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Shields BM, Dennis JM, Angwin CD, Warren F, Henley WE, Farmer AJ, Sattar N, Holman RR, Jones AG, Pearson ER, Hattersley AT. Patient stratification for determining optimal second-line and third-line therapy for type 2 diabetes: the TriMaster study. Nat Med 2023; 29:376-383. [PMID: 36477733 PMCID: PMC7614216 DOI: 10.1038/s41591-022-02120-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 11/07/2022] [Indexed: 12/13/2022]
Abstract
Precision medicine aims to treat an individual based on their clinical characteristics. A differential drug response, critical to using these features for therapy selection, has never been examined directly in type 2 diabetes. In this study, we tested two hypotheses: (1) individuals with body mass index (BMI) > 30 kg/m2, compared to BMI ≤ 30 kg/m2, have greater glucose lowering with thiazolidinediones than with DPP4 inhibitors, and (2) individuals with estimated glomerular filtration rate (eGFR) 60-90 ml/min/1.73 m2, compared to eGFR >90 ml/min/1.73 m2, have greater glucose lowering with DPP4 inhibitors than with SGLT2 inhibitors. The primary endpoint for both hypotheses was the achieved HbA1c difference between strata for the two drugs. In total, 525 people with type 2 diabetes participated in this UK-based randomized, double-blind, three-way crossover trial of 16 weeks of treatment with each of sitagliptin 100 mg once daily, canagliflozin 100 mg once daily and pioglitazone 30 mg once daily added to metformin alone or metformin plus sulfonylurea. Overall, the achieved HbA1c was similar for the three drugs: pioglitazone 59.6 mmol/mol, sitagliptin 60.0 mmol/mol and canagliflozin 60.6 mmol/mol (P = 0.2). Participants with BMI > 30 kg/m2, compared to BMI ≤ 30 kg/m2, had a 2.88 mmol/mol (95% confidence interval (CI): 0.98, 4.79) lower HbA1c on pioglitazone than on sitagliptin (n = 356, P = 0.003). Participants with eGFR 60-90 ml/min/1.73 m2, compared to eGFR >90 ml/min/1.73 m2, had a 2.90 mmol/mol (95% CI: 1.19, 4.61) lower HbA1c on sitagliptin than on canagliflozin (n = 342, P = 0.001). There were 2,201 adverse events reported, and 447/525 (85%) randomized participants experienced an adverse event on at least one of the study drugs. In this precision medicine trial in type 2 diabetes, our findings support the use of simple, routinely available clinical measures to identify the drug class most likely to deliver the greatest glycemic reduction for a given patient. (ClinicalTrials.gov registration: NCT02653209 ; ISRCTN registration: 12039221 .).
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Affiliation(s)
- Beverley M Shields
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - John M Dennis
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Catherine D Angwin
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Fiona Warren
- Clinical Trials Unit, University of Exeter Medical School, Exeter, UK
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - William E Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Andrew J Farmer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Naveed Sattar
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Rury R Holman
- Diabetes Trials Unit, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Angus G Jones
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK
| | - Ewan R Pearson
- Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Andrew T Hattersley
- Department of Clinical and Biomedical Sciences, University of Exeter, Exeter, UK.
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Dennis JM, Young KG, McGovern AP, Mateen BA, Vollmer SJ, Simpson MD, Henley WE, Holman RR, Sattar N, Pearson ER, Hattersley AT, Jones AG, Shields BM. Development of a treatment selection algorithm for SGLT2 and DPP-4 inhibitor therapies in people with type 2 diabetes: a retrospective cohort study. Lancet Digit Health 2022; 4:e873-e883. [PMID: 36427949 DOI: 10.1016/s2589-7500(22)00174-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Current treatment guidelines do not provide recommendations to support the selection of treatment for most people with type 2 diabetes. We aimed to develop and validate an algorithm to allow selection of optimal treatment based on glycaemic response, weight change, and tolerability outcomes when choosing between SGLT2 inhibitor or DPP-4 inhibitor therapies. METHODS In this retrospective cohort study, we identified patients initiating SGLT2 and DPP-4 inhibitor therapies after Jan 1, 2013, from the UK Clinical Practice Research Datalink (CPRD). We excluded those who received SGLT2 or DPP-4 inhibitors as first-line treatment or insulin at the same time, had estimated glomerular filtration rate (eGFR) of less than 45 mL/min per 1·73 m2, or did not have a valid baseline glycated haemoglobin (HbA1c) measure (<53 or ≥120 mmol/mol). The primary efficacy outcome was the HbA1c value reached 6 months after drug initiation, adjusted for baseline HbA1c. Clinical features associated with differential HbA1c outcome on the two therapies were identified in CPRD (n=26 877), and replicated in reanalysis of 14 clinical trials (n=10 414). An algorithm to predict individual-level differential HbA1c outcome on the two therapies was developed in CPRD (derivation; n=14 069) and validated in head-to-head trials (n=2499) and CPRD (independent validation; n=9376). In CPRD, we further explored heterogeneity in 6-month weight change and treatment discontinuation. FINDINGS Among 10 253 patients initiating SGLT2 inhibitors and 16 624 patients initiating DPP-4 inhibitors in CPRD, baseline HbA1c, age, BMI, eGFR, and alanine aminotransferase were associated with differential HbA1c outcome with SGLT2 inhibitor and DPP-4 inhibitor therapies. The median age of participants was 62·0 years (IQR 55·0-70·0). 10 016 (37·3%) were women and 16 861 (62·7%) were men. An algorithm based on these five features identified a subgroup, representing around four in ten CPRD patients, with a 5 mmol/mol or greater observed benefit with SGLT2 inhibitors in all validation cohorts (CPRD 8·8 mmol/mol [95% CI 7·8-9·8]; CANTATA-D and CANTATA-D2 trials 5·8 mmol/mol [3·9-7·7]; BI1245.20 trial 6·6 mmol/mol [2·2-11·0]). In CPRD, predicted differential HbA1c response with SGLT2 inhibitor and DPP-4 inhibitor therapies was not associated with weight change. Overall treatment discontinuation within 6 months was similar in patients predicted to have an HbA1c benefit with SGLT2 inhibitors over DPP-4 inhibitors (median 15·2% [13·2-20·3] vs 14·4% [12·9-16·7]). A smaller subgroup predicted to have greater HbA1c reduction with DPP-4 inhibitors were twice as likely to discontinue SGLT2 inhibitors than DPP-4 inhibitors (median 26·8% [23·4-31·0] vs 14·8% [12·9-16·8]). INTERPRETATION A validated treatment selection algorithm for SGLT2 inhibitor and DPP-4 inhibitor therapies can support decisions on optimal treatment for people with type 2 diabetes. FUNDING BHF-Turing Cardiovascular Data Science Award and the UK Medical Research Council.
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Affiliation(s)
- John M Dennis
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, Exeter, UK.
| | - Katherine G Young
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, Exeter, UK
| | - Andrew P McGovern
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, Exeter, UK
| | - Bilal A Mateen
- The Alan Turing Institute, British Library, London, UK; Institute of Health Informatics, University College London, London, UK
| | | | | | - William E Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Rury R Holman
- Oxford Centre for Diabetes, Endocrinology, and Metabolism, University of Oxford, Churchill Hospital, Oxford, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ewan R Pearson
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Andrew T Hattersley
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, Exeter, UK
| | - Angus G Jones
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, Exeter, UK
| | - Beverley M Shields
- University of Exeter Medical School, Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, Exeter, UK
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Streeter AJ, Rodgers LR, Hamilton F, Masoli JAH, Blé A, Hamilton WT, Henley WE. Influenza vaccination reduced myocardial infarctions in United Kingdom older adults: a prior event rate ratio study. J Clin Epidemiol 2022; 151:122-131. [PMID: 35817230 DOI: 10.1016/j.jclinepi.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 06/22/2022] [Accepted: 06/28/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVES We aimed to estimate the real-world effectiveness of the influenza vaccine against myocardial infarction (MI) and influenza in the decade since adults aged ≥ 65 years were first recommended the vaccine. STUDY DESIGN AND SETTING We identified annual cohorts, 1997 to 2011, of adults aged ≥ 65 years, without previous influenza vaccination, from UK general practices, registered with the Clinical Practice Research Datalink. Using a quasi-experimental study design to control for confounding bias, we estimated influenza vaccine effectiveness on hospitalization for MI, influenza, and antibiotic prescriptions for lower respiratory tract infections. RESULTS Vaccination was moderately effective against influenza, the prior event rate ratio-adjusted hazard ratios ranging from 0.70 in 1999 to 0.99 in 2001. Prior event rate ratio-adjusted hazard ratios demonstrated a protective effect against MIs, varying between 0.40 in 2010 and 0.89 in 2001. Aggregated across the cohorts, influenza vaccination reduced the risk of MIs by 39% (95% confidence interval: 34%, 44%). CONCLUSION Effectiveness of the flu vaccine in preventing MIs in older UK adults is consistent with the limited evidence from clinical trials. Similar trends in effectiveness against influenza and against MIs suggest the risk of influenza mediates the effectiveness against MIs, although divergence in some years implies the mechanism may be complex.
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Affiliation(s)
- Adam J Streeter
- Institute for Epidemiology and Social Medicine, University of Münster, Münster, North Rhine-Westphalia, Germany; Medical Statistics, Faculty of Health, University of Plymouth, Plymouth Science Park, Derriford, Plymouth, UK; Health Statistics Group, University of Exeter Medical School, University of Exeter, South Cloisters, St. Luke's Campus, Exeter, UK.
| | - Lauren R Rodgers
- Health Statistics Group, University of Exeter Medical School, University of Exeter, South Cloisters, St. Luke's Campus, Exeter, UK
| | - Fergus Hamilton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol BS8 2PS, UK
| | - Jane A H Masoli
- College of Medicine and Health, University of Exeter Medical School, St. Luke's Campus, Exeter, UK; Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Alessandro Blé
- College of Medicine and Health, University of Exeter Medical School, St. Luke's Campus, Exeter, UK
| | - William T Hamilton
- College of Medicine and Health, University of Exeter Medical School, St. Luke's Campus, Exeter, UK
| | - William E Henley
- Health Statistics Group, University of Exeter Medical School, University of Exeter, South Cloisters, St. Luke's Campus, Exeter, UK
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Streeter AJ, Rodgers LR, Masoli J, Lin NX, Blé A, Hamilton W, Henley WE. Real-world effectiveness of pneumococcal vaccination in older adults: Cohort study using the UK Clinical Practice Research Datalink. PLoS One 2022; 17:e0275642. [PMID: 36227889 PMCID: PMC9560513 DOI: 10.1371/journal.pone.0275642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/21/2022] [Indexed: 11/05/2022] Open
Abstract
Background The 23-valent pneumococcal polysaccharide vaccine (PPV23) is recommended for UK older adults, but how age moderates effectiveness is unclear. Methods Three annual cohorts of primary-care patients aged≥65y from the Clinical Practice Research Datalink selected from 2003–5 created a natural experiment (n = 324,804), reflecting the staged introduction of the vaccine. The outcome was symptoms consistent with community-acquired pneumococcal pneumonia (CAP) requiring antibiotics or hospitalisation. We used the prior event rate ratio (PERR) approach to address bias from unmeasured confounders. Results Vaccinated patients had higher rates of CAP in the year before vaccination than their controls, indicating the potential for confounding bias. After adjustment for confounding using the prior event rate ratio (PERR) method, PPV23 was estimated to be effective against CAP for two years after vaccination in all age sub-groups with hazard ratios (95% confidence intervals) of 0.86 (0.80 to 0.93), 0.74 (0.65 to 0.85) and 0.65 (0.57 to 0.74) in patients aged 65–74, 75–79 and 80+ respectively in the 2005 cohort. Age moderated the effect of vaccination with predicted risk reductions of 8% at 65y and 29% at 80y. Conclusions PPV23 is moderately effective at reducing CAP among UK patients aged≥65y, in the two years after vaccination. Vaccine effectiveness is maintained, and may increase, in the oldest age groups in step with increasing susceptibility to CAP.
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Affiliation(s)
- Adam J. Streeter
- Institute for Epidemiology and Social Medicine, University of Münster, Münster, North Rhine-Westphalia, Germany
- Medical Statistics, Faculty of Health, University of Plymouth, Plymouth, United Kingdom
- Institute for Health Research, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
- * E-mail:
| | - Lauren R. Rodgers
- Institute for Health Research, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Jane Masoli
- Institute for Health Research, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Nan X. Lin
- Department of Mathematics, Physics and Electrical Engineering, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Alessandro Blé
- Institute for Health Research, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Willie Hamilton
- Institute for Health Research, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - William E. Henley
- Institute for Health Research, University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
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Ross JAD, Barron E, McGough B, Valabhji J, Daff K, Irwin J, Henley WE, Murray E. Uptake and impact of the English National Health Service digital diabetes prevention programme: observational study. BMJ Open Diabetes Res Care 2022; 10:10/3/e002736. [PMID: 35504697 PMCID: PMC9066480 DOI: 10.1136/bmjdrc-2021-002736] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/27/2022] [Indexed: 01/12/2023] Open
Abstract
INTRODUCTION 'Healthier You', the National Health Service (NHS) diabetes prevention programme (DPP) offers adults in England at high risk of type 2 diabetes (T2DM) an evidence-based behavioral intervention to prevent or delay T2DM onset. This study assesses the impact of a pilot digital stream of the DPP (DDPP) on glycated hemoglobin (HbA1c) and weight. RESEARCH DESIGN AND METHODS A service evaluation employing prospectively collected data in a prospective cohort design in nine NHS local pilot areas across England. Participants were adults with non-diabetic hyperglycemia (NDH) (HbA1c 42-47 mmol/mol or fasting plasma glucose 5.5-6.9 mmol/L) in the 12 months prior to referral. The DDPP comprised five digital health interventions (DHI). Joint primary outcomes were changes in HbA1c and weight between baseline and 12 months. HbA1c and weight readings were recorded at referral (baseline) by general practices, and then at 12-month postregistration. Demographic data and service variables were collected from the DHI providers. RESULTS 3623 participants with NDH registered for the DDPP and of these, 2734 (75%) were eligible for inclusion in the analyses. Final (12-month) follow-up data for HbA1c were available for 1799 (50%) and for weight 1817 (50%) of registered participants. Mean change at 12 months was -3.1 (-3.4 to -2.8) kg, p<0.001 for weight and -1.6 (-1.8 to -1.4) mmol/mol, p<0.001 for HbA1c. Access to peer support and a website and telephone service was associated with significantly greater reductions in HbA1c and weight. CONCLUSIONS Participation in the DDPP was associated with clinically significant reductions in weight and HbA1c. Digital diabetes prevention can be an effective and wide-reaching component of a population-based approach to addressing type 2 diabetes prevention.
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Affiliation(s)
- Jamie Anne Dolan Ross
- Research Department of Primary Care and Population Health, University College London, London, UK
| | | | | | - Jonathan Valabhji
- NHS England and Improvement, London, UK
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | | | | | - William E Henley
- Health Statistics Group, Institute of Health Research, University of Exeter, Exeter, UK
| | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London, London, UK
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Rodgers LR, Streeter AJ, Lin N, Hamilton W, Henley WE. Impact of influenza vaccination on amoxicillin prescriptions in older adults: A retrospective cohort study using primary care data. PLoS One 2021; 16:e0246156. [PMID: 33513169 PMCID: PMC7846013 DOI: 10.1371/journal.pone.0246156] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/15/2021] [Indexed: 11/18/2022] Open
Abstract
Background Bacterial infections of the upper and lower respiratory tract are a frequent complication of influenza and contribute to the widespread use of antibiotics. Influenza vaccination may help reduce both appropriate and inappropriate prescribing of antibiotics. Electronic health records provide a rich source of information for assessing secondary effects of influenza vaccination. Methods We conducted a retrospective study to estimate effects of influenza vaccine on antibiotic (amoxicillin) prescription in the elderly based on data from the Clinical Practice Research Datalink. The introduction of UK policy to recommend the influenza vaccine to older adults in 2000 led to a substantial increase in uptake, creating a natural experiment. Of 259,753 eligible patients that were unvaccinated in 1999 and aged≥65y by January 2000, 88,519 patients received influenza vaccination in 2000. These were propensity score matched 1:1 to unvaccinated patients. Time-to-amoxicillin was analysed using the Prior Event Rate Ratio (PERR) Pairwise method to address bias from time-invariant measured and unmeasured confounders. A simulation study and negative control outcome were used to help strengthen the validity of results. Results Compared to unvaccinated patients, those from the vaccinated group were more likely to be prescribed amoxicillin in the year prior to vaccination: hazard ratio (HR) 1.90 (95% confidence interval 1.83, 1.98). Following vaccination, the vaccinated group were again more likely to be prescribed amoxicillin, HR 1.64 (1.58,1.71). After adjusting for prior differences between the two groups using PERR Pairwise, overall vaccine effectiveness was 0.86 (0.81, 0.92). Additional analyses suggested that provided data meet the PERR assumptions, these estimates were robust. Conclusions Once differences between groups were taken into account, influenza vaccine had a beneficial effect, lowering the frequency of amoxicillin prescribing in the vaccinated group. Ensuring successful implementation of national programmes of vaccinating older adults against influenza may help contribute to reducing antibiotic resistance.
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Affiliation(s)
- Lauren R. Rodgers
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
- * E-mail:
| | - Adam J. Streeter
- Medical Statistics, Faculty of Health: Medicine, Dentistry & Human Sciences, University of Plymouth, Plymouth, United Kingdom
| | - Nan Lin
- Department of Mathematics, Physics and Electrical Engineering, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Willie Hamilton
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
| | - William E. Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
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Rodgers LR, Dennis JM, Shields BM, Mounce L, Fisher I, Hattersley AT, Henley WE. Prior event rate ratio adjustment produced estimates consistent with randomized trial: a diabetes case study. J Clin Epidemiol 2020; 122:78-86. [PMID: 32194148 PMCID: PMC7262589 DOI: 10.1016/j.jclinepi.2020.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/06/2020] [Accepted: 03/12/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Electronic health records (EHR) provide a valuable resource for assessing drug side-effects, but treatments are not randomly allocated in routine care creating the potential for bias. We conduct a case study using the Prior Event Rate Ratio (PERR) Pairwise method to reduce unmeasured confounding bias in side-effect estimates for two second-line therapies for type 2 diabetes, thiazolidinediones, and sulfonylureas. STUDY DESIGN AND SETTINGS Primary care data were extracted from the Clinical Practice Research Datalink (n = 41,871). We utilized outcomes from the period when patients took first-line metformin to adjust for unmeasured confounding. Estimates for known side-effects and a negative control outcome were compared with the A Diabetes Outcome Progression Trial (ADOPT) trial (n = 2,545). RESULTS When on metformin, patients later prescribed thiazolidinediones had greater risks of edema, HR 95% CI 1.38 (1.13, 1.68) and gastrointestinal side-effects (GI) 1.47 (1.28, 1.68), suggesting the presence of unmeasured confounding. Conventional Cox regression overestimated the risk of edema on thiazolidinediones and identified a false association with GI. The PERR Pairwise estimates were consistent with ADOPT: 1.43 (1.10, 1.83) vs. 1.39 (1.04, 1.86), respectively, for edema, and 0.91 (0.79, 1.05) vs. 0.94 (0.80, 1.10) for GI. CONCLUSION The PERR Pairwise approach offers potential for enhancing postmarketing surveillance of side-effects from EHRs but requires careful consideration of assumptions.
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Affiliation(s)
- Lauren R Rodgers
- Institute of Health Research, University of Exeter Medical School, Exeter, UK.
| | - John M Dennis
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Beverley M Shields
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK
| | - Luke Mounce
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | | | - Andrew T Hattersley
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - William E Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
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Dennis JM, Shields BM, Henley WE, Jones AG, Hattersley AT. Clusters provide a better holistic view of type 2 diabetes than simple clinical features - Authors' reply. Lancet Diabetes Endocrinol 2019; 7:669. [PMID: 31439274 DOI: 10.1016/s2213-8587(19)30250-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 11/29/2022]
Affiliation(s)
- John M Dennis
- Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - Beverley M Shields
- Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - William E Henley
- Health Statistics Group, Institute of Health Research, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - Angus G Jones
- Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK.
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Dennis JM, Henley WE, McGovern AP, Farmer AJ, Sattar N, Holman RR, Pearson ER, Hattersley AT, Shields BM, Jones AG. Time trends in prescribing of type 2 diabetes drugs, glycaemic response and risk factors: A retrospective analysis of primary care data, 2010-2017. Diabetes Obes Metab 2019; 21:1576-1584. [PMID: 30828962 PMCID: PMC6618851 DOI: 10.1111/dom.13687] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/13/2019] [Accepted: 02/28/2019] [Indexed: 12/25/2022]
Abstract
AIM To describe population-level time trends in prescribing patterns of type 2 diabetes therapy, and in short-term clinical outcomes (glycated haemoglobin [HbA1c], weight, blood pressure, hypoglycaemia and treatment discontinuation) after initiating new therapy. MATERIALS AND METHODS We studied 81 532 people with type 2 diabetes initiating a first- to fourth-line drug in primary care between 2010 and 2017 inclusive in United Kingdom electronic health records (Clinical Practice Research Datalink). Trends in new prescriptions and subsequent 6- and 12-month adjusted changes in glycaemic response (reduction in HbA1c), weight, blood pressure and rates of hypoglycaemia and treatment discontinuation were examined. RESULTS Use of dipeptidyl peptidase-4 inhibitors as second-line therapy near doubled (41% of new prescriptions in 2017 vs. 22% in 2010), replacing sulphonylureas as the most common second-line drug (29% in 2017 vs. 53% in 2010). Sodium-glucose co-transporter-2 inhibitors, introduced in 2013, comprised 17% of new first- to fourth-line prescriptions by 2017. First-line use of metformin remained stable (91% of new prescriptions in 2017 vs. 91% in 2010). Over the study period there was little change in average glycaemic response and in the proportion of people discontinuing treatment. There was a modest reduction in weight after initiating second- and third-line therapy (improvement in weight change 2017 vs. 2010 for second-line therapy: -1.5 kg, 95% confidence interval [CI] -1.9, -1.1; P < 0.001), and a slight reduction in systolic blood pressure after initiating first-, second- and third-line therapy (improvement in systolic blood pressure change 2017 vs. 2010 range: -1.7 to -2.1 mmHg; all P < 0.001). Hypoglycaemia rates decreased over time with second-line therapy (incidence rate ratio 0.94 per year, 95% CI 0.88, 1.00; P = 0.04), mirroring the decline in use of sulphonylureas. CONCLUSIONS Recent changes in prescribing of therapy for people with type 2 diabetes have not led to a change in glycaemic response and have resulted in modest improvements in other population-level short-term clinical outcomes.
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Affiliation(s)
- John M. Dennis
- Health Statistics GroupInstitute of Health Research, University of Exeter Medical SchoolExeterUK
| | - William E. Henley
- Health Statistics GroupInstitute of Health Research, University of Exeter Medical SchoolExeterUK
| | - Andrew P. McGovern
- Institute of Biomedical and Clinical ScienceRoyal Devon and Exeter HospitalExeterUK
| | - Andrew J. Farmer
- Nuffield Department of Primary Care Health SciencesUniversity of OxfordOxfordUK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical SciencesUniversity of GlasgowGlasgowUK
| | - Rury R. Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and MetabolismUniversity of OxfordOxfordUK
| | - Ewan R. Pearson
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical SchoolUniversity of DundeeDundeeUK
| | - Andrew T. Hattersley
- Institute of Biomedical and Clinical ScienceRoyal Devon and Exeter HospitalExeterUK
| | - Beverley M. Shields
- Institute of Biomedical and Clinical ScienceRoyal Devon and Exeter HospitalExeterUK
| | - Angus G. Jones
- Institute of Biomedical and Clinical ScienceRoyal Devon and Exeter HospitalExeterUK
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Dennis JM, Shields BM, Henley WE, Jones AG, Hattersley AT. Disease progression and treatment response in data-driven subgroups of type 2 diabetes compared with models based on simple clinical features: an analysis using clinical trial data. Lancet Diabetes Endocrinol 2019; 7:442-451. [PMID: 31047901 PMCID: PMC6520497 DOI: 10.1016/s2213-8587(19)30087-7] [Citation(s) in RCA: 217] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Research using data-driven cluster analysis has proposed five subgroups of diabetes with differences in diabetes progression and risk of complications. We aimed to compare the clinical utility of this subgroup-based approach for predicting patient outcomes with an alternative strategy of developing models for each outcome using simple patient characteristics. METHODS We identified five clusters in the ADOPT trial (n=4351) using the same data-driven cluster analysis as reported by Ahlqvist and colleagues. Differences between clusters in glycaemic and renal progression were investigated and contrasted with stratification using simple continuous clinical features (age at diagnosis for glycaemic progression and baseline renal function for renal progression). We compared the effectiveness of a strategy of selecting glucose-lowering therapy using clusters with one combining simple clinical features (sex, BMI, age at diagnosis, baseline HbA1c) in an independent trial cohort (RECORD [n=4447]). FINDINGS Clusters identified in trial data were similar to those described in the original study by Ahlqvist and colleagues. Clusters showed differences in glycaemic progression, but a model using age at diagnosis alone explained a similar amount of variation in progression. We found differences in incidence of chronic kidney disease between clusters; however, estimated glomerular filtration rate at baseline was a better predictor of time to chronic kidney disease. Clusters differed in glycaemic response, with a particular benefit for thiazolidinediones in patients in the severe insulin-resistant diabetes cluster and for sulfonylureas in patients in the mild age-related diabetes cluster. However, simple clinical features outperformed clusters to select therapy for individual patients. INTERPRETATION The proposed data-driven clusters differ in diabetes progression and treatment response, but models that are based on simple continuous clinical features are more useful to stratify patients. This finding suggests that precision medicine in type 2 diabetes is likely to have most clinical utility if it is based on an approach of using specific phenotypic measures to predict specific outcomes, rather than assigning patients to subgroups. FUNDING UK Medical Research Council.
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Affiliation(s)
- John M Dennis
- Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - Beverley M Shields
- Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - William E Henley
- Health Statistics Group, Institute of Health Research, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - Angus G Jones
- Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, Royal Devon and Exeter Hospital, University of Exeter Medical School, Exeter, UK.
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Dennis JM, Shields BM, Jones AG, Pearson ER, Hattersley AT, Henley WE. Evaluating associations between the benefits and risks of drug therapy in type 2 diabetes: a joint modeling approach. Clin Epidemiol 2018; 10:1869-1877. [PMID: 30588118 PMCID: PMC6298877 DOI: 10.2147/clep.s179555] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Precision medicine drug therapy seeks to maximize efficacy and minimize harm for individual patients. This will be difficult if drug response and side effects are positively associated, meaning that patients likely to respond best are at increased risk of side effects. We applied joint longitudinal-survival models to evaluate associations between drug response (longitudinal outcome) and the risk of side effects (survival outcome) for patients initiating type 2 diabetes therapy. STUDY DESIGN AND SETTING Participants were randomized to metformin (MFN), sulfonylurea (SU), or thiazolidinedione (TZD) therapy in the A Diabetes Outcome Progression Trial (ADOPT) drug efficacy trial (n=4,351). Joint models were parameterized for 1) current HbA1c response (change from baseline in HbA1c) and 2) cumulative HbA1c response (total HbA1c change). RESULTS With MFN, greater HbA1c response did not increase the risk of gastrointestinal events (HR per 1% absolute greater current response 0.82 [95% CI 0.67, 1.01]; HR per 1% higher cumulative response 0.90 [95% CI 0.81, 1.00]). With SU, greater current response was associated with an increased risk of hypoglycemia (HR 1.41 [95% CI 1.04, 1.91]). With TZD, greater response was associated with an increased risk of edema (current HR 1.45 [95% CI 1.05, 2.01]; cumulative 1.22 [95% CI 1.07, 1.38]) but not fracture. CONCLUSION Joint modeling provides a useful framework to evaluate the association between response to a drug and the risk of developing side effects. There may be great potential for widespread application of joint modeling to evaluate the risks and benefits of both new and established medications.
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Affiliation(s)
- John M Dennis
- Health Statistics Group, University of Exeter Medical School, Exeter, UK,
| | - Beverley M Shields
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK
| | - Angus G Jones
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK
| | - Ewan R Pearson
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Andrew T Hattersley
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK
| | - William E Henley
- Health Statistics Group, University of Exeter Medical School, Exeter, UK,
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Dennis JM, Henley WE, Weedon MN, Lonergan M, Rodgers LR, Jones AG, Hamilton WT, Sattar N, Janmohamed S, Holman RR, Pearson ER, Shields BM, Hattersley AT, Angwin C, Cruickshank KJ, Farmer AJ, Gough SC, Gray AM, Hyde C, Jennison C, Walker M. Sex and BMI Alter the Benefits and Risks of Sulfonylureas and Thiazolidinediones in Type 2 Diabetes: A Framework for Evaluating Stratification Using Routine Clinical and Individual Trial Data. Diabetes Care 2018; 41:1844-1853. [PMID: 30072404 PMCID: PMC6591127 DOI: 10.2337/dc18-0344] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 05/17/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The choice of therapy for type 2 diabetes after metformin is guided by overall estimates of glycemic response and side effects seen in large cohorts. A stratified approach to therapy would aim to improve on this by identifying subgroups of patients whose glycemic response or risk of side effects differs markedly. We assessed whether simple clinical characteristics could identify patients with differing glycemic response and side effects with sulfonylureas and thiazolidinediones. RESEARCH DESIGN AND METHODS We studied 22,379 patients starting sulfonylurea or thiazolidinedione therapy in the U.K. Clinical Practice Research Datalink (CPRD) to identify features associated with increased 1-year HbA1c fall with one therapy class and reduced fall with the second. We then assessed whether prespecified patient subgroups defined by the differential clinical factors showed differing 5-year glycemic response and side effects with sulfonylureas and thiazolidinediones using individual randomized trial data from ADOPT (A Diabetes Outcome Progression Trial) (first-line therapy, n = 2,725) and RECORD (Rosiglitazone Evaluated for Cardiovascular Outcomes and Regulation of Glycemia in Diabetes) (second-line therapy, n = 2,222). Further replication was conducted using routine clinical data from GoDARTS (Genetics of Diabetes Audit and Research in Tayside Scotland) (n = 1,977). RESULTS In CPRD, male sex and lower BMI were associated with greater glycemic response with sulfonylureas and a lesser response with thiazolidinediones (both P < 0.001). In ADOPT and RECORD, nonobese males had a greater overall HbA1c reduction with sulfonylureas than with thiazolidinediones (P < 0.001); in contrast, obese females had a greater HbA1c reduction with thiazolidinediones than with sulfonylureas (P < 0.001). Weight gain and edema risk with thiazolidinediones were greatest in obese females; however, hypoglycemia risk with sulfonylureas was similar across all subgroups. CONCLUSIONS Patient subgroups defined by sex and BMI have different patterns of benefits and risks on thiazolidinedione and sulfonylurea therapy. Subgroup-specific estimates can inform discussion about the choice of therapy after metformin for an individual patient. Our approach using routine and shared trial data provides a framework for future stratification research in type 2 diabetes.
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Affiliation(s)
- John M. Dennis
- Health Statistics Group, University of Exeter Medical School, Exeter, U.K
| | - William E. Henley
- Health Statistics Group, University of Exeter Medical School, Exeter, U.K
| | - Michael N. Weedon
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Mike Lonergan
- Division of Molecular & Clinical Medicine, Ninewells Hospital, Dundee, U.K
| | - Lauren R. Rodgers
- Health Statistics Group, University of Exeter Medical School, Exeter, U.K
| | - Angus G. Jones
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
- Royal Devon and Exeter National Health Service Foundation Trust, Exeter, U.K
| | - William T. Hamilton
- Institute of Biomedical & Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | | | - Rury R. Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
- National Institute for Health Research Oxford Biomedical Research Centre, Churchill Hospital, Oxford, U.K
| | - Ewan R. Pearson
- Division of Molecular & Clinical Medicine, Ninewells Hospital, Dundee, U.K
| | - Beverley M. Shields
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Andrew T. Hattersley
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
- Royal Devon and Exeter National Health Service Foundation Trust, Exeter, U.K
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Mounce LTA, Campbell JL, Henley WE, Tejerina Arreal MC, Porter I, Valderas JM. Predicting Incident Multimorbidity. Ann Fam Med 2018; 16:322-329. [PMID: 29987080 PMCID: PMC6037507 DOI: 10.1370/afm.2271] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 04/03/2018] [Accepted: 04/19/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Multimorbidity is associated with adverse outcomes, yet research on the determinants of its incidence is lacking. We investigated which sociodemographic, health, and individual lifestyle (eg, physical activity, smoking behavior, body mass index) characteristics predict new cases of multimorbidity. METHODS We used data from 4,564 participants aged 50 years and older in the English Longitudinal Study of Aging that included a 10-year follow-up period. Discrete time-to-event (complementary log-log) models were constructed for exploring the associations of baseline characteristics with outcomes between 2002-2003 and 2012-2013 separately for participants with no initial conditions (n = 1,377) developing multimorbidity, any increase in conditions within 10 years regardless of initial conditions, and the impact of individual conditions on incident multimorbidity. RESULTS The risks of developing multimorbidity were positively associated with age, and they were greater for the least wealthy, for participants who were obese, and for those who reported the lowest levels of physical activity or an external locus of control (believing that life events are outside of one's control) for all groups regardless of baseline conditions (all linear trends <.05). No significant associations were observed for sex, educational attainment, or social detachment. For participants with any increase in conditions (n = 4,564), a history of smoking was the only additional predictor. For participants with a single baseline condition (n = 1,534), chronic obstructive pulmonary disease (COPD), asthma, and arrhythmia showed the strongest associations with subsequent multimorbidity. CONCLUSIONS Our findings support the development and implementation of a strategy targeting the prevention of multimorbidity for susceptible groups. This approach should incorporate behavior change addressing lifestyle factors and target health-related locus of control.
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Affiliation(s)
- Luke T A Mounce
- University of Exeter Medical School, St Luke's Campus, Exeter, Devon, United Kingdom
| | - John L Campbell
- University of Exeter Medical School, St Luke's Campus, Exeter, Devon, United Kingdom
| | - William E Henley
- University of Exeter Medical School, St Luke's Campus, Exeter, Devon, United Kingdom
| | | | - Ian Porter
- University of Exeter Medical School, St Luke's Campus, Exeter, Devon, United Kingdom
| | - Jose M Valderas
- University of Exeter Medical School, St Luke's Campus, Exeter, Devon, United Kingdom
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Dennis JM, Shields BM, Hill AV, Knight BA, McDonald TJ, Rodgers LR, Weedon MN, Henley WE, Sattar N, Holman RR, Pearson ER, Hattersley AT, Jones AG. Precision Medicine in Type 2 Diabetes: Clinical Markers of Insulin Resistance Are Associated With Altered Short- and Long-term Glycemic Response to DPP-4 Inhibitor Therapy. Diabetes Care 2018; 41:705-712. [PMID: 29386249 PMCID: PMC6591121 DOI: 10.2337/dc17-1827] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/28/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE A precision approach to type 2 diabetes therapy would aim to target treatment according to patient characteristics. We examined if measures of insulin resistance and secretion were associated with glycemic response to dipeptidyl peptidase 4 (DPP-4) inhibitor therapy. RESEARCH DESIGN AND METHODS We evaluated whether markers of insulin resistance and insulin secretion were associated with 6-month glycemic response in a prospective study of noninsulin-treated participants starting DPP-4 inhibitor therapy (Predicting Response to Incretin Based Agents [PRIBA] study; n = 254), with replication for routinely available markers in U.K. electronic health care records (Clinical Practice Research Datalink [CPRD]; n = 23,001). In CPRD, we evaluated associations between baseline markers and 3-year durability of response. To test the specificity of findings, we repeated analyses for glucagon-like peptide 1 (GLP-1) receptor agonists (PRIBA, n = 339; CPRD, n = 4,464). RESULTS In PRIBA, markers of higher insulin resistance (higher fasting C-peptide [P = 0.03], HOMA2 insulin resistance [P = 0.01], and triglycerides [P < 0.01]) were associated with reduced 6-month HbA1c response to DPP-4 inhibitors. In CPRD, higher triglycerides and BMI were associated with reduced HbA1c response (both P < 0.01). A subgroup defined by obesity (BMI ≥30 kg/m2) and high triglycerides (≥2.3 mmol/L) had reduced 6-month response in both data sets (PRIBA HbA1c reduction 5.3 [95% CI 1.8, 8.6] mmol/mol [0.5%] [obese and high triglycerides] vs. 11.3 [8.4, 14.1] mmol/mol [1.0%] [nonobese and normal triglycerides]; P = 0.01). In CPRD, the obese, high- triglycerides subgroup also had less durable response (hazard ratio 1.28 [1.16, 1.41]; P < 0.001). There was no association between markers of insulin resistance and response to GLP-1 receptor agonists. CONCLUSIONS Markers of higher insulin resistance are consistently associated with reduced glycemic response to DPP-4 inhibitors. This finding provides a starting point for the application of a precision diabetes approach to DPP-4 inhibitor therapy.
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Affiliation(s)
- John M Dennis
- Health Statistics Group, University of Exeter Medical School, Exeter, U.K
| | - Beverley M Shields
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Anita V Hill
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Bridget A Knight
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Timothy J McDonald
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K.,Blood Sciences, Royal Devon and Exeter Hospital, Exeter, U.K
| | - Lauren R Rodgers
- Health Statistics Group, University of Exeter Medical School, Exeter, U.K
| | - Michael N Weedon
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, U.K
| | - William E Henley
- Health Statistics Group, University of Exeter Medical School, Exeter, U.K
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Rury R Holman
- Diabetes Trials Unit, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
| | - Ewan R Pearson
- Division of Molecular & Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, U.K
| | - Andrew T Hattersley
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | - Angus G Jones
- National Institute for Health Research Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K.
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Rodgers LR, Weedon MN, Henley WE, Hattersley AT, Shields BM. Cohort profile for the MASTERMIND study: using the Clinical Practice Research Datalink (CPRD) to investigate stratification of response to treatment in patients with type 2 diabetes. BMJ Open 2017; 7:e017989. [PMID: 29025846 PMCID: PMC5652624 DOI: 10.1136/bmjopen-2017-017989] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE This is a retrospective cohort study using observational data from anonymised primary care records. We identify and extract all patients with type 2 diabetes and associated clinical data from the Clinical Practice Research Datalink (CPRD) to inform models of disease progression and stratification of treatment. PARTICIPANTS Data were extracted from CPRD on 8 August 2016. The initial data set contained all patients (n=313 485) in the database who had received a type 2 diabetes medication. Criteria were applied to identify and exclude those with type 1 diabetes, polycystic ovarian syndrome or other forms of diabetes (n=40 204), and for data quality control (n=12). We identified 251 338 patients for inclusion in future analyses of diabetes progression and treatment response. FINDINGS TO DATE For 6-month response to treatment, measured by change in glycated haemoglobin (HbA1c), we have 91 765 patients with 119 785 treatment response episodes. The greatest impact on reduction of HbA1c occurs with first-line and second-line treatments, metformin and sulfonylurea. Patients moving to third-line treatments tend to have greater weights and higher body mass index. We have investigated the impact of non-adherence to commonly used glucose-lowering medications on HbA1c. For baseline-adjusted HbA1c change over 1 year, non-adherent patients had lower HbA1c reductions than adherent patients, with mean and 95% CI of -4.4 (-4.7 to -4.0) mmol/mol (-0.40 (-0.43 to -0.37) %). FUTURE PLANS Findings from studies using these data will help inform future treatment plans and guidelines. Additional data are added with updates from CPRD. This will increase the numbers of patients on newer medications and add more data on those already receiving treatment. There are several ongoing studies investigating different hypotheses regarding differential response to treatment and progression of diabetes. For side effects, links to Hospital Episode Statistics data, where severe events such as hypoglycaemia will be recorded, will also be explored.
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Affiliation(s)
- Lauren R Rodgers
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Michael N Weedon
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - William E Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Andrew T Hattersley
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Beverley M Shields
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK
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Streeter AJ, Lin NX, Crathorne L, Haasova M, Hyde C, Melzer D, Henley WE. Adjusting for unmeasured confounding in nonrandomized longitudinal studies: a methodological review. J Clin Epidemiol 2017; 87:23-34. [PMID: 28460857 PMCID: PMC5589113 DOI: 10.1016/j.jclinepi.2017.04.022] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 04/03/2017] [Accepted: 04/24/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Motivated by recent calls to use electronic health records for research, we reviewed the application and development of methods for addressing the bias from unmeasured confounding in longitudinal data. STUDY DESIGN AND SETTING Methodological review of existing literature. We searched MEDLINE and EMBASE for articles addressing the threat to causal inference from unmeasured confounding in nonrandomized longitudinal health data through quasi-experimental analysis. RESULTS Among the 121 studies included for review, 84 used instrumental variable analysis (IVA), of which 36 used lagged or historical instruments. Difference-in-differences (DiD) and fixed effects (FE) models were found in 29 studies. Five of these combined IVA with DiD or FE to try to mitigate for time-dependent confounding. Other less frequently used methods included prior event rate ratio adjustment, regression discontinuity nested within pre-post studies, propensity score calibration, perturbation analysis, and negative control outcomes. CONCLUSION Well-established econometric methods such as DiD and IVA are commonly used to address unmeasured confounding in nonrandomized longitudinal studies, but researchers often fail to take full advantage of available longitudinal information. A range of promising new methods have been developed, but further studies are needed to understand their relative performance in different contexts before they can be recommended for widespread use.
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Affiliation(s)
- Adam J Streeter
- Health Statistics Group, Institute of Health Research, University of Exeter Medical School, University of Exeter, St. Luke's Campus, Exeter EX1 2LU, United Kingdom; Medical Statistics, Institute of Translational and Stratified Medicine, Plymouth University Peninsula School of Medicine & Dentistry, University of Plymouth, Plymouth Science Park, Derriford, Plymouth PL6 8BX, United Kingdom
| | - Nan Xuan Lin
- Health Statistics Group, Institute of Health Research, University of Exeter Medical School, University of Exeter, St. Luke's Campus, Exeter EX1 2LU, United Kingdom; Mathematics, Physics & Electrical Engineering, Northumbria University, Sutherland Building, Newcastle upon Tyne NE1 8ST, United Kingdom
| | - Louise Crathorne
- Health Economics, Institute of Health Research, University of Exeter Medical School, University of Exeter, St. Luke's Campus, Exeter EX1 2LU, United Kingdom
| | - Marcela Haasova
- Evidence Synthesis & Modelling for Health Improvement, Institute of Health Research, University of Exeter Medical School, University of Exeter, St. Luke's Campus, Exeter EX1 2LU, United Kingdom
| | - Christopher Hyde
- Peninsula Technology Assessment Group, Institute of Health Research, University of Exeter Medical School, University of Exeter, St. Luke's Campus, Exeter EX1 2LU, United Kingdom
| | - David Melzer
- Epidemiology & Public Health, RD&E Hospital Wonford, University of Exeter Medical School, RILD Building, Barrack Road, Exeter EX2 5DW, United Kingdom
| | - William E Henley
- Health Statistics Group, Institute of Health Research, University of Exeter Medical School, University of Exeter, St. Luke's Campus, Exeter EX1 2LU, United Kingdom.
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Ble A, Hughes PM, Delgado J, Masoli JA, Bowman K, Zirk-Sadowski J, Mujica Mota RE, Henley WE, Melzer D. Safety and Effectiveness of Statins for Prevention of Recurrent Myocardial Infarction in 12 156 Typical Older Patients: A Quasi-Experimental Study. J Gerontol A Biol Sci Med Sci 2017; 72:243-250. [PMID: 27146371 PMCID: PMC5233909 DOI: 10.1093/gerona/glw082] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 04/14/2016] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND There is limited evidence on statin risk and effectiveness for patients aged 80+. We estimated risk of recurrent myocardial infarction, muscle-related and other adverse events, and statin-related incremental costs in "real-world" older patients treated with statins versus no statins. METHODS We used primary care electronic medical records from the UK Clinical Practice Research Datalink. Subhazard ratios (competing risk of death) for myocardial infarction recurrence (primary end point), falls, fractures, ischemic stroke, and dementia, and hazard ratios (Cox) for all-cause mortality were used to compare older (60+) statin users and 1:1 propensity-score-matched controls (n = 12,156). Participants were followed-up for 10 years. RESULTS Mean age was 76.5±9.2 years; 45.5% were women. Statins were associated with near significant reduction in myocardial infarction recurrence (subhazard ratio = 0.84, 0.69-1.02, p = .073), with protective effect in the 60-79 age group (0.73, 0.57-0.94) but a nonsignificant result in the 80+ group (1.06, 0.78-1.44; age interaction p = .094). No significant associations were found for stroke or dementia. Data suggest an increased risk of falls (1.36, 1.17-1.60) and fractures (1.33, 1.04-1.69) in the first 2 years of treatment, particularly in the 80+ group. Treatment was associated with lower all-cause mortality. Statin use was associated with health care cost savings in the 60-79 group but higher costs in the 80+ group. CONCLUSIONS Estimates of statin effectiveness for the prevention of recurrent myocardial infarction in patients aged 60-79 years were similar to trial results, but more evidence is needed in the older group. There may be an excess of falls and fractures in very old patients, which deserves further investigation.
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Affiliation(s)
- Alessandro Ble
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, UK.
- School for Public Health Research, National Institute for Health Research, UK
| | - Peter M Hughes
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula, Institute of Health Service Research, University of Exeter Medical School, UK
| | - Joao Delgado
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, UK
- School for Public Health Research, National Institute for Health Research, UK
| | - Jane A Masoli
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, UK
- Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, UK
| | - Kirsty Bowman
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, UK
- School for Public Health Research, National Institute for Health Research, UK
| | - Jan Zirk-Sadowski
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, UK
| | - Ruben E Mujica Mota
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula, Institute of Health Service Research, University of Exeter Medical School, UK
| | - William E Henley
- Health Statistics, Institute of Health Research, University of Exeter Medical School, UK
| | - David Melzer
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, UK
- School for Public Health Research, National Institute for Health Research, UK
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Bowman K, Delgado J, Henley WE, Masoli JA, Kos K, Brayne C, Thokala P, Lafortune L, Kuchel GA, Ble A, Melzer D. Obesity in Older People With and Without Conditions Associated With Weight Loss: Follow-up of 955,000 Primary Care Patients. J Gerontol A Biol Sci Med Sci 2016; 72:203-209. [PMID: 27492450 PMCID: PMC5233914 DOI: 10.1093/gerona/glw147] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 07/10/2016] [Indexed: 11/26/2022] Open
Abstract
Background: Moderate obesity in later life may improve survival, prompting calls to revise obesity control policies. However, this obesity paradox may be due to confounding from smoking, diseases causing weight-loss, plus varying follow-up periods. We aimed to estimate body mass index (BMI) associations with mortality, incident type 2 diabetes, and coronary heart disease in older people with and without the above confounders. Methods: Cohort analysis in Clinical Practice Research Datalink primary care, hospital and death certificate electronic medical records in England for ages 60 to more than 85 years. Models were adjusted for age, gender, alcohol use, smoking, calendar year, and socioeconomic status. Results: Overall, BMI 30–34.9 (obesity class 1) was associated with lower overall death rates in all age groups. However, after excluding the specific confounders and follow-up less than 4 years, BMI mortality risk curves at age 65–69 were U-shaped, with raised risks at lower BMIs, a nadir between 23 and 26.9 and steeply rising risks above. In older age groups, mortality nadirs were at modestly higher BMIs (all <30) and risk slopes at higher BMIs were less marked, becoming nonsignificant at age 85 and older. Incidence of diabetes was raised for obesity-1 at all ages and for coronary heart disease to age 84. Conclusions: Obesity is associated with shorter survival plus higher incidence of coronary heart disease and type 2 diabetes in older populations after accounting for the studied confounders, at least to age 84. These results cast doubt on calls to revise obesity control policies based on the claimed risk paradox at older ages.
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Affiliation(s)
- Kirsty Bowman
- Epidemiology and Public Health, Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, UK
| | - João Delgado
- Epidemiology and Public Health, Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, UK
| | - William E Henley
- Health Statistics Group, Institute of Health Research, University of Exeter Medical School, UK
| | - Jane A Masoli
- Epidemiology and Public Health, Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, UK
| | - Katarina Kos
- Diabetes and Obesity Research Group, Institute of Biomedical and Clinical Science, University of Exeter Medical School, UK
| | - Carol Brayne
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, UK
| | - Louise Lafortune
- Department of Public Health and Primary Care, Cambridge Institute of Public Health, University of Cambridge, UK
| | - George A Kuchel
- UConn Center on Aging, University of Connecticut Health Center, Farmington, USA
| | - Alessandro Ble
- Epidemiology and Public Health, Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, UK
| | - David Melzer
- Epidemiology and Public Health, Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, UK. .,UConn Center on Aging, University of Connecticut Health Center, Farmington, USA
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Metcalf BS, Hosking J, Jeffery AN, Henley WE, Wilkin TJ. Exploring the Adolescent Fall in Physical Activity: A 10-yr Cohort Study (EarlyBird 41). Med Sci Sports Exerc 2016; 47:2084-92. [PMID: 25706294 DOI: 10.1249/mss.0000000000000644] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Contemporary adolescents are deemed inactive, especially girls, but whether for biological reasons associated with their maturation, changes in their behavior or because of environmental constraints, is uncertain. We examined the trends in physical activity (PA) in relation to both biological and environmental factors in an attempt to establish what drives activity patterns from childhood through adolescence. METHODS Physical activity (7-d Actigraph accelerometry) was measured annually from 5 to 15 yr in a single cohort of some 300 UK children. Total PA (TPA; in-school and out-of-school separately and combined as whole day) and intensity-specific PA (sedentary, light, and moderate-and-vigorous [MVPA]) were analyzed. Biological age (years before/after measured peak height velocity) and pubertal stage (self-reported pubic hair development-Tanner staging) were also measured as was socioeconomic status (postcode-derived index of multiple deprivation [IMD]). RESULTS Total PA was stable from 5 to 8 yr (trend P = 0.10) but fell progressively from 9 to 15 yr (by approximately 30% in girls and approximately 20% in boys, both P < 0.001; sex interaction, P < 0.01). Half of this fall was attributable to light intensity PA and only a quarter to MVPA. The decline in PA was related similarly to chronological and biological age, whereas pubertal stage explained the more rapid PA decline in girls (puberty-adjusted sex interaction, P = 0.51). Total PA fell to the same extent for in-school and out-of-school settings (both P < 0.001), and for lower and higher IMD areas (both P < 0.001). Total PA tracked moderately to strongly from childhood into adolescence (r = 0.58; P < 0.001). CONCLUSIONS The adolescent decline in PA is consistent across different environmental settings, attributable to falls in light-intensity/habitual activity and influenced by puberty, suggesting that the inactivity of adolescence may, in part, be under biological control.
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Affiliation(s)
- Brad S Metcalf
- 1Institute of Health Research, University of Exeter Medical School, Exeter, UNITED KINGDOM; 2Sport and Health Science, College of Life and Environmental Sciences, University of Exeter, Exeter, UNITED KINGDOM; and 3Department of Endocrinology and Metabolism, Peninsula Schools of Medicine and Dentistry, Plymouth University Plymouth, UNITED KINGDOM
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20
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Littlejohns TJ, Kos K, Henley WE, Lang IA, Annweiler C, Beauchet O, Chaves PHM, Kestenbaum BR, Kuller LH, Langa KM, Lopez OL, Llewellyn DJ. Vitamin D and Risk of Neuroimaging Abnormalities. PLoS One 2016; 11:e0154896. [PMID: 27166613 PMCID: PMC4864237 DOI: 10.1371/journal.pone.0154896] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 04/20/2016] [Indexed: 01/01/2023] Open
Abstract
Vitamin D deficiency has been linked with an increased risk of incident all-cause dementia and Alzheimer’s disease. The aim of the current study was to explore the potential mechanisms underlying these associations by determining whether low vitamin D concentrations are associated with the development of incident cerebrovascular and neurodegenerative neuroimaging abnormalities. The population consisted of 1,658 participants aged ≥65 years from the US-based Cardiovascular Health Study who were free from prevalent cardiovascular disease, stroke and dementia at baseline in 1992–93. Serum 25-hydroxyvitamin D (25(OH)D) concentrations were determined by liquid chromatography-tandem mass spectrometry from blood samples collected at baseline. The first MRI scan was conducted between 1991–1994 and the second MRI scan was conducted between 1997–1999. Change in white matter grade, ventricular grade and presence of infarcts between MRI scan one and two were used to define neuroimaging abnormalities. During a mean follow-up of 5.0 years, serum 25(OH)D status was not significantly associated with the development of any neuroimaging abnormalities. Using logistic regression models, the multivariate adjusted odds ratios (95% confidence interval) for worsening white matter grade in participants who were severely 25(OH)D deficient (<25 nmol/L) and deficient (≥25–50 nmol/L) were 0.76 (0.35–1.66) and 1.09 (0.76–1.55) compared to participants with sufficient concentrations (≥50 nmol/L). The multivariate adjusted odds ratios for ventricular grade in participants who were severely 25(OH)D deficient and deficient were 0.49 (0.20–1.19) and 1.12 (0.79–1.59) compared to those sufficient. The multivariate adjusted odds ratios for incident infarcts in participants who were severely 25(OH)D deficient and deficient were 1.95 (0.84–4.54) and 0.73 (0.47–1.95) compared to those sufficient. Overall, serum vitamin D concentrations could not be shown to be associated with the development of cerebrovascular or neurodegenerative neuroimaging abnormalities in Cardiovascular Health Study participants.
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Affiliation(s)
- Thomas J. Littlejohns
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Katarina Kos
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - William E. Henley
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Iain A. Lang
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Cedric Annweiler
- Department of Neuroscience, Geriatrics Division, Angers University Hospital, Angers, France
| | - Olivier Beauchet
- Department of Neuroscience, Geriatrics Division, Angers University Hospital, Angers, France
| | - Paulo H. M. Chaves
- Herbert Wertheim College of Medicine, Florida International University, Miami, United States of America
| | - Bryan R. Kestenbaum
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, United States of America
| | - Lewis H. Kuller
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, United States of America
| | - Kenneth M. Langa
- Division of General Medicine, University of Michigan Health System, Ann Arbor, Michigan, United States of America
- Institute for Social Research, Institute of Gerontology and Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, United States of America
- Veteran Affairs Center for Clinical Management Research, Ann Arbor, Michigan, United States of America
| | - Oscar L. Lopez
- Department of Neurology and Psychiatry Division of General Medicine, University of Pittsburgh, Pittsburgh, United States of America
| | - David J. Llewellyn
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
- * E-mail:
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Kuźma E, Soni M, Littlejohns TJ, Ranson JM, van Schoor NM, Deeg DJH, Comijs H, Chaves PHM, Kestenbaum BR, Kuller LH, Lopez OL, Becker JT, Langa KM, Henley WE, Lang IA, Ukoumunne OC, Llewellyn DJ. Vitamin D and Memory Decline: Two Population-Based Prospective Studies. J Alzheimers Dis 2016; 50:1099-108. [PMID: 26836174 PMCID: PMC5525144 DOI: 10.3233/jad-150811] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Vitamin D deficiency has been linked with dementia risk, cognitive decline, and executive dysfunction. However, the association with memory remains largely unknown. OBJECTIVE To investigate whether low serum 25-hydroxyvitamin D (25(OH)D) concentrations are associated with memory decline. METHODS We used data on 1,291 participants from the US Cardiovascular Health Study (CHS) and 915 participants from the Dutch Longitudinal Aging Study Amsterdam (LASA) who were dementia-free at baseline, had valid vitamin D measurements, and follow-up memory assessments. The Benton Visual Retention Test (in the CHS) and Rey's Auditory Verbal Learning Test (in the LASA) were used to assess visual and verbal memory, respectively. RESULTS In the CHS, those moderately and severely deficient in serum 25(OH)D changed -0.03 SD (95% CI: -0.06 to 0.01) and -0.10 SD (95% CI: -0.19 to -0.02) per year respectively in visual memory compared to those sufficient (p = 0.02). In the LASA, moderate and severe deficiency in serum 25(OH)D was associated with a mean change of 0.01 SD (95% CI: -0.01 to 0.02) and -0.01 SD (95% CI: -0.04 to 0.02) per year respectively in verbal memory compared to sufficiency (p = 0.34). CONCLUSIONS Our findings suggest an association between severe vitamin D deficiency and visual memory decline but no association with verbal memory decline. They warrant further investigation in prospective studies assessing different memory subtypes.
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Affiliation(s)
| | - Maya Soni
- University of Exeter Medical School, Exeter, UK
| | - Thomas J. Littlejohns
- University of Exeter Medical School, Exeter, UK
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, UK
| | | | - Natasja M. van Schoor
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Dorly J. H. Deeg
- Department of Epidemiology and Biostatistics, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- Department of Psychiatry, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Hannie Comijs
- Department of Psychiatry, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Paulo H. M. Chaves
- Benjamin Leon Center for Geriatric Research and Education, Florida International University, Miami, USA
| | - Bryan R. Kestenbaum
- Kidney Research Institute, Division of Nephrology, University of Washington, Seattle, USA
| | - Lewis H. Kuller
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, USA
| | - Oscar L. Lopez
- Department of Neurology and Psychiatry, University of Pittsburgh, Pittsburgh, USA
| | - James T. Becker
- Department of Neurology and Psychiatry, University of Pittsburgh, Pittsburgh, USA
| | - Kenneth M. Langa
- Division of General Medicine, Veterans Affairs Ann Arbor Center for Clinical Management Research, Institute for Social Research, and Institute for Healthcare Policy and Innovation, University of Michigan, all in Ann Arbor, USA
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Williams AJ, Wyatt KM, Williams CA, Logan S, Henley WE. Exploring the Potential of a School Impact on Pupil Weight Status: Exploratory Factor Analysis and Repeat Cross-Sectional Study of the National Child Measurement Programme. PLoS One 2015; 10:e0145128. [PMID: 26700027 PMCID: PMC4699206 DOI: 10.1371/journal.pone.0145128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 11/27/2015] [Indexed: 11/19/2022] Open
Abstract
Schools are common sites for obesity prevention interventions. Although many theories suggest that the school context influences weight status, there has been little empirical research. The objective of this study was to explore whether features of the school context were consistently and meaningfully associated with pupil weight status (overweight or obese). Exploratory factor analysis of routinely collected data on 319 primary schools in Devon, England, was used to identify possible school-based contextual factors. Repeated cross-sectional multilevel analysis of five years (2006/07-2010/11) of data from the National Child Measurement Programme was then used to test for consistent and meaningful associations. Four school-based contextual factors were derived which ranked schools according to deprivation, location, resource and prioritisation of physical activity. None of which were meaningfully and consistently associated with pupil weight status, across the five years. The lack of consistent associations between the factors and pupil weight status suggests that the school context is not inherently obesogenic. In contrast, incorporating findings from education research indicates that schools may be equalising weight status, and obesity prevention research, policy and practice might need to address what is happening outside schools and particularly during the school holidays.
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Affiliation(s)
- Andrew James Williams
- Farr Institute @ Scotland and Scottish Collaboration for Public Health Research and Policy, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, 20 West Richmond Street, Edinburgh EH8 9DX, United Kingdom
- Institute of Health Services Research, University of Exeter Medical School (formerly Peninsula College of Medicine and Dentistry), South Cloisters, St. Luke’s Campus, Exeter EX1 2LU, United Kingdom
- Children’s Health and Exercise Research Centre, Sport and Health Sciences, St. Luke’s Campus, University of Exeter, Exeter, EX1 2LU, United Kingdom
- * E-mail:
| | - Katrina M. Wyatt
- Institute of Health Services Research, University of Exeter Medical School (formerly Peninsula College of Medicine and Dentistry), South Cloisters, St. Luke’s Campus, Exeter EX1 2LU, United Kingdom
| | - Craig A. Williams
- Children’s Health and Exercise Research Centre, Sport and Health Sciences, St. Luke’s Campus, University of Exeter, Exeter, EX1 2LU, United Kingdom
| | - Stuart Logan
- Institute of Health Services Research, University of Exeter Medical School (formerly Peninsula College of Medicine and Dentistry), South Cloisters, St. Luke’s Campus, Exeter EX1 2LU, United Kingdom
| | - William E. Henley
- Institute of Health Services Research, University of Exeter Medical School (formerly Peninsula College of Medicine and Dentistry), College House, St. Luke’s Campus, Exeter EX1 2LU, United Kingdom
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Metcalf BS, Hosking J, Henley WE, Jeffery AN, Mostazir M, Voss LD, Wilkin TJ. Erratum to: Physical activity attenuates the mid-adolescent peak in insulin resistance but by late adolescence the effect is lost: a longitudinal study with annual measures from 9-16 years (EarlyBird 66). Diabetologia 2015; 58:2900. [PMID: 26358581 DOI: 10.1007/s00125-015-3753-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Brad S Metcalf
- Institute of Health Research, University of Exeter Medical School, Exeter, UK.
- Sport and Health Sciences, College of Life and Environmental Sciences, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Joanne Hosking
- Department of Endocrinology and Metabolism, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - William E Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Alison N Jeffery
- Department of Endocrinology and Metabolism, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Mohammod Mostazir
- Wellcome Trust Biomedical Informatics Hub, College of Life and Environmental Sciences (CLES), University of Exeter, Exeter, UK
| | - Linda D Voss
- Department of Endocrinology and Metabolism, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Terence J Wilkin
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
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Metcalf BS, Hosking J, Henley WE, Jeffery AN, Mostazir M, Voss LD, Wilkin TJ. Physical activity attenuates the mid-adolescent peak in insulin resistance but by late adolescence the effect is lost: a longitudinal study with annual measures from 9-16 years (EarlyBird 66). Diabetologia 2015; 58:2699-708. [PMID: 26264061 DOI: 10.1007/s00125-015-3714-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/10/2015] [Indexed: 11/25/2022]
Abstract
AIMS/HYPOTHESIS The aim of this work was to test whether the mid-adolescent peak in insulin resistance (IR) and trends in other metabolic markers are influenced by long-term exposure to physical activity. METHODS Physical activity (7 day ActiGraph accelerometry), HOMA-IR and other metabolic markers (glucose, fasting insulin, HbA1c, lipids and BP) were measured annually from age 9 years to 16 years in 300 children (151 boys) from the EarlyBird study in Plymouth, UK. The activity level of each child was characterised, with 95% reliability, by averaging their eight annual physical activity measures. Age-related trends in IR and metabolic health were analysed by multi-level modelling, with physical activity as the exposure measure (categorical and continuous) and body fat percentage (assessed by dual-energy X-ray absorptiometry) and pubertal status (according to age at peak height velocity and Tanner stage) as covariates. RESULTS The peak in IR at age 12-13 years was 17% lower (p < 0.001) in the more active adolescents independently of body fat percentage and pubertal status. However, this difference diminished progressively over the next 3 years and had disappeared completely by the age of 16 years (e.g. difference was -14% at 14 years, -8% at 15 years and +1% at 16 years; 'physical activity × age(2), interaction, p < 0.01). Triacylglycerol levels in girls (-9.7%, p = 0.05) and diastolic blood pressure in boys (-1.20 mmHg, p = 0.03) tended to be lower throughout adolescence in the more active group. CONCLUSIONS/INTERPRETATION Our finding that physical activity attenuates IR during mid-adolescence may be clinically important. It remains to be established whether the temporary attenuation in IR during this period has implications for the development of diabetes in adolescence and for future metabolic health generally.
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Affiliation(s)
- Brad S Metcalf
- Institute of Health Research, University of Exeter Medical School, Exeter, UK.
- Sport and Health Sciences, College of Life and Environmental Sciences, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Joanne Hosking
- Department of Endocrinology and Metabolism, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - William E Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Alison N Jeffery
- Department of Endocrinology and Metabolism, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Mohammod Mostazir
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Linda D Voss
- Department of Endocrinology and Metabolism, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Terence J Wilkin
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
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Littlejohns TJ, Kos K, Henley WE, Cherubini A, Ferrucci L, Lang IA, Langa KM, Melzer D, Llewellyn DJ. Serum leptin and risk of cognitive decline in elderly italians. J Alzheimers Dis 2015; 44:1231-9. [PMID: 25502764 PMCID: PMC5873309 DOI: 10.3233/jad-141836] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background US studies suggest that leptin, a fat-derived hormone, may be protective against the development of dementia. Objective To investigate the complex relationship between leptin levels and cognitive decline in elderly Italians. Methods We studied circulating fasting leptin levels in 809 elderly adults free from dementia who participated in the prospective Italian population-based InCHIANTI study between 1998 and 2009 (mean follow-up of 8.0 years). Global cognitive decline was defined as a reduction of ≥5 points on the Mini-Mental State Examination (MMSE). Trail-Making Tests A and B were also incorporated, with cognitive decline defined as discontinued testing or the worst 10% of change from baseline. We also investigated whether any association could be explained by midlife weight and whether cognitive decline was associated with changing leptin levels. Results The multivariate adjusted relative risk ([RR]; 95% confidence interval [CI]) of cognitive decline on the MMSE was 0.84 (95% CI 0.73–0.97) in relation to baseline sex-standardized log-leptin levels. High leptin levels showed a non-significant trend toward a reduced risk of decline on the Trail-Making Tests A (RR = 0.85, 95% CI 0.71–1.02) and B (RR = 0.90, 0.79–1.02). Adjusting for midlife weight or change in weight did not alter the pattern of results, and cognitive decline was not associated with changing leptin levels. Conclusions High leptin levels were independently associated with a reduced risk of cognitive decline in elderly Italians.
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Affiliation(s)
| | - Katarina Kos
- The University of Exeter Medical School, Exeter, UK
| | | | | | - Luigi Ferrucci
- National Institute on Aging, National Institutes of Health, Baltimore, Maryland, USA
| | - Iain A Lang
- The University of Exeter Medical School, Exeter, UK
| | - Kenneth M Langa
- The Division of General Medicine, Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, Michigan, USA The Institute for Social Research and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - David Melzer
- The University of Exeter Medical School, Exeter, UK
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Ble A, Masoli JAH, Barry HE, Winder RE, Tavakoly B, Henley WE, Kuchel GA, Valderas JM, Melzer D, Richards SH. Any versus long-term prescribing of high risk medications in older people using 2012 Beers Criteria: results from three cross-sectional samples of primary care records for 2003/4, 2007/8 and 2011/12. BMC Geriatr 2015; 15:146. [PMID: 26542116 PMCID: PMC4635594 DOI: 10.1186/s12877-015-0143-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 10/30/2015] [Indexed: 11/30/2022] Open
Abstract
Background High risk medications are commonly prescribed to older US patients. Currently, less is known about high risk medication prescribing in other Western Countries, including the UK. We measured trends and correlates of high risk medication prescribing in a subset of the older UK population (community/institutionalized) to inform harm minimization efforts. Methods Three cross-sectional samples from primary care electronic clinical records (UK Clinical Practice Research Datalink, CPRD) in fiscal years 2003/04, 2007/08 and 2011/12 were taken. This yielded a sample of 13,900 people aged 65 years or over from 504 UK general practices. High risk medications were defined by 2012 Beers Criteria adapted for the UK. Using descriptive statistical methods and regression modelling, prevalence of ‘any’ (drugs prescribed at least once per year) and ‘long-term’ (drugs prescribed all quarters of year) high risk medication prescribing and correlates were determined. Results While polypharmacy rates have risen sharply, high risk medication prevalence has remained stable across a decade. A third of older (65+) people are exposed to high risk medications, but only half of the total prevalence was long-term (any = 38.4 % [95 % CI: 36.3, 40.5]; long-term = 17.4 % [15.9, 19.9] in 2011/12). Long-term but not any high risk medication exposure was associated with older ages (85 years or over). Women and people with higher polypharmacy burden were at greater risk of exposure; lower socio-economic status was not associated. Ten drugs/drug classes accounted for most of high risk medication prescribing in 2011/12. Conclusions High risk medication prescribing has not increased over time against a background of increasing polypharmacy in the UK. Half of patients receiving high risk medications do so for less than a year. Reducing or optimising the use of a limited number of drugs could dramatically reduce high risk medications in older people. Further research is needed to investigate why the oldest old and women are at greater risk. Interventions to reduce high risk medications may need to target shorter and long-term use separately. Electronic supplementary material The online version of this article (doi:10.1186/s12877-015-0143-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alessandro Ble
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, EX2 5DW, UK. .,National Institute for Health Research (NIHR)'School for Public Health Research, ᅟ, UK.
| | - Jane A H Masoli
- Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, Barrack Rd, Exeter, EX2 5DW, UK.
| | - Heather E Barry
- Primary Care, Institute of Health Research, University of Exeter Medical School, Smeall Building, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - Rachel E Winder
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Smeall Building, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - Behrooz Tavakoly
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, EX2 5DW, UK.
| | - William E Henley
- Health Statistics, Institute of Health Research, University of Exeter Medical School, College House, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - George A Kuchel
- UConn Center on Aging, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06030-5215, USA.
| | - Jose M Valderas
- Health Services & Policy Research, Institute of Health Research, University of Exeter Medical School, Smeall Building, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - David Melzer
- Epidemiology and Public Health, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Barrack Road, Exeter, EX2 5DW, UK. .,National Institute for Health Research (NIHR)'School for Public Health Research, ᅟ, UK.
| | - Suzanne H Richards
- Primary Care Research Group, Institute of Health Research, University of Exeter Medical School, Smeall Building, St Luke's Campus, Exeter, EX1 2LU, UK.
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Mounce LTA, Barry HE, Calitri R, Henley WE, Campbell J, Roland M, Richards S. Establishing the validity of English GP Patient Survey items evaluating out-of-hours care. BMJ Qual Saf 2015; 25:842-850. [PMID: 26490002 PMCID: PMC5136712 DOI: 10.1136/bmjqs-2015-004215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 07/13/2015] [Accepted: 09/26/2015] [Indexed: 11/26/2022]
Abstract
Background A 2014 national audit used the English General Practice Patient Survey (GPPS) to compare service users’ experience of out-of-hours general practitioner (GP) services, yet there is no published evidence on the validity of these GPPS items. Objectives Establish the construct and concurrent validity of GPPS items evaluating service users’ experience of GP out-of-hours care. Methods Cross-sectional postal survey of service users (n=1396) of six English out-of-hours providers. Participants reported on four GPPS items evaluating out-of-hours care (three items modified following cognitive interviews with service users), and 14 evaluative items from the Out-of-hours Patient Questionnaire (OPQ). Construct validity was assessed through correlations between any reliable (Cochran's α>0.7) scales, as suggested by a principal component analysis of the modified GPPS items, with the ‘entry access’ (four items) and ‘consultation satisfaction’ (10 items) OPQ subscales. Concurrent validity was determined by investigating whether each modified GPPS item was associated with thematically related items from the OPQ using linear regressions. Results The modified GPPS item-set formed a single scale (α=0.77), which summarised the two-component structure of the OPQ moderately well; explaining 39.7% of variation in the ‘entry access’ scores (r=0.63) and 44.0% of variation in the ‘consultation satisfaction’ scores (r=0.66), demonstrating acceptable construct validity. Concurrent validity was verified as each modified GPPS item was highly associated with a distinct set of related items from the OPQ. Conclusions Minor modifications are required for the English GPPS items evaluating out-of-hours care to improve comprehension by service users. A modified question set was demonstrated to comprise a valid measure of service users’ overall satisfaction with out-of-hours care received. This demonstrates the potential for the use of as few as four items in benchmarking providers and assisting services in identifying, implementing and assessing quality improvement initiatives.
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Affiliation(s)
- Luke T A Mounce
- Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Heather E Barry
- Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Raffaele Calitri
- Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - William E Henley
- Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - John Campbell
- Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Martin Roland
- Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Suzanne Richards
- Collaboration for Academic Primary Care (APEx), University of Exeter Medical School, University of Exeter, Exeter, UK
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Kuzma E, Littlejohns TJ, Soni M, Chaves PH, Kestenbaum BR, Kuller LH, Lopez OL, Becker JT, Langa KM, Henley WE, Lang IA, Llewellyn DJ. O2‐03‐01: Vitamin D and decline in global cognition and memory in the cardiovascular health study. Alzheimers Dement 2015. [DOI: 10.1016/j.jalz.2015.07.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | | | - Maya Soni
- University of ExeterExeterUnited Kingdom
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Hardcastle AC, Mounce LTA, Richards SH, Bachmann MO, Clark A, Henley WE, Campbell JL, Melzer D, Steel N. The dynamics of quality: a national panel study of evidence-based standards. Health Services and Delivery Research 2015. [DOI: 10.3310/hsdr03110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundShortfalls in the receipt of recommended health care have been previously reported in England, leading to preventable poor health.ObjectivesTo assess changes over 6 years in the receipt of effective health-care interventions for people aged 50 years or over in England with cardiovascular disease, depression, diabetes or osteoarthritis; to identify how quality varied with participant characteristics; and to compare the distribution of illness burden in the population with the distributions of diagnosis and treatment.Setting and participantsInformation on health-care quality indicators and participant characteristics was collected using face-to-face structured interviews and nurse visits in participants’ homes by the English Longitudinal Study of Ageing in 2004–5, 2006–7, 2008–9 and 2010–11. A total of 16,773 participants aged 50 years or older were interviewed at least once and 5114 were interviewed in all four waves; 5404 reported diagnosis of one or more of four conditions in 2010–11.Main outcome measuresPercentage of indicated health care received by eligible participants for 19 quality indicators: seven for cardiovascular disease, three for depression, five for diabetes and four for osteoarthritis, and condition-level quality indicator achievement, including achievement of a bundle of three diabetes indicators.AnalysisChanges in quality indicator achievement over time and variations in quality with participant characteristics were tested with Pearson’s chi-squared test and logistic regression models. The size of inequality between the hypothetically wealthiest and poorest participants, for illness burden, diagnosis and treatment, was estimated using slope indices of wealth inequality.ResultsAchievement of indicators for cardiovascular disease was 82.7% [95% confidence interval (CI) 79.9% to 85.5%] in 2004–5 and 84.2% (95% CI 82.1% to 86.2%) in 2010–11, for depression 63.3% (95% CI 57.6% to 69.0%) and 59.8% (95% CI 52.4% to 64.3%), for diabetes 76.0% (95% CI 74.1% to 77.8%) and 76.5% (95% CI 74.8% to 78.1%), and for osteoarthritis 31.2% (95% CI 28.5% to 33.8%) and 35.6% (95% CI 34.2% to 37.1%). Achievement of the diabetes care bundle was 67.8% (95% CI 64.5% to 70.9%) in 2010–11. Variations in quality by participant characteristics were generally small. Diabetes indicator achievement was worse in participants with cognitive impairment [odds ratio (OR) 0.5, 95% CI 0.4 to 0.7] and better in those living alone (OR 1.7, 95% CI 1.3 to 2.0). Hypertension care was better for those aged over 74 years (vs. 50–64 years) (OR 3.2, 95% CI 2.0 to 5.3). Osteoarthritis care was better for those with severe (vs. mild) pain (OR 1.8, 95% CI 1.4 to 2.2), limiting illness (OR 1.8, 95% CI 1.5 to 2.1), and obesity (OR 1.6, 95% CI 1.2 to 2.0). Previous non-achievement of the diabetes care bundle was the biggest predictor of non-achievement 2 years later (OR 3.3, 95% CI 2.2 to 4.7). Poorer participants were always more likely than wealthier participants to have illness burden (statistically significant OR 3.9 to 16.0), but not always more likely to be diagnosed or receive treatment (0.2 to 5.3).ConclusionsShortfalls in quality of care for these four conditions have persisted over 6 years, with only half of the level of indicated health care achieved for osteoarthritis, compared with the other three conditions. Quality for osteoarthritis improved slightly over time but remains poor. The relatively high prevalence of specific illness burden in poorer participants was not matched by an equally high prevalence of diagnosis or treatment, suggesting that barriers to equity may exist at the stage at diagnosis. Further research is needed into the association between quality and health system characteristics at the level of clinicians, general practices or hospitals, and regions. Linkage to routinely collected data could provide information on health service characteristics at the individual patient level.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Antonia C Hardcastle
- Population Health and Primary Care Group, Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Luke TA Mounce
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Suzanne H Richards
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - Max O Bachmann
- Population Health and Primary Care Group, Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Allan Clark
- Population Health and Primary Care Group, Norwich Medical School, University of East Anglia, Norfolk, UK
| | - William E Henley
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - John L Campbell
- Primary Care Research Group, University of Exeter Medical School, Exeter, UK
| | - David Melzer
- Epidemiology and Public Health Group, University of Exeter Medical School, Exeter, UK
| | - Nicholas Steel
- Population Health and Primary Care Group, Norwich Medical School, University of East Anglia, Norfolk, UK
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Mounce LTA, Steel N, Hardcastle AC, Henley WE, Bachmann MO, Campbell JL, Clark A, Melzer D, Richards SH. Patient characteristics predicting failure to receive indicated care for type 2 diabetes. Diabetes Res Clin Pract 2015; 107:247-58. [PMID: 25533855 DOI: 10.1016/j.diabres.2014.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 10/01/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
Abstract
AIMS To determine which patient characteristics were associated with failure to receive indicated care for diabetes over time. METHODS English Longitudinal Study of Ageing participants aged 50 or older with diabetes reported receipt of care described by four diabetes quality indicators (QIs) in 2008-9 and 2010-11. Annual checks for glycated haemoglobin (HbA1c), proteinuria and foot examination were assessed as a care bundle (n=907). A further QI (n=759) assessed whether participants with cardiac risk factors were offered ACE inhibitors or angiotensin II receptor blockers (ARBs). Logistic regression modelled associations between failure to receive indicated care in 2010-11 and participants' socio-demographic, lifestyle and health characteristics, diabetes self-management knowledge, health literacy, and previous QI achievement in 2008-9. RESULTS A third of participants (2008-9=32.8%; 2010-11=32.2%) did not receive all annual checks in the care bundle. Nearly half of those eligible were not offered ACE inhibitors/ARBs (2008-9=44.6%; 2010-11=44.5%). Failure to receive a complete care bundle was associated with lower diabetes self-management knowledge (odds ratio (OR) 2.05), poorer cognitive performance (1.78), or having previously received incomplete care (3.32). Participants who were single (OR=2.16), had low health literacy (1.50) or had received incomplete care previously (6.94) were more likely to not be offered ACE inhibitors/ARBs. Increasing age (OR=0.76) or body mass index (OR=0.70) was associated with lower odds of failing to receive this aspect of care. CONCLUSIONS Quality improvement initiatives for diabetes might usefully target patients with previous receipt of incomplete care, poor knowledge of annual diabetes care processes, and poorer cognition and health literacy.
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Affiliation(s)
- L T A Mounce
- Primary Care Research Group and School of Public Health and Epidemiology, University of Exeter Medical School, United Kingdom
| | - N Steel
- Norwich Medical School, University of East Anglia, United Kingdom
| | - A C Hardcastle
- Norwich Medical School, University of East Anglia, United Kingdom
| | - W E Henley
- Health Statistics Research Group, University of Exeter Medical School, United Kingdom
| | - M O Bachmann
- Norwich Medical School, University of East Anglia, United Kingdom
| | - J L Campbell
- Primary Care Research Group, University of Exeter Medical School, United Kingdom
| | - A Clark
- Norwich Medical School, University of East Anglia, United Kingdom
| | - D Melzer
- School of Public Health and Epidemiology, University of Exeter Medical School, United Kingdom
| | - S H Richards
- Primary Care Research Group, University of Exeter Medical School, United Kingdom.
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Abstract
BACKGROUND the oldest old (85+) pose complex medical challenges. Both underdiagnosis and overdiagnosis are claimed in this group. OBJECTIVE to estimate diagnosis, prescribing and hospital admission prevalence from 2003/4 to 2011/12, to monitor trends in medicalisation. DESIGN AND SETTING observational study of Clinical Practice Research Datalink (CPRD) electronic medical records from general practice populations (eligible; n = 27,109) with oversampling of the oldest old. METHODS we identified 18 common diseases and five geriatric syndromes (dizziness, incontinence, skin ulcers, falls and fractures) from Read codes. We counted medications prescribed ≥1 time in all quarters of studied years. RESULTS there were major increases in recorded prevalence of most conditions in the 85+ group, especially chronic kidney disease (stages 3-5: prevalence <1% rising to 36.4%). The proportions of the 85+ group with ≥3 conditions rose from 32.2 to 55.1% (27.1 to 35.1% in the 65-84 year group). Geriatric syndrome trends were less marked. In the 85+ age group the proportion receiving no chronically prescribed medications fell from 29.6 to 13.6%, while the proportion on ≥3 rose from 44.6 to 66.2%. The proportion of 85+ year olds with ≥1 hospital admissions per year rose from 27.6 to 35.4%. CONCLUSIONS there has been a dramatic increase in the medicalisation of the oldest old, evident in increased diagnosis (likely partly due to better record keeping) but also increased prescribing and hospitalisation. Diagnostic trends especially for chronic kidney disease may raise concerns about overdiagnosis. These findings provide new urgency to questions about the appropriateness of multiple diagnostic labelling.
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Affiliation(s)
- David Melzer
- Epidemiology and Public Health, University of Exeter Medical School, Barrack Road, Exeter EX2 5DW, UK
| | - Behrooz Tavakoly
- Epidemiology and Public Health, University of Exeter Medical School, Barrack Road, Exeter EX2 5DW, UK
| | - Rachel E Winder
- Epidemiology and Public Health, University of Exeter Medical School, Smeall Building, St Luke's Campus, Exeter EX1 2LU, UK
| | - Jane A H Masoli
- Epidemiology and Public Health, University of Exeter Medical School, Barrack Road, Exeter EX2 5DW, UK
| | - William E Henley
- Health Statistics Group, University of Exeter Medical School, St Luke's Campus, Exeter EX1 2LU, UK
| | - Alessandro Ble
- Epidemiology and Public Health, University of Exeter Medical School, Barrack Road, Exeter EX2 5DW, UK
| | - Suzanne H Richards
- Primary Care Research Group, University of Exeter Medical School, Smeall Building, St Luke's Campus, Exeter EX1 2LU, UK
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Henley WE, Anderson LJ, Wyatt KM, Nikolaou V, Anderson R, Logan S. The NCS-LSD cohort study: a description of the methods and analyses used to assess the long-term effectiveness of enzyme replacement therapy and substrate reduction therapy in patients with lysosomal storage disorders. J Inherit Metab Dis 2014; 37:939-44. [PMID: 24519353 DOI: 10.1007/s10545-014-9679-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 10/30/2013] [Accepted: 01/20/2014] [Indexed: 11/26/2022]
Abstract
Lysosomal storage disorders (LSDs) comprise more than 50 extremely rare, inherited metabolic diseases resulting from a deficiency of specific lysosomal enzymes required for normal macromolecular metabolism. The National Collaborative Study for Lysosomal Storage Disorders (NCS-LSD), was a longitudinal cohort study which collected prospective and retrospective clinical data, and patient-reported data from adults and children with a confirmed diagnosis of Gaucher disease, Fabry disease, mucopolysaccharidosis type I (MPS I), mucopolysaccharidosis type II (MPS II), Pompe disease and Niemann Pick disease type C (NPC) in the UK. The study aimed to determine the natural history of these conditions and estimate the effectiveness and cost of therapies. Clinical outcomes were chosen to reflect disease progression. Age- and gender-adjusted treatment effects were estimated using generalised linear mixed models. Treated patients contributed data before and during treatment while untreated patients contributed natural history data. A total of 711 adults and children were recruited to this study from the seven LSD treatment centres in England. Data was collected from 2008 to 2011. This paper describes the methods used to collect and analyse clinical data for this study. The clinical findings are reported separately in a series of condition-specific articles in this issue.
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Affiliation(s)
- W E Henley
- Institute of Health Research, University of Exeter Medical School, College House, St Luke's Campus, Exeter, Devon, UK, EX1 2LU,
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Jones AG, Shields BM, Hyde CJ, Henley WE, Hattersley AT. Identifying good responders to glucose lowering therapy in type 2 diabetes: implications for stratified medicine. PLoS One 2014; 9:e111235. [PMID: 25340784 PMCID: PMC4207765 DOI: 10.1371/journal.pone.0111235] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 09/29/2014] [Indexed: 11/24/2022] Open
Abstract
Aims Defining responders to glucose lowering therapy can be important for both clinical care and for the development of a stratified approach to diabetes management. Response is commonly defined by either HbA1c change after treatment or whether a target HbA1c is achieved. We aimed to determine the extent to which the individuals identified as responders and non-responders to glucose lowering therapy, and their characteristics, depend on the response definition chosen. Methods We prospectively studied 230 participants commencing GLP-1 agonist therapy. We assessed participant characteristics at baseline and repeated HbA1c after 3 months treatment. We defined responders (best quartile of response) based on HbA1c change or HbA1c achieved. We assessed the extent to which these methods identified the same individuals and how this affected the baseline characteristics associated with treatment response. Results Different definitions of response identified different participants. Only 39% of responders by one definition were also good responders by the other. Characteristics associated with good response depend on the response definition chosen: good response by HbA1c achieved was associated with low baseline HbA1c (p<0.001), high C-peptide (p<0.001) and shorter diabetes duration (p = 0.01) whereas response defined by HbA1c change was associated with high HbA1c (p<0.001) only. We describe a simple novel method of defining treatment response based on a combination of HbA1c change and HbA1c achieved that defines response groups with similar baseline glycaemia. Conclusions The outcome of studies aiming to identify predictors of treatment response to glucose lowering therapy may depend on how response is defined. Alternative definitions of response should be considered which minimise influence of baseline glycaemia.
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Affiliation(s)
- Angus G. Jones
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
- * E-mail:
| | - Beverley M. Shields
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
| | - Christopher J. Hyde
- Public Health and Epidemiology, University of Exeter Medical School, Exeter, United Kingdom
| | - William E. Henley
- Institute of Health Research, University of Exeter Medical School, Exeter, United Kingdom
| | - Andrew T. Hattersley
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
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Littlejohns TJ, Henley WE, Lang IA, Annweiler C, Beauchet O, Chaves PHM, Fried L, Kestenbaum BR, Kuller LH, Langa KM, Lopez OL, Kos K, Soni M, Llewellyn DJ. Vitamin D and the risk of dementia and Alzheimer disease. Neurology 2014; 83:920-8. [PMID: 25098535 PMCID: PMC4153851 DOI: 10.1212/wnl.0000000000000755] [Citation(s) in RCA: 330] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 05/28/2014] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To determine whether low vitamin D concentrations are associated with an increased risk of incident all-cause dementia and Alzheimer disease. METHODS One thousand six hundred fifty-eight elderly ambulatory adults free from dementia, cardiovascular disease, and stroke who participated in the US population-based Cardiovascular Health Study between 1992-1993 and 1999 were included. Serum 25-hydroxyvitamin D (25(OH)D) concentrations were determined by liquid chromatography-tandem mass spectrometry from blood samples collected in 1992-1993. Incident all-cause dementia and Alzheimer disease status were assessed during follow-up using National Institute of Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association criteria. RESULTS During a mean follow-up of 5.6 years, 171 participants developed all-cause dementia, including 102 cases of Alzheimer disease. Using Cox proportional hazards models, the multivariate adjusted hazard ratios (95% confidence interval [CI]) for incident all-cause dementia in participants who were severely 25(OH)D deficient (<25 nmol/L) and deficient (≥25 to <50 nmol/L) were 2.25 (95% CI: 1.23-4.13) and 1.53 (95% CI: 1.06-2.21) compared to participants with sufficient concentrations (≥50 nmol/L). The multivariate adjusted hazard ratios for incident Alzheimer disease in participants who were severely 25(OH)D deficient and deficient compared to participants with sufficient concentrations were 2.22 (95% CI: 1.02-4.83) and 1.69 (95% CI: 1.06-2.69). In multivariate adjusted penalized smoothing spline plots, the risk of all-cause dementia and Alzheimer disease markedly increased below a threshold of 50 nmol/L. CONCLUSION Our results confirm that vitamin D deficiency is associated with a substantially increased risk of all-cause dementia and Alzheimer disease. This adds to the ongoing debate about the role of vitamin D in nonskeletal conditions.
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Affiliation(s)
- Thomas J Littlejohns
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - William E Henley
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - Iain A Lang
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - Cedric Annweiler
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - Olivier Beauchet
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - Paulo H M Chaves
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - Linda Fried
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - Bryan R Kestenbaum
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - Lewis H Kuller
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - Kenneth M Langa
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - Oscar L Lopez
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - Katarina Kos
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - Maya Soni
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor
| | - David J Llewellyn
- From the University of Exeter Medical School (T.J.L., W.E.H., I.A.L., K.K., M.S., D.J.L.), Exeter, UK; Department of Internal Medicine and Geriatrics (C.A., O.B.), Angers University Hospital, Angers, France; Herbert Wertheim College of Medicine (P.H.M.C.), Florida International University, Miami; Mailman School of Public Health (L.F.), Columbia University, New York; Kidney Research Institute, Division of Nephrology (B.R.K.), University of Washington, Seattle; Departments of Epidemiology (L.H.K.) and Neurology and Psychiatry (O.L.L.), University of Pittsburgh, PA; Division of General Medicine (K.M.L.), Veterans Affairs Ann Arbor Center for Clinical Management Research, Ann Arbor, MI; and the Institute for Social Research and the Institute for Healthcare Policy and Innovation (K.M.L.), University of Michigan, Ann Arbor.
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Steel N, Hardcastle AC, Clark A, Mounce LTA, Bachmann MO, Richards SH, Henley WE, Campbell JL, Melzer D. Self-reported quality of care for older adults from 2004 to 2011: a cohort study. Age Ageing 2014; 43:716-20. [PMID: 25015897 PMCID: PMC4143491 DOI: 10.1093/ageing/afu091] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND little is known about changes in the quality of medical care for older adults over time. OBJECTIVE to assess changes in technical quality of care over 6 years, and associations with participants' characteristics. DESIGN a national cohort survey covering RAND Corporation-derived quality indicators (QIs) in face-to-face structured interviews in participants' households. PARTICIPANTS a total of 5,114 people aged 50 or more in four waves of the English Longitudinal Study of Ageing. METHODS the percentage achievement of 24 QIs in 10 general medical and geriatric clinical conditions was calculated for each time point, and associations with participants' characteristics were estimated using logistic regression. RESULTS participants were eligible for 21,220 QIs. QI achievement for geriatric conditions (cataract, falls, osteoarthritis and osteoporosis) was 41% [95% confidence interval (CI): 38-44] in 2004-05 and 38% (36-39) in 2010-11. Achievement for general medical conditions (depression, diabetes mellitus, hypertension, ischaemic heart disease, pain and cerebrovascular disease) improved from 75% (73-77) in 2004-05 to 80% (79-82) in 2010-11. Achievement ranged from 89% for cerebrovascular disease to 34% for osteoarthritis. Overall achievement was lower for participants who were men, wealthier, infrequent alcohol drinkers, not obese and living alone. CONCLUSION substantial system-level shortfalls in quality of care for geriatric conditions persisted over 6 years, with relatively small and inconsistent variations in quality by participants' characteristics. The relative lack of variation by participants' characteristics suggests that quality improvement interventions may be more effective when directed at healthcare delivery systems rather than individuals.
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Affiliation(s)
- Nick Steel
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | | | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Luke T A Mounce
- Primary Care Research Group, University of Exeter Medical School, Exeter, Devon, UK
| | - Max O Bachmann
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Suzanne H Richards
- Primary Care Research Group, University of Exeter Medical School, Exeter, Devon, UK
| | - William E Henley
- Health Statistics Group, University of Exeter Medical School, Exeter, Devon, UK
| | - John L Campbell
- Primary Care Research Group, University of Exeter Medical School, Exeter, Devon, UK
| | - David Melzer
- Epidemiology and Public Health, University of Exeter Medical School, Barrack Road, Exeter, Devon, UK
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Littlejohns TJ, Kos K, Henley WE, Cherubini A, Ferrucci L, Lang IA, Langa KM, Melzer D, Llewellyn DJ. OP01 Serum leptin and risk of cognitive decline in elderly Italians: a prospective cohort study. Br J Soc Med 2014. [DOI: 10.1136/jech-2014-204726.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Williams AJ, Wyatt KM, Williams CA, Logan S, Henley WE. A repeated cross-sectional study examining the school impact on child weight status. Prev Med 2014; 64:103-7. [PMID: 24732718 PMCID: PMC4070023 DOI: 10.1016/j.ypmed.2014.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 02/26/2014] [Accepted: 04/03/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The aim of this study is to examine whether there is a differential impact of primary schools upon children's weight status. METHODS A repeated cross-sectional study was undertaken using five years (2006/07-2010/11) of National Child Measurement Programme data, comprising 57,976 children (aged 4-5 (Reception) and 10-11 (Year 6) years) from 300 primary schools across Devon, England. Examining each year separately, the schools were ranked according to their observed and residual (having accounted for school and neighbourhood clustering and pupil ethnicity and socioeconomic status) school mean body mass index standard deviation score (BMI-SDS). Subtracting the Reception from the Year 6 mean residuals gave 'value-added' scores for each school which were also ranked. The rankings were compared within and across the years to assess consistency. RESULTS Although pupil BMI-SDS was high, >97% of the variation in BMI-SDS was attributable to environments other than the school. The 'value-added' by each school was only poorly correlated with the observed and residual pupil BMI-SDS; but none of the rankings were consistent across the five years. CONCLUSION The inconsistency of the rankings and the small variation in BMI-SDS at the level of the school suggests that there is no systematic differential impact of primary schools upon pupil weight status.
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Affiliation(s)
- Andrew James Williams
- Institute of Health Research, University of Exeter Medical School (formerly Peninsula College of Medicine and Dentistry), Veysey Building, Salmon Pool Lane, Exeter, Devon EX2 4SG, United Kingdom; Children's Health and Exercise Research Centre, Sport and Health Sciences, College of Life and Environmental Sciences, University of Exeter, St. Luke's Campus, Heavitree Road, Exeter, Devon EX1 2LU, United Kingdom.
| | - Katrina Mary Wyatt
- Institute of Health Research, University of Exeter Medical School (formerly Peninsula College of Medicine and Dentistry), Veysey Building, Salmon Pool Lane, Exeter, Devon EX2 4SG, United Kingdom.
| | - Craig Anthony Williams
- Children's Health and Exercise Research Centre, Sport and Health Sciences, College of Life and Environmental Sciences, University of Exeter, St. Luke's Campus, Heavitree Road, Exeter, Devon EX1 2LU, United Kingdom.
| | - Stuart Logan
- Institute of Health Research, University of Exeter Medical School (formerly Peninsula College of Medicine and Dentistry), Veysey Building, Salmon Pool Lane, Exeter, Devon EX2 4SG, United Kingdom.
| | - William E Henley
- Institute of Health Research, University of Exeter Medical School (formerly Peninsula College of Medicine and Dentistry), Veysey Building, Salmon Pool Lane, Exeter, Devon EX2 4SG, United Kingdom.
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Williams AJ, Henley WE, Williams CA, Hurst AJ, Logan S, Wyatt KM. Systematic review and meta-analysis of the association between childhood overweight and obesity and primary school diet and physical activity policies. Int J Behav Nutr Phys Act 2013; 10:101. [PMID: 23965018 PMCID: PMC3844408 DOI: 10.1186/1479-5868-10-101] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Accepted: 08/16/2013] [Indexed: 11/10/2022] Open
Abstract
Obesity is a major public health concern and there are increasing calls for policy intervention. As obesity and the related health conditions develop during childhood, schools are being seen as important locations for obesity prevention, including multifaceted interventions incorporating policy elements. The objective of this systematic review was to evaluate the effects of policies related to diet and physical activity in schools, either alone, or as part of an intervention programme on the weight status of children aged 4 to 11 years. A comprehensive and systematic search of medical, education, exercise science, and social science databases identified 21 studies which met the inclusion criteria. There were no date, location or language restrictions. The identified studies evaluated a range of either, or both, diet and physical activity related policies, or intervention programmes including such policies, using a variety of observational and experimental designs. The policies were clustered into those which sought to affect diet, those which sought to affect physical activity and those which sought to affect both diet and physical activity to undertake random effects meta-analysis. Within the diet cluster, studies of the United States of America National School Lunch and School Breakfast Programs were analysed separately; however there was significant heterogeneity in the pooled results. The pooled effects of the physical activity, and other diet related policies on BMI-SDS were non-significant. The multifaceted interventions tended to include policy elements related to both diet and physical activity (combined cluster), and although these interventions were too varied to pool their results, significant reductions in weight-related outcomes were demonstrated. The evidence from this review suggests that, when implemented alone, school diet and physical activity related policies appear insufficient to prevent or treat overweight or obesity in children, however, they do appear to have an effect when developed and implemented as part of a more extensive intervention programme. Additional evidence is required before recommendations regarding the focus of policies can be made and therefore, increased effort should be made to evaluate the effect of policies and policy containing intervention programmes upon weight status.
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Affiliation(s)
- Andrew James Williams
- Institute of Health Services Research, University of Exeter Medical School (formerly Peninsula College of Medicine and Dentistry), Veysey Building, Salmon Pool Lane, EX2 4SG, Exeter, Devon, UK.
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Harrison A, Scobie L, Crossan C, Parry R, Johnston P, Stratton J, Dickinson S, Ellis V, Hunter JG, Prescott OR, Madden R, Lin NX, Henley WE, Bendall RP, Dalton HR. Hepatitis E seroprevalence in recipients of renal transplants or haemodialysis in southwest England: a case-control study. J Med Virol 2012; 85:266-71. [PMID: 23169048 DOI: 10.1002/jmv.23463] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 01/05/2023]
Abstract
Locally acquired HEV infection is increasingly recognized in developed countries. Anti-HEV IgG seroprevalence has been shown to be high in haemodialysis patients in a number of previous studies, employing assays of uncertain sensitivity. The aim of this study was to investigate anti-HEV IgG seroprevalence in recipients of haemodialysis and renal transplants compared to a control group using a validated, highly sensitive assay. Eighty-eight patients with functioning renal transplants and 76 receiving chronic haemodialysis were tested for HEV RNA and anti-HEV IgG and IgM. Six hundred seventy controls were tested for anti-HEV IgG. Anti-HEV IgG was positive in 28/76 (36.8%) of haemodialysis and 16/88 (18.2%) of transplant patients. HEV RNA was not found in any patient. 126/670 (18.8%) of control subjects were anti-HEV IgG positive. After adjusting for age and sex, there was a significantly higher anti-HEV IgG seroprevalence amongst haemodialysis patients compared to controls (OR = 1.97, 95% CI = 1.16-3.31, P = 0.01) or transplant recipients (OR = 2.63, 95% CI = 1.18-6.07, P = 0.02). Patients with a functioning transplant showed no difference in anti-HEV IgG seroprevalence compared to controls. The duration of haemodialysis or receipt of blood products were not significant risk factors for HEV IgG positivity. Patients receiving haemodialysis have a higher seroprevalence of anti-HEV IgG than both age- and sex-matched controls and a cohort of renal transplant patients. None of the haemodialysis patients had evidence of chronic infection. The reason haemodialysis patients have a high seroprevalence remains uncertain and merits further study.
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Affiliation(s)
- Alex Harrison
- Department of Nephrology, Royal Cornwall Hospital Truro, Cornwall, United Kingdom
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Melzer D, Gates P, Osborne NJ, Henley WE, Cipelli R, Young A, Money C, McCormack P, Schofield P, Mosedale D, Grainger D, Galloway TS. Urinary bisphenol a concentration and angiography-defined coronary artery stenosis. PLoS One 2012; 7:e43378. [PMID: 22916252 PMCID: PMC3419714 DOI: 10.1371/journal.pone.0043378] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 07/23/2012] [Indexed: 11/30/2022] Open
Abstract
Background Bisphenol A is widely used in food and drinks packaging. There is evidence of associations between raised urinary bisphenol A (uBPA) and increased incidence of reported cardiovascular diagnoses. Methodology/Principal Findings To estimate associations between BPA exposure and angiographically graded coronary atherosclerosis. 591 patients participating in The Metabonomics and Genomics in Coronary Artery Disease (MaGiCAD) study in Cambridgeshire UK, comparing urinary BPA (uBPA) with grades of severity of coronary artery disease (CAD) on angiography. Linear models were adjusted for BMI, occupational social class and diabetes status. Severe (one to three vessel) CAD was present in 385 patients, 86 had intermediate disease (n = 86) and 120 had normal coronary arteries. The (unadjusted) median uBPA concentration was 1.28 ng/mL with normal coronary arteries, and 1.53 ng/mL with severe CAD. Compared to those with normal coronary arteries, uBPA concentration was significantly higher in those with severe CAD (OR per uBPA SD = 5.96 ng/ml OR = 1.43, CI 1.03 to 1.98, p = 0.033), and near significant for intermediate disease (OR = 1.69, CI 0.98 to 2.94, p = 0.061). There was no significant uBPA difference between patients with severe CAD (needing surgery) and the remaining groups combined. Conclusions/Significance BPA exposure was higher in those with severe coronary artery stenoses compared to those with no vessel disease. Larger studies are needed to estimate true dose response relationships. The mechanisms underlying the association remain to be established.
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Affiliation(s)
- David Melzer
- Epidemiology and Public Health Group, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, United Kingdom.
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Melzer D, Osborne NJ, Henley WE, Cipelli R, Young A, Money C, McCormack P, Luben R, Khaw KT, Wareham NJ, Galloway TS. Urinary Bisphenol A Concentration and Risk of Future Coronary Artery Disease in Apparently Healthy Men and Women. Circulation 2012; 125:1482-90. [DOI: 10.1161/circulationaha.111.069153] [Citation(s) in RCA: 208] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David Melzer
- From the Epidemiology and Public Health Group, Peninsula Medical School, University of Exeter, Exeter (D.M.); School of Biosciences, University of Exeter, Exeter (T.S.G., R.C.); School of Computing and Mathematics, University of Plymouth, Plymouth (W.E.H.); European Center for Environment and Human Health, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter (D.M., N.J.O., T.S.G.); Brixham Environmental Laboratory, Brixham (A.Y., C.M., P.M.); Medical Research Council
| | - Nicholas J. Osborne
- From the Epidemiology and Public Health Group, Peninsula Medical School, University of Exeter, Exeter (D.M.); School of Biosciences, University of Exeter, Exeter (T.S.G., R.C.); School of Computing and Mathematics, University of Plymouth, Plymouth (W.E.H.); European Center for Environment and Human Health, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter (D.M., N.J.O., T.S.G.); Brixham Environmental Laboratory, Brixham (A.Y., C.M., P.M.); Medical Research Council
| | - William E. Henley
- From the Epidemiology and Public Health Group, Peninsula Medical School, University of Exeter, Exeter (D.M.); School of Biosciences, University of Exeter, Exeter (T.S.G., R.C.); School of Computing and Mathematics, University of Plymouth, Plymouth (W.E.H.); European Center for Environment and Human Health, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter (D.M., N.J.O., T.S.G.); Brixham Environmental Laboratory, Brixham (A.Y., C.M., P.M.); Medical Research Council
| | - Riccardo Cipelli
- From the Epidemiology and Public Health Group, Peninsula Medical School, University of Exeter, Exeter (D.M.); School of Biosciences, University of Exeter, Exeter (T.S.G., R.C.); School of Computing and Mathematics, University of Plymouth, Plymouth (W.E.H.); European Center for Environment and Human Health, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter (D.M., N.J.O., T.S.G.); Brixham Environmental Laboratory, Brixham (A.Y., C.M., P.M.); Medical Research Council
| | - Anita Young
- From the Epidemiology and Public Health Group, Peninsula Medical School, University of Exeter, Exeter (D.M.); School of Biosciences, University of Exeter, Exeter (T.S.G., R.C.); School of Computing and Mathematics, University of Plymouth, Plymouth (W.E.H.); European Center for Environment and Human Health, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter (D.M., N.J.O., T.S.G.); Brixham Environmental Laboratory, Brixham (A.Y., C.M., P.M.); Medical Research Council
| | - Cathryn Money
- From the Epidemiology and Public Health Group, Peninsula Medical School, University of Exeter, Exeter (D.M.); School of Biosciences, University of Exeter, Exeter (T.S.G., R.C.); School of Computing and Mathematics, University of Plymouth, Plymouth (W.E.H.); European Center for Environment and Human Health, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter (D.M., N.J.O., T.S.G.); Brixham Environmental Laboratory, Brixham (A.Y., C.M., P.M.); Medical Research Council
| | - Paul McCormack
- From the Epidemiology and Public Health Group, Peninsula Medical School, University of Exeter, Exeter (D.M.); School of Biosciences, University of Exeter, Exeter (T.S.G., R.C.); School of Computing and Mathematics, University of Plymouth, Plymouth (W.E.H.); European Center for Environment and Human Health, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter (D.M., N.J.O., T.S.G.); Brixham Environmental Laboratory, Brixham (A.Y., C.M., P.M.); Medical Research Council
| | - Robert Luben
- From the Epidemiology and Public Health Group, Peninsula Medical School, University of Exeter, Exeter (D.M.); School of Biosciences, University of Exeter, Exeter (T.S.G., R.C.); School of Computing and Mathematics, University of Plymouth, Plymouth (W.E.H.); European Center for Environment and Human Health, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter (D.M., N.J.O., T.S.G.); Brixham Environmental Laboratory, Brixham (A.Y., C.M., P.M.); Medical Research Council
| | - Kay-Tee Khaw
- From the Epidemiology and Public Health Group, Peninsula Medical School, University of Exeter, Exeter (D.M.); School of Biosciences, University of Exeter, Exeter (T.S.G., R.C.); School of Computing and Mathematics, University of Plymouth, Plymouth (W.E.H.); European Center for Environment and Human Health, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter (D.M., N.J.O., T.S.G.); Brixham Environmental Laboratory, Brixham (A.Y., C.M., P.M.); Medical Research Council
| | - Nicholas J. Wareham
- From the Epidemiology and Public Health Group, Peninsula Medical School, University of Exeter, Exeter (D.M.); School of Biosciences, University of Exeter, Exeter (T.S.G., R.C.); School of Computing and Mathematics, University of Plymouth, Plymouth (W.E.H.); European Center for Environment and Human Health, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter (D.M., N.J.O., T.S.G.); Brixham Environmental Laboratory, Brixham (A.Y., C.M., P.M.); Medical Research Council
| | - Tamara S. Galloway
- From the Epidemiology and Public Health Group, Peninsula Medical School, University of Exeter, Exeter (D.M.); School of Biosciences, University of Exeter, Exeter (T.S.G., R.C.); School of Computing and Mathematics, University of Plymouth, Plymouth (W.E.H.); European Center for Environment and Human Health, Peninsula College of Medicine and Dentistry, University of Exeter, Exeter (D.M., N.J.O., T.S.G.); Brixham Environmental Laboratory, Brixham (A.Y., C.M., P.M.); Medical Research Council
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MacKichan F, Paterson C, Henley WE, Britten N. Self-care in people with long term health problems: a community based survey. BMC Fam Pract 2011; 12:53. [PMID: 21689455 PMCID: PMC3143929 DOI: 10.1186/1471-2296-12-53] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 06/20/2011] [Indexed: 12/28/2022]
Abstract
BACKGROUND Self-care is a key component of current policies to manage long term conditions. Although most people with long-term health problems care for themselves within lay networks, consultation rates for long-term undifferentiated illness remain high. Promotion of self-care in these individuals requires an understanding of their own self-care practices and needs to be understood in the context of health care pluralism. The aim was to investigate the extent and nature of self-care practices in patients experiencing long term health problems, sources of information used for self-care, and use of other forms of health care (conventional health care and complementary and alternative medicine). METHODS The study involved a cross-sectional community-based survey set in three general practices in South West England: two in urban areas, one in a rural area. Data were collected using a postal questionnaire sent to a random sample of 3,060 registered adult patients. Respondents were asked to indicate which of six long term health problems they were experiencing, and to complete the questionnaire in reference to a single (most bothersome) problem only. RESULTS Of the 1,347 (45% unadjusted response rate) who responded, 583 reported having one or more of the six long term health problems and 572 completed the survey questionnaire. Use of self-care was notably more prevalent than other forms of health care. Nearly all respondents reported using self-care (mean of four self-care practices each). Predictors of high self-care reported in regression analysis included the reported number of health problems, bothersomeness of the health problem and having received a diagnosis. Although GPs were the most frequently used and trusted source of information, their advice was not associated with greater use of self-care. CONCLUSIONS This study reveals both the high level and wide range of self-care practices undertaken by this population. It also highlights the importance of GPs as a source of trusted information and advice. Our findings suggest that in order to increase self-care without increasing consultation rates, GPs and other health care providers may need more resources to help them to endorse appropriate self-care practices and signpost patients to trusted sources of self-care support.
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Affiliation(s)
- Fiona MacKichan
- Institite of Health Services Research, Peninsula Medical School, University of Exeter, Exeter EX2 4SG, UK
| | - Charlotte Paterson
- Institite of Health Services Research, Peninsula Medical School, University of Exeter, Exeter EX2 4SG, UK
| | - William E Henley
- Institite of Health Services Research, Peninsula Medical School, University of Exeter, Exeter EX2 4SG, UK
| | - Nicky Britten
- Institite of Health Services Research, Peninsula Medical School, University of Exeter, Exeter EX2 4SG, UK
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Deaton CM, Brown-Feltner H, Henley WE, Roberts CA, Lekeux P, Schroter RC, Marlin DJ. The effect of inspired gas density on pulmonary artery transmural pressure and exercise induced pulmonary haemorrhage. Equine Vet J 2010:490-4. [PMID: 17402472 DOI: 10.1111/j.2042-3306.2006.tb05593.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
REASONS FOR PERFORMING STUDY Pulmonary capillary stress failure, largely as a result of high pulmonary vascular pressures, has been implicated in the aetiology of EIPH. However, the role of the respiratory system in determining the magnitude of EIPH has received little attention. HYPOTHESIS Horses breathing a gas of greater density than air will exhibit greater transmural pulmonary arterial pressures (TPAP) and more severe EIPH, and horses breathing a gas of lower density than air will exhibit lower TPAP and less severe EIPH, both compared with horses breathing air. METHODS Following a warm-up, 8 Thoroughbred horses were exercised for 1 min at 10, 11 and 12 m/sec (5 degrees incline) breathing air or 21% oxygen/79% helium or 21% oxygen/79% argon in a randomised order. Heart rate, respiratory rate, pulmonary arterial pressure and oesophageal pressure were measured during exercise. Bronchoalveolar lavage fluid (BALF) was collected from the dorsocaudal regions of the left and right lungs 40 min post exercise and red blood cell (RBC) counts were performed. RESULTS The exercise tests induced mild EIPH. Maximum changes in oesophageal pressure were lower on helium-oxygen compared to argon-oxygen (P<0.001). TPAP and median RBC counts did not differ between gas mixtures. BALF RBC counts from the left lung correlated with counts from the right lung (P<0.0001). However BALF RBC counts from the left lung were higher than those from the right lung (P = 0.004). CONCLUSION As alterations in pulmonary arterial and oesophageal pressure caused by changes in inspired gas density were of similar magnitude, TPAP remained unchanged and there was no significant effect on EIPH severity. POTENTIAL RELEVANCE Manipulations that decrease swings in intrapleural pressure may only decrease the degree of EIPH in horses severely affected by the condition.
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Affiliation(s)
- C M Deaton
- Animal Health Trust, Lanwades Park, Kentford, Suffolk, UK
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Melzer D, Rice N, Depledge MH, Henley WE, Galloway TS. Association between serum perfluorooctanoic acid (PFOA) and thyroid disease in the U.S. National Health and Nutrition Examination Survey. Environ Health Perspect 2010; 118:686-92. [PMID: 20089479 PMCID: PMC2866686 DOI: 10.1289/ehp.0901584] [Citation(s) in RCA: 328] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2009] [Accepted: 01/07/2010] [Indexed: 05/03/2023]
Abstract
BACKGROUND Perfluorooctanoic acid (PFOA, also known as C8) and perfluorooctane sulfonate (PFOS) are stable compounds with many industrial and consumer uses. Their persistence in the environment plus toxicity in animal models has raised concern over low-level chronic exposure effects on human health. OBJECTIVES We estimated associations between serum PFOA and PFOS concentrations and thyroid disease prevalence in representative samples of the U.S. general population. METHODS Analyses of PFOA/PFOS versus disease status in the National Health and Nutrition Examination Survey (NHANES) for 1999-2000, 2003-2004, and 2005-2006 included 3,974 adults with measured concentrations for perfluorinated chemicals. Regression models were adjusted for age, sex, race/ethnicity, education, smoking status, body mass index, and alcohol intake. RESULTS The NHANES-weighted prevalence of reporting any thyroid disease was 16.18% (n = 292) in women and 3.06% (n = 69) in men; prevalence of current thyroid disease with related medication was 9.89% (n = 163) in women and 1.88% (n = 46) in men. In fully adjusted logistic models, women with PFOA >or= 5.7 ng/mL [fourth (highest) population quartile] were more likely to report current treated thyroid disease [odds ratio (OR) = 2.24; 95% confidence interval (CI), 1.38-3.65; p = 0.002] compared with PFOA <or= 4.0 ng/mL (quartiles 1 and 2); we found a near significant similar trend in men (OR = 2.12; 95% CI, 0.93-4.82; p = 0.073). For PFOS, in men we found a similar association for those with PFOS >or= 36.8 ng/mL (quartile 4) versus <or= 25.5 ng/mL (quartiles 1 and 2: OR for treated disease = 2.68; 95% CI, 1.03-6.98; p = 0.043); in women this association was not significant. CONCLUSIONS Higher concentrations of serum PFOA and PFOS are associated with current thyroid disease in the U.S. general adult population. More work is needed to establish the mechanisms involved and to exclude confounding and pharmacokinetic explanations.
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Affiliation(s)
| | - Neil Rice
- Epidemiology and Public Health Group and
| | - Michael H. Depledge
- Environment and Human Health Group, Peninsula Medical School, Exeter, United Kingdom
| | - William E. Henley
- School of Mathematics and Statistics, University of Plymouth, Plymouth, United Kingdom
| | - Tamara S. Galloway
- School of Biosciences, University of Exeter, Exeter, United Kingdom
- Address correspondence to T. Galloway, Department of Ecotoxicology, School of Biosciences, Prince of Wales Rd., Exeter EX4 4PS, UK. Telephone: 44-0-1392-263436. Fax: 44-0-1392-263700. E-mail:
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Melzer D, Rice NE, Lewis C, Henley WE, Galloway TS. Association of urinary bisphenol a concentration with heart disease: evidence from NHANES 2003/06. PLoS One 2010; 5:e8673. [PMID: 20084273 PMCID: PMC2800195 DOI: 10.1371/journal.pone.0008673] [Citation(s) in RCA: 374] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Accepted: 12/03/2009] [Indexed: 11/30/2022] Open
Abstract
Background Bisphenol A (BPA) is a high production volume chemical widely used in food and drinks packaging. Associations have previously been reported between urinary BPA concentrations and heart disease, diabetes and liver enzymes in adult participants of the National Health and Nutrition Examination Survey (NHANES) 2003/04. We aimed to estimate associations between urinary BPA concentrations and health measures in NHANES 2005/06 and in data pooled across collection years. Methodology and Findings A cross-sectional analysis of NHANES: subjects were n = 1455 (2003/04) and n = 1493 (2005/06) adults aged 18–74 years, representative of the general adult population of the United States. Regression models were adjusted for age, sex, race/ethnicity, education, income, smoking, BMI, waist circumference, and urinary creatinine concentration. Main outcomes were reported diagnoses of heart attack, coronary heart disease, angina and diabetes and serum liver enzyme levels. Urinary BPA concentrations in 2005/06 (geometric mean 1.79 ng/ml, 95% CI: 1.64 to 1.96) were lower than in 2003/04 (2.49 ng/ml, CI: 2.20 to 2.83, difference p-value = 0.00002). Higher BPA concentrations were associated with coronary heart disease in 2005/06 (OR per z-score increase in BPA = 1.33, 95%CI: 1.01 to 1.75, p = 0.043) and in pooled data (OR = 1.42, CI: 1.17 to 1.72, p = 0.001). Associations with diabetes did not reach significance in 2005/06, but pooled estimates remained significant (OR = 1.24, CI: 1.10 to 1.40, p = 0.001). There was no overall association with gamma glutamyl transferase concentrations, but pooled associations with alkaline phosphatase and lactate dehydrogenase remained significant. Conclusions Higher BPA exposure, reflected in higher urinary concentrations of BPA, is consistently associated with reported heart disease in the general adult population of the USA. Studies to clarify the mechanisms of these associations are urgently needed.
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Affiliation(s)
- David Melzer
- Epidemiology and Public Health Group, Peninsula Medical School, University of Exeter, Exeter, United Kingdom.
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Verheyen KLP, Henley WE, Price JS, Wood JLN. Training-related factors associated with dorsometacarpal disease in young Thoroughbred racehorses in the UK. Equine Vet J 2010; 37:442-8. [PMID: 16163947 DOI: 10.2746/042516405774480085] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
REASONS FOR PERFORMING STUDY Dorsometacarpal disease (DMD) is common in young Thoroughbred (TB) racehorses, often interfering with their training programme. No reports exist on incidence rate or associated risk factors in the UK. OBJECTIVES To estimate the incidence rate of DMD in TB horses in training for flat racing in the UK and identify associated risk factors, particularly in relation to training regimens. METHODS Data were drawn from a large prospective study in which TB horses in 13 training yards were monitored for a period of up to 2 years, recording daily training information and details of musculoskeletal injury, including DMD. The incidence of DMD was calculated and survival analysis performed to determine features of the training regimen related to the risk of disease. RESULTS A total of 335 horses provided 4235 months at risk of DMD. Seventy-nine first episodes were recorded, resulting in an incidence rate of 1.87/100 horse months (95% confidence interval 1.50-2.33). Increasing exercise distances at canter and high speed in short periods (up to 1 month) were associated with an increasing risk of DMD. However, increasing cumulative exercise distances since entering training were associated with a decreasing risk of the disease. CONCLUSIONS The risk of DMD in young TBs decreases with accumulation of distances exercised at canter and high speed; this reflects the adaptive response of the third metacarpal bone to the loads placed upon it. However, increasing exercise distances in short periods (up to 1 month) increases the risk of DMD, probably as a consequence of microdamage and its associated remodelling response, and should therefore be avoided. POTENTIAL RELEVANCE Training regimens for young TBs can be adjusted to prevent the occurrence of DMD. Early but gradual introduction of small amounts of high-speed exercise may be beneficial. Canter exercise should be kept minimal on high-speed work days and large amounts of both cantering and high-speed work per week, 2 weeks or per month should be avoided, particularly during the early stages of training, in order to minimise the risk of DMD.
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Affiliation(s)
- K L P Verheyen
- Epidemiology Unit, Animal Health Trust, Lanwades Park, Kentford, Suffolk CB8 7UU, UK
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Lang IA, Galloway TS, Scarlett A, Henley WE, Depledge M, Wallace RB, Melzer D. Association of urinary bisphenol A concentration with medical disorders and laboratory abnormalities in adults. JAMA 2008; 300:1303-10. [PMID: 18799442 DOI: 10.1001/jama.300.11.1303] [Citation(s) in RCA: 876] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT Bisphenol A (BPA) is widely used in epoxy resins lining food and beverage containers. Evidence of effects in animals has generated concern over low-level chronic exposures in humans. OBJECTIVE To examine associations between urinary BPA concentrations and adult health status. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis of BPA concentrations and health status in the general adult population of the United States, using data from the National Health and Nutrition Examination Survey 2003-2004. Participants were 1455 adults aged 18 through 74 years with measured urinary BPA and urine creatinine concentrations. Regression models were adjusted for age, sex, race/ethnicity, education, income, smoking, body mass index, waist circumference, and urinary creatinine concentration. The sample provided 80% power to detect unadjusted odds ratios (ORs) of 1.4 for diagnoses of 5% prevalence per 1-SD change in BPA concentration, or standardized regression coefficients of 0.075 for liver enzyme concentrations, at a significance level of P < .05. MAIN OUTCOME MEASURES Chronic disease diagnoses plus blood markers of liver function, glucose homeostasis, inflammation, and lipid changes. RESULTS Higher urinary BPA concentrations were associated with cardiovascular diagnoses in age-, sex-, and fully adjusted models (OR per 1-SD increase in BPA concentration, 1.39; 95% confidence interval [CI], 1.18-1.63; P = .001 with full adjustment). Higher BPA concentrations were also associated with diabetes (OR per 1-SD increase in BPA concentration, 1.39; 95% confidence interval [CI], 1.21-1.60; P < .001) but not with other studied common diseases. In addition, higher BPA concentrations were associated with clinically abnormal concentrations of the liver enzymes gamma-glutamyltransferase (OR per 1-SD increase in BPA concentration, 1.29; 95% CI, 1.14-1.46; P < .001) and alkaline phosphatase (OR per 1-SD increase in BPA concentration, 1.48; 95% CI, 1.18-1.85; P = .002). CONCLUSION Higher BPA exposure, reflected in higher urinary concentrations of BPA, may be associated with avoidable morbidity in the community-dwelling adult population.
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Affiliation(s)
- Iain A Lang
- Epidemiology and Public Health Group, Peninsula Medical School, Barrack Rd, Exeter EX2 5DW, UK
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Blissitt KJ, Raisis AL, Adams VJ, Rogers KH, Henley WE, Young LE. The effects of halothane and isoflurane on cardiovascular function in dorsally recumbent horses undergoing surgery. Vet Anaesth Analg 2008; 35:208-19. [DOI: 10.1111/j.1467-2995.2007.00376.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Survival analysis was used to assess risk factors for fatal injuries on UK race courses. This allowed assessment of variation due to temporal horse-level effects, including previous racing intensity and historical distribution of race types, as well as race-level factors. Comparisons were made between measuring survival time as number of days and as number of races to injury from the first race. Two related models were presented for time as number of races to injury: a Cox regression model fitted using partial likelihood, with the Efron approximation to handling ties, and a discrete-time logit model fitted using maximum likelihood. The latter approach had the advantages of being computationally more efficient and enabling the testing of different functional forms for the dependence of hazard on time. Retrospective data were available from all race starts on the 59 courses in Britain from 1990 to the end of 1999, as analysed by . The analysis was conducted on the data for the 47,424 horses that had started racing in the UK: 538,895 starts with 1,228 fatal injuries. Horses starting racing abroad were excluded, but some included horses would have raced abroad at some stage during their racing career. The results for the selected models were broadly consistent with each other and with previously published studies. Steeplechase and hurdle races had a higher risk of fatal injury than flat races (relative hazards 1.5 and 1.7, respectively). Risk increased with the firmness of surface, age and race distance (reaching a plateau at 20 furlongs) and decreased with previous racing intensity (reaching a plateau after seven races run in the last 12 months). Horses running their first race of a new type were also found to be at higher risk (relative hazard 1.5). The main difference between the models for time as number of days and number of races concerned the role of age: age at race was identified as the more important factor in the latter model, whereas, age at first race was more significant in the former model.
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Affiliation(s)
- W E Henley
- Animal Health Trust, Lanwades Park, Kentford, Newmarket, Suffolk CB8 7UU, UK.
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Sparkes AH, Rogers K, Henley WE, Gunn-Moore DA, May JM, Gruffydd-Jones TJ, Bessant C. A questionnaire-based study of gestation, parturition and neonatal mortality in pedigree breeding cats in the UK. J Feline Med Surg 2006; 8:145-57. [PMID: 16442825 DOI: 10.1016/j.jfms.2005.10.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2005] [Indexed: 10/25/2022]
Abstract
This study was based on a convenience-sampling questionnaire study of pedigree cat breeding in the UK. Data were collated for the births of 1,056 litters from 14 different pedigree breeds and 942 different households. Significant relationships between various outcomes and relevant predictors were assessed by multiple linear regression or logistic regression as appropriate. The overall mean gestation length of 65.1 days varied significantly between the breeds (P<0.0001), and larger litter sizes were associated with shorter gestation lengths (P=0.04). The mean litter size of 4.6 kittens also varied significantly according to breed (P<0.0001). The weight of kittens born alive (overall mean 93.5 g) increased with longer gestation lengths (P=0.0003), decreased with larger litter sizes (P<0.0001) and varied between the breeds (P<0.0001). A total of 8.0% of pregnancies resulted in a caesarean section, with a higher risk associated with smaller litter sizes (P=0.002). Although the frequency of caesarean sections varied from 0 to 18.5% between individual breeds, breed itself was not shown to have a significant independent effect on this likelihood. A mean of 7.2% of all the kittens were stillborn, which varied according to breed (P=0.0003), and the risk of a stillborn kitten increased with litter size (P=0.0001), and with the presence of congenital defects in the litter (P=0.0002). The mean kitten mortality between birth and 8 weeks of age was 9.1%, and the majority of these occurred in the first week of life. Parturition intervals varied widely. The duration of first stage of labour was less than 2h in 82.9% of cats. The interval between the birth of the first and last kitten was less than 6h in 85.7%, but more than 48 h in three cats. A maximum of 48 h was recorded between the births of individual kittens in unassisted deliveries.
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Affiliation(s)
- Andrew H Sparkes
- Centre for Small Animal Studies, Animal Health Trust, Lanwades Park, Kentford, Suffolk CB8 7UU, UK.
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