.9) boys for whites/others. Age and sex-specific rates were higher for South Asians over 5 years of age but differences were not statistically significant.

CONCLUSION/INTERPRETATION

Type I diabetes incidence rates for South Asian children in Leicestershire were very similar to those for children who were in the white/other ethnic group, in contrast to very low rates reported from Asia. The convergence of rates for South Asians with other ethnic groups in Leicestershire suggests that environmental factors are more important than genetic predisposition in causing Type I diabetes in people of South Asian ethnic background.

Does the heartbeat award scheme change employees' dietary attitudes and knowledge?

The Heartbeat Award scheme (HBA) aims to encourage provision and promotion of healthier food choices in catering premises and has been operating in Leicestershire since its launch in England in 1990. This study assessed if the scheme changes dietary attitudes and knowledge of employees in HBA premises. A longitudinal survey of employees in six workplaces was conducted using a structured questionnaire. Employees were investigated before the scheme was implemented and 6 months afterwards. Using a series of validated questions that assessed predisposing and enabling psycho-social factors. Four workplaces with the HBA (N= 453) were compared with two comparison workplaces (N= 124). Nutritional knowledge did not change significantly as a result of the scheme. Employees at HBA workplaces had noticed healthy eating information and acknowledged that it was easier to eat a healthy diet at work after the scheme had been introduced. There was some evidence that the intervention had a maintenance effect in understanding of healthy eating messages, and could act as a buffer to negative external influences. Overall, the scheme was successful in raising awareness of healthy eating in the workplace, but not in enhancing predisposing factors.

Impaired glucose tolerance and fasting hyperglycaemia have different characteristics

AIMS

Use of the oral glucose tolerance test (OGTT) to define glucose intolerance in the general population may bias towards selection of those with insulin resistance. Beta cell function and insulin resistance markers were analysed in four groups: controls (n = 101); fasting hyperglycaemia (FH, n 45); impaired glucose tolerance; (IGT, n = 16) and those with features of both FH and IGT ('Both', n = 30).

METHODS

Subjects underwent an OGTT. Plasma glucose, fasting lipid profiles, fasting, 30 and 120 min insulin were measured and beta cell function (% B) and insulin sensitivity (% S) assessed by homeostatic model assessment (HOMA) RESULTS: The FH group compared to controls had a significantly lower % B. The IGT group compared to controls had features of insulin resistance (higher body mass index (BMI), systolic blood pressure and 2 h insulin concentration). Subjects with 'both' IGT and FH had features of insulin resistance (higher BMI, systolic and diastolic blood pressure and triglyceride concentration) as well as beta cell dysfunction with a lower % B and 30 min insulin-glucose ratio compared to controls. There was a preponderance of males in this group. In all, 192 subjects' 30-min insulin concentration and incremental insulin response showed only a significantly negative correlation with fasting glucose concentration. In a linear regression analysis, a low 30-min insulin-glucose ratio was only a significant factor in the fasting glucose model. Thus, higher fasting glucose concentrations appear to be associated with beta cell dysfunction. However, HbA1 only showed a significant correlation with 120-min glucose, not fasting glucose concentration.

CONCLUSIONS

In those with milder degrees of glucose intolerance, FH is associated with beta cell dysfunction and those with IGT and a relatively 'normal' fasting glucose have features of the insulin resistance syndrome.

Multiple sclerosis, dental caries and fillings: a case-control study

OBJECTIVES

To investigate the association between multiple sclerosis, dental caries, amalgam fillings, body mercury and lead.

DESIGN

Matched case-control study.

SETTING

Leicestershire in the years 1989-1990.

SUBJECTS

Thirty-nine females with multiple sclerosis (of recent onset) were matched with 62 controls for age, sex and general practitioner.

METHODS

Home interview of cases and controls within which there was an assessment of the DMFT index and blood and urine mercury and lead levels.

RESULTS

The odds of being a MS case increased multiplicatively by 1.09 (95% CI 1.00, 1.18) for every additional unit of DMFT index of dental caries. This represents an odds ratio of 1.213 or a 21% increase in risk of MS in relation to dental caries in this population. There was no difference between cases and controls in the number of amalgam fillings or in body mercury or lead levels. There was a significant correlation between body mercury levels and the number of teeth filled with amalgam (controls: r = +0.430, P = 0.006, cases: r = +0.596, P = 0.001).

CONCLUSION

There was evidence of excess dental caries among MS cases compared with the controls. This finding supports the strong geographical correlation between the two diseases. A further study of this association is recommended.

Partial remission phase of diabetes in children younger than age 10 years

There is renewed interest in the phase of partial remission in recently diagnosed diabetes because of the potential for pharmacological and immune intervention to preserve beta cell function. 95 children younger than 10 years were investigated to assess the influence of age, sex, diabetic ketoacidosis (DKA), admission at diagnosis, and ethnicity on the frequency of remission and insulin requirements during the first two years after diagnosis. Partial remission was defined as a requirement of insulin < 0.5 U/kg body weight/day. There was partial remission in 41 patients, with no differences for children aged 2-4 years and those aged 5-9 years. None of the five children aged < 2 years remitted. Forty five of 95 children were admitted to hospital at diagnosis, of whom 26 of 45 had DKA (blood pH < 7.25). In this number of children we were unable to show a statistical difference in the rate of remission with respect to DKA, admission to hospital at diagnosis, sex, or South Asian ethnic background. There were no differences in insulin requirements between the different groups by the end of two years and at that time seven of the children required insulin < 0.5 U/kg/day. The results suggest that even in preschool children there is potential for attempting to preserve beta cell function.

Effectiveness of influenza vaccine in reducing hospital admissions in people with diabetes

The effectiveness of influenza vaccination in reducing hospitalization of people with diabetes for influenza, pneumonia, or diabetic events during influenza epidemics was assessed in a case control study in Leicestershire, England. Cases were 80 patients on the Leicestershire Diabetes Register who were admitted and discharged from hospital with International Classification of Disease codes for pneumonia, bronchitis, influenza, diabetic ketoacidosis, coma and diabetes, without mention of complications, during the influenza epidemics of 1989-90 and 1993. One hundred and sixty-controls, who were not admitted to hospital during this period, were randomly selected from the Register. Immunization against influenza was assessed in 37 cases and 77 controls for whom consent was obtained to access their clinical notes and for whom notes were available. Significant association was detected between reduction in hospitalization and influenza vaccination during the period immediately preceding an epidemic. Multiple logistic regression analysis estimated that influenza vaccination reduced hospital admissions by 79% (95% CI 19-95%) during the two epidemics, after adjustment for potential confounders.

A Survey of the Dietary Management of Children's Diabetes

A cross-sectional survey of dietitians using a structured postal questionnaire was sent to 148 dietitians who provided a service to children with diabetes. One hundred and twenty-two (82%) replied, of whom 50 were paediatric dietitians (4 paediatric diabetes dietitians) and 72 were other grades. One hundred and eighteen (97%) dietitians reviewed newly diagnosed children within 24-48 hours of diagnosis but only 81 (66%) used literature specifically designed for children. The majority 116 (95%) felt they worked within a multidisciplinary team. Only 15 (12%) dietitians used purely qualitative carbohydrate dietary education; the remainder used quantitative methods, e.g. 10 g exchange system. Ninety-one (75%) used carbohydrate exchange lists. High fibre foods were suggested but dietitians felt only a moderate intake was achievable. One hundred and twelve (92%) recommended a reduced fat intake but guidance was not as unanimous on reducing specific fatty acids. Objective assessment of dietary outcomes was limited. Paediatric dietitians compared with other grades were more likely to use innovative methods of education but no other differences in dietary practice existed. A minority of dietitians 17 (18%) felt families would find implementing the diet easy. The survey confirmed national inconsistencies in dietary messages and poor evaluation of patient compliance. Research is required into effective dietary counselling to support evidence-based practice.

Insulin treated diabetes mellitus: causes of death determined from record linkage of population based registers in Leicestershire, UK

STUDY OBJECTIVE

Analyses of causes of mortality in people with diabetes using data form death certificates mentioning diabetes provide unreliable estimates of mortality. Under-recording of diabetes as a cause on death certificates has been widely reported, ranging from 15-60%. Using a population based register on people with diabetes and linking data from another source is a viable alternative. Data from the Office of Population Censuses and Surveys (OPCS) are the most acceptable mortality data available for such an exercise, as direct comparison with other published mortality rates is then possible.

DESIGN

A locally maintained population-based mortality register and all insulin-treated diabetes mellitus cases notified to the Leicestershire diabetes register (n = 4680) were linked using record linkage software developed in-house (Lynx). This software has been extensively used in a maintenance and update cycle designed to maximise accuracy and minimise duplication and false registration on the diabetes register. Deaths identified were initially coded locally to the International Classification of Diseases, 9th revision (ICD9), and later a linkage was performed to use official OPCS coding. Mortality data identified by the linkage was indirectly standardised using population data for Leicestershire for 1991. Standardised mortality ratios (SMR) were estimated, with 95% confidence intervals. Insulin dependent diabetes (IDDM) was defined as diabetes diagnosed before age 30 years with insulin therapy begun within one year of diagnosis. All other types were considered non-insulin dependent diabetes (NIDDM). Analyses were performed for the whole sample and then for the NIDDM subgroup. Results from these analyses were similar and therefore only whole group analyses are presented.

MAIN RESULTS

A total of 370 deaths were identified for the period of 1990-92 inclusive - 56% were in men and 44% in women, median age (range) 71 years (12-94). Approximately 90% of deaths were subjects with NIDDM. Diabetes was mentioned on 215 (58%) death certificates. The all causes SMRs were significantly raised for men and women for all ages less than 75 years. Ischaemic heart disease (ICD9) rubrics 410-414) accounted for 146 (40%) deaths - 41% of male and 38% of female deaths. Male and female SMRs were significantly raised for the age groups 45-64, 65-74, and 75-84 years. Cerebrovascular disease (ICD9 rubrics 430-438) accounted for 39 (10%) deaths and the SMR for women the external causes of death (ICD9 rubrics E800-E999) were also significantly raised overall and in age groups 15-44 and 45-64 years. This was not true for men, although numbers of deaths in this category were small for both men (4) and women (9).

CONCLUSION

Record linkage has been used successfully to link two local, population based registers. This has enabled an analysis of mortality in people with diabetes to be performed which overcomes the problems associated with using as a sample, death certificates where diabetes is mentioned. The mortality rates and SMRs estimated should more accurately reflect the true rates than would be possible using other methods. The persisting excess mortality identified for people with diabetes is of a similar magnitude and attributable to similar causes as has been reported elsewhere in population based studies.

Trends in mortality of childhood-onset insulin-dependent diabetes mellitus in Leicestershire: 1940-1991

The relative risk of death by calendar date of diagnosis was investigated in a population-based incident cohort of 845 (463 males:382 females) IDDM diagnosed in Leicestershire before the age of 17 years between 1940 and 1989. The mortality status of 844 (99.9%) patients was determined as of the 31 December 1991, representing 14,346 person-years of risk. Trends in relative risk of death were investigated using Cox proportional hazards modelling for within cohort comparisons and age/sex and calendar time adjusted standardized mortality ratios (SMR) using generalized linear modelling for external comparisons. Median age at diagnosis was 10 years (range 3 months to 16 years); median duration of diabetes 15 years (range 1-51 years). Forty-four patients had died (5.2%; median age at death 31 years, range 11-51 years). A further four patients died at presentation (within 24 h) from ketoacidosis and are excluded from all analyses. Calendar date of diagnosis was found to be an important predictor of mortality. Adjusting for attained age there was evidence of a decline in relative risk of death with calendar date of diagnosis of 3.4% (95% CI, 0.005-6.9%) per annum, equivalent to a 32% fall per decade (95% CI, 5-51%), or 84% (95% CI, 21-97) from 1940 to 1989. The data are consistent with a large fall in mortality between the 1940s and 1950s representing over 50% of the total reduction in mortality between 1940 and 1991. Neither sex nor age at diagnosis were significant predictors of mortality. Over the study period 1940-89 the SMR (male and female combined) fell from 981 (541-1556) to 238 (60-953) relative to the general population. This population-based study shows that the prognosis for Type 1 (insulin-dependent) diabetes mellitus has improved markedly over the period 1940-1991.

Use of general practitioner beds in Leicestershire community hospitals

BACKGROUND

The shift in care from secondary to primary services is likely to place greater demands on community hospitals. Before changes in the provision of community hospitals can occur, baseline data are needed, outlining their current use.

AIM

A study was undertaken to obtain baseline data describing the use of general practitioner beds in Leicestershire community hospitals.

METHOD

A three-month prospective, observational study was carried out between February and May 1992 using data from a questionnaire completed by nurses and general practitioners and from patient hospital records. Study patients comprised all patients admitted to general practitioner beds in all eight Leicestershire community hospitals.

RESULTS

A 100% questionnaire response rate was obtained giving data on 685 hospital admissions. Around 70% of admissions were of patients aged 75 years and over. Of admissions, 35% were for acute care, 31% for respite care, 22% for rehabilitation, 7% for terminal/palliative care and 5% for other reasons. Fifteen per cent of patients had been transferred from a consultant bed. Of those not transferred, 91% were admitted by their usual general practitioner or practice partner and for 96% of these patients this was the general practitioner's first choice for care. There was significant variation in both the age mix and care category mix of patients between individual hospitals. Medical deterioration in an underlying condition and family pressure on the general practitioner or carers' inability to cope each contributed to around half of all admissions. Of all admissions, 38% lived alone, and 18% of carers were disabled. Incontinence was reported for 35% of patients, and 26% of all patients were of a high nursing dependency. There was low utilization of community services before admission and 33% received none. There was variation between individual hospitals in use of local and district general hospital investigations, specialist referral and types of therapy. Of 685 admissions 11% died during their stay. Of those discharged, 76% went to their own or a relative's home, 10% to a residential or nursing home and 9% were transferred to an acute bed. Nine percent of discharges were postponed and 10% were brought forward. On discharge to non-residential care, 26% of patients received no community services.

CONCLUSION

Shifting resources from secondary to primary care is a priority for purchasers. Both the introduction of the National Health Service and community care act 1990, and acute units having increasing incentives for earlier discharge, are likely to place greater demands on community hospital beds. Not all general practitioners have the option of community hospital beds. Before access to general practitioner beds can be broadened, existing beds should be used appropriately and shown to be cost-effective. Purchasers therefore require criteria for the appropriateness of admissions to general practitioner beds, and the results of a general practitioner bed cost-benefit analysis.

Early onset diabetes: parents' views

During 1990-91 postal questionnaires were sent to the parents of 309 children living in the United Kingdom who developed diabetes before the age of 2 years during 1972-1981. The aim of the survey was to explore how they had coped with their child's condition. Completed questionnaires were returned by 85% of parents. The children had a mean age of 14 (range 9-19) years and diabetes for a mean duration of 13 (range 9-18) years. The cohort's mean age for starting self-injection was reported to be 8 years and most of the children (82%) were still attending full-time education. Diabetes-related difficulties of school were reported for 34% (95% C I 28-40) of the children and 70 (27%, 95% C I 22-32) were estimated to have missed more schooldays than their peers. With increasing duration of diabetes, parents expressed a reduction in anxiety about practical aspects of management such as injections and monitoring, but concern about hypoglycaemia and long-term vascular complications remained high. Parents of girls were more likely to express worries compared to parents of boys, and this excess was significant for worry about diet (chi 2 1df = 17.021, p < 0.001). The paediatric diabetes team caring for early diagnosed children should be aware of the need to discuss the long-term implications of the disorder and be sensitive to the transition period when the child takes progressively more responsibility for self management and the parent's role diminishes.

Does the prepubertal duration of diabetes influence the onset of microvascular complications?

This study investigated the relationship between the development of diabetic retinopathy and pubertal status at onset of diabetes in 521 Type 1 diabetic patients diagnosed between 1950 and 1985. Pubertal status was based on age at onset (girls > or = 11 years and boys > or = 12 years). Retinopathy (all forms) developed in 112 patients (21.5%; 65 background and 47 proliferative retinopathy). For subjects diagnosed in either the prepubertal or postpubertal period, a similar proportion survived without developing retinopathy for any given duration of diabetes (chi 2 = 0.3822, p = 0.54). However, if only the postpubertal duration of diabetes is considered, then the proportion of patients surviving without retinopathy was significantly less for those diagnosed in the prepubertal period (chi 2 = 14.2, p = 0.002). This study suggests that the prepubertal duration of diabetes is an important phase and that the years prior to puberty do contribute to the risk of developing microvascular injury.

More and better services for people with learning disabilities

A prevalence study of disability, use of and need for services was undertaken to estimate the need for NHS and other forms of residential, day and respite care for people with severe learning disabilities. Subjects aged 20 or more were drawn from the Leicestershire Learning Disabilities Register (n = 1887). Information was collected by interview with a professional career. The age-specific prevalence was 2.9 per 1000 and the response rate was 88 per cent. A disability rating predicted consultant opinion on need for NHS residential care with a sensitivity and specificity of 82 per cent. Predictive disability factors included problems with behaviour, toileting, speech, epilepsy, postural deformity and use of a wheelchair. Planning targets per 100,000 population aged 20 or more were estimated as follows: NHS residential care--47 places; other residential care--103 places; respite care--36 people; day care--224 places. The need for residential care and medical support remains eminently predictable within the new philosophical framework of provision. Since 1971 the need for NHS residential places has decreased but remains important for people with high dependence. Day care targets have increased and diversified.

A decade of diabetes: keeping children out of hospital

OBJECTIVES

To document the number of children aged less than 15 years who developed diabetes and were managed within one large health district, and to evaluate the outcome of those children managed without hospital admission at diagnosis.

DESIGN

A retrospective study over 1979-88, when a paediatrician and a physician with special interests in childhood diabetes initiated joint clinics. Data collected from the district diabetes register and files of consultants and health visitors specialising in diabetes.

SETTING

Referral of children to consultants in Leicestershire (total population 863,000).

MAIN OUTCOME MEASURES

The proportion of children managed without hospital admission, comparison of readmission rates and glycated haemoglobin concentrations between children admitted and those not admitted.

RESULTS

Over 10 years 236 children aged 10-14 years developed diabetes (annual incidence rate 12.8/100,000 child population (95% confidence interval 11.3 to 14.7)). In total 138 were not admitted to hospital but received supervised management based at home. Admitted children were younger or acidotic or their family doctors did not contact the diabetes team. Duration of admission declined from seven days in 1979-80 to three days in 1987-8. Ninety two were not admitted to hospital during the 10 years for any reason. Significantly fewer children who received management at home were readmitted for reasons related to diabetes than the group treated in hospital (30 (22%) v 40 (41%); p = 0.004). Concentrations of glycated haemoglobin were no different between the two groups.

CONCLUSIONS

Children with newly diagnosed diabetes may be safely and effectively managed out of hospital. Domiciliary or community based management depends on the commitment of consultants specialising in diabetes working in close cooperation with general practitioners, specialist nurses in diabetes, and dietitians.

Diabetes diagnosed before the age of 2 years: mortality in a British cohort 8-17 years after onset

Childhood diabetes diagnosed before the age of 24 months presents specific management problems. We report here on the establishment (using the British Diabetic Association [BDA] Children's Register) and mortality of a cohort of children with diabetes diagnosed before age 24 months. Children registered during the period 1972-1981 were traced by contacting consultants or by using the National Health Service Central Registers (NHSCR) of the Office of Population Censuses and Surveys (OPCS). Standardized mortality ratios (SMR) were estimated using person-years of follow-up for each child and age-specific death rates for the England and Wales population for the years 1972-1989. Of 339 children notified during 1972-1981, 231 were traced through consultants and 99 of the remaining 108 through the NHSCR. Twenty were found to be ineligible. The cohort available for mortality analysis comprised 310 (97%) of 319 eligible children. Their age at the time the cohort was established was 8-18 years, and their duration of diabetes 8-17 years. The male:female ratio is 1.4:1. Of 310 children studied, seven have already died: SMR 5.4 (95% CI: 2.5-11.5). We have established a large, unique cohort of children with diabetes diagnosed before age 24 months and still living in the UK and Ireland. The natural history including mortality and occurrence of complications will be analysed prospectively in this cohort and compared to other cohorts of similar disease duration, but later age at onset.