Risk of Infection in Type 1 and Type 2 Diabetes Compared With the General Population: A Matched Cohort Study

OBJECTIVE

We describe in detail the burden of infections in adults with diabetes within a large national population cohort. We also compare infection rates between patients with type 1 and type 2 diabetes mellitus (T1DM and T2DM).

RESEARCH DESIGN AND METHODS

A retrospective cohort study compared 102,493 English primary care patients aged 40-89 years with a diabetes diagnosis by 2008 (n = 5,863 T1DM and n = 96,630 T2DM) with 203,518 age-sex-practice-matched control subjects without diabetes. Infection rates during 2008-2015, compiled from primary care and linked hospital and mortality records, were compared across 19 individual infection categories. These were further summarized as any requiring a prescription or hospitalization or as cause of death. Poisson regression was used to estimate incidence rate ratios (IRRs) between 1) people with diabetes and control subjects and 2) T1DM and T2DM adjusted for age, sex, smoking, BMI, and deprivation.

RESULTS

Compared with control subjects without diabetes, patients with diabetes had higher rates for all infections, with the highest IRRs seen for bone and joint infections, sepsis, and cellulitis. IRRs for infection-related hospitalizations were 3.71 (95% CI 3.27-4.21) for T1DM and 1.88 (95% CI 1.83-1.92) for T2DM. A direct comparison of types confirmed higher adjusted risks for T1DM versus T2DM (death from infection IRR 2.19 [95% CI 1.75-2.74]). We estimate that 6% of infection-related hospitalizations and 12% of infection-related deaths were attributable to diabetes.

CONCLUSIONS

People with diabetes, particularly T1DM, are at increased risk of serious infection, representing an important population burden. Strategies that reduce the risk of developing severe infections and poor treatment outcomes are under-researched and should be explored.

C-reactive protein concentration in children: relationship to adiposity and other cardiovascular risk factors

Whether or not C-reactive protein (CRP) predicts heart disease in adults because it is a marker of damage or atherosclerosis is difficult to assess. In children, there is no confounding with coronary disease or active smoking. We measured CRP in 699 children aged 10-11 years. CRP levels were 47% higher in girls than boys, and rose with age by 15%/year. CRP levels were 270% (95% CI, 155-439%) higher in the top fifth than the bottom fifth of Ponderal index (weight/height(3)). After adjustment, CRP levels remained 104% (95% CI, 23-236%) higher in the 56 children of South Asian origin. CRP was unrelated to: birth weight, height, social class, Helicobacter pylori infection or passive smoke exposure. CRP was correlated with several cardiovascular risk factors, but only fibrinogen (r = 0.33, P = 0.0001), HDL-cholesterol (r = -0.13, P = 0.0006), heart rate (r = 0.12, P = 0.002) and systolic blood pressure (r = 0.08, P = 0.02) remained statistically significant after adjustment. We conclude that adiposity is the major determinant of CRP levels in children while physical fitness has a small independent effect. The strong relationships with fibrinogen and HDL-cholesterol suggest a role for inflammation throughout life in the development of atherosclerosis and cardiovascular disease. Longitudinal studies are needed to determine whether these associations reflect long term elevations of these risk factors in some individuals, or short term fluctuations in different individuals.

Glycemic Control and Risk of Infections Among People With Type 1 or Type 2 Diabetes in a Large Primary Care Cohort Study

OBJECTIVE

Diabetes mellitus (DM) increases the risk of infections, but the effect of better control has not been thoroughly investigated.

RESEARCH DESIGN AND METHODS

With the use of English primary care data, average glycated hemoglobin (HbA_1c) during 2008-2009 was estimated for 85,312 patients with DM ages 40-89 years. Infection rates during 2010-2015 compiled from primary care, linked hospital, and mortality records were estimated across 18 infection categories and further summarized as any requiring a prescription or hospitalization or as cause of death. Poisson regression was used to estimate adjusted incidence rate ratios (IRRs) by HbA_1c categories across all DM, and type 1 and type 2 DM separately. IRRs also were compared with 153,341 age-sex-practice-matched controls without DM. Attributable fractions (AF%) among patients with DM were estimated for an optimal control scenario (HbA_1c 6-7% [42-53 mmol/mol]).

RESULTS

Long-term infection risk rose with increasing HbA_1c for most outcomes. Compared with patients without DM, those with DM and optimal control (HbA_1c 6-7% [42-53 mmol/mol], IRR 1.41 [95% CI 1.36-1.47]) and poor control (≥11% [97 mmol/mol], 4.70 [4.24-5.21]) had elevated hospitalization risks for infection. In patients with type 1 DM and poor control, this risk was even greater (IRR 8.47 [5.86-12.24]). Comparisons within patients with DM confirmed the risk of hospitalization with poor control (2.70 [2.43-3.00]) after adjustment for duration and other confounders. AF% of poor control were high for serious infections, particularly bone and joint (46%), endocarditis (26%), tuberculosis (24%), sepsis (21%), infection-related hospitalization (17%), and mortality (16%).

CONCLUSIONS

Poor glycemic control is powerfully associated with serious infections and should be a high priority.

Mortality associations with long-term exposure to outdoor air pollution in a national English cohort

RATIONALE

Cohort evidence linking long-term exposure to outdoor particulate air pollution and mortality has come largely from the United States. There is relatively little evidence from nationally representative cohorts in other countries.

OBJECTIVES

To investigate the relationship between long-term exposure to a range of pollutants and causes of death in a national English cohort.

METHODS

A total of 835,607 patients aged 40-89 years registered with 205 general practices were followed from 2003-2007. Annual average concentrations in 2002 for particulate matter with a median aerodynamic diameter less than 10 (PM(10)) and less than 2.5 μm (PM(2.5)), nitrogen dioxide (NO(2)), ozone, and sulfur dioxide (SO(2)) at 1 km(2) resolution, estimated from emission-based models, were linked to residential postcode. Deaths (n = 83,103) were ascertained from linkage to death certificates, and hazard ratios (HRs) for all- and cause-specific mortality for pollutants were estimated for interquartile pollutant changes from Cox models adjusting for age, sex, smoking, body mass index, and area-level socioeconomic status markers.

MEASUREMENTS AND MAIN RESULTS

Residential concentrations of all pollutants except ozone were positively associated with all-cause mortality (HR, 1.02, 1.03, and 1.04 for PM(2.5), NO(2), and SO(2), respectively). Associations for PM(2.5), NO(2), and SO(2) were larger for respiratory deaths (HR, 1.09 each) and lung cancer (HR, 1.02, 1.06, and 1.05) but nearer unity for cardiovascular deaths (1.00, 1.00, and 1.04).

CONCLUSIONS

These results strengthen the evidence linking long-term ambient air pollution exposure to increased all-cause mortality. However, the stronger associations with respiratory mortality are not consistent with most US studies in which associations with cardiovascular causes of death tend to predominate.

Health effects of passive smoking. 9. Parental smoking and spirometric indices in children

BACKGROUND

A systematic quantitative review was conducted of the evidence relating parental smoking to spirometric indices in children.

METHODS

An electronic search of the Embase and Medline databases was completed in April 1997 and identified 692 articles from which we included four studies in neonates, 42 cross-sectional studies in school aged children (22 were included in a meta-analysis), and six longitudinal studies of lung function development.

RESULTS

In a pooled analyses of 21 surveys of school aged children the percentage reduction in forced expiratory volume in one second (FEV1) in children exposed to parental smoking compared with those not exposed was 1.4% (95% CI 1.0 to 1.9). Effects were greater on mid expiratory flow rates (5.0% reduction, 95% CI 3.3 to 6.6) and end expiratory flow rates (4.3% reduction, 95% CI 3.1 to 5.5). Adjustment for potential confounding variables had little effect on the estimates. A number of studies reported clear evidence of exposure response. Where exposure was explicitly identified it was usually maternal smoking. Two studies in neonates have reported effects of prenatal exposure to maternal smoking. Of five cross sectional studies that compared effects of perinatal exposure (retrospectively assessed) with current exposure to maternal smoking in later childhood, the three largest concluded that the major effect was in utero or neonatal exposure. Longitudinal studies suggest a small effect of current exposure on growth in lung function, but with some heterogeneity between studies.

CONCLUSIONS

Maternal smoking is associated with small but statistically significant deficits in FEV1 and other spirometric indices in school aged children. This is almost certainly a causal relationship. Much of the effect may be due to maternal smoking during pregnancy.

Are noise and air pollution related to the incidence of dementia? A cohort study in London, England

OBJECTIVE

To investigate whether the incidence of dementia is related to residential levels of air and noise pollution in London.

DESIGN

Retrospective cohort study using primary care data.

SETTING

75 Greater London practices.

PARTICIPANTS

130 978 adults aged 50-79 years registered with their general practices on 1 January 2005, with no recorded history of dementia or care home residence.

PRIMARY AND SECONDARY OUTCOME MEASURES

A first recorded diagnosis of dementia and, where specified, subgroups of Alzheimer's disease and vascular dementia during 2005-2013. The average annual concentrations during 2004 of nitrogen dioxide (NO2), particulate matter with a median aerodynamic diameter ≤2.5 µm (PM2.5) and ozone (O3) were estimated at 20×20 m resolution from dispersion models. Traffic intensity, distance from major road and night-time noise levels (Lnight) were estimated at the postcode level. All exposure measures were linked anonymously to clinical data via residential postcode. HRs from Cox models were adjusted for age, sex, ethnicity, smoking and body mass index, with further adjustments explored for area deprivation and comorbidity.

RESULTS

2181 subjects (1.7%) received an incident diagnosis of dementia (39% mentioning Alzheimer's disease, 29% vascular dementia). There was a positive exposure response relationship between dementia and all measures of air pollution except O3, which was not readily explained by further adjustment. Adults living in areas with the highest fifth of NO2 concentration (>41.5 µg/m3) versus the lowest fifth (<31.9 µg/m3) were at a higher risk of dementia (HR=1.40, 95% CI 1.12 to 1.74). Increases in dementia risk were also observed with PM2.5, PM2.5 specifically from primary traffic sources only and Lnight, but only NO2 and PM2.5 remained statistically significant in multipollutant models. Associations were more consistent for Alzheimer's disease than vascular dementia.

CONCLUSIONS

We have found evidence of a positive association between residential levels of air pollution across London and being diagnosed with dementia, which is unexplained by known confounding factors.

Protection against vertical transmission in bovine neosporosis

In this study we were interested to determine whether infection of cattle prior to pregnancy would afford any protection to the foetus if the dams were challenged with Neospora caninum at mid-gestation. The experiment comprised four groups of cattle: group 1, uninfected controls; group 2, inoculated with N. caninum tachyzoites 6 weeks prior to mating and then challenged with N. caninum at mid-gestation; group 3, naive cattle challenged with N. caninum at mid-gestation and group 4 were infected with N. caninum prior to mating and left unchallenged throughout pregnancy. Positive cell-mediated and humoral immune responses to N. caninum were recorded in groups 2 and 4 prior to pregnancy and in groups 2, 3 and 4 following challenge at mid-gestation. However there was a marked down regulation of the cell-mediated immune response in all groups around mid-gestation. There was a significant increase in rectal temperature response in animals in group 3 compared to group 2 following challenge but no other clinical symptoms of disease were recorded and all cattle proceeded to calving. At calving, pre-colostral blood samples were negative for antibodies to N. caninum in all the calves born to dams in groups 1, 2 and 4. In contrast, all the calves born to dams in group 3 had high levels of specific antibody to N. caninum indicating that they had been exposed to the parasite in utero. At post-mortem N. caninum DNA was detected in CNS, thymus and placental cotyledon samples in calves from group 3. All tissue samples from calves in the other 3 groups were negative for N. caninum DNA with the exception of one calf from group 2 where specific DNA was detected in a sample of spinal cord. These results suggest that the immune response generated in the dams in group 2 prior to pregnancy had protected against vertical transmission of the parasite following challenge at mid-gestation.

Trends in the prevalence of diagnosed atrial fibrillation, its treatment with anticoagulation and predictors of such treatment in UK primary care

OBJECTIVES

To examine trends in the prevalence of diagnosed atrial fibrillation (AF), its treatment with oral anticoagulants between 1994 and 2003, and predictors of anticoagulant treatment in 2003.

METHODS

Analysis of electronic data from 131 general practices (about one million registered patients annually) contributing to the DIN-LINK database.

RESULTS

From 1994 to 2003 the prevalence of "active" AF rose from 0.78% to 1.31% in men and from 0.79% to 1.15% in women. The proportion of patients with AF taking anticoagulants rose from 25% to 53% in men and from 21% to 40% in women. Most others received antiplatelets. The likelihood of receiving anticoagulants was greater for men and with increasing stroke risk. It decreased sharply with age after 75 years. Socioeconomic status, urbanisation and region had no influence. Non-steroidal anti-inflammatory drugs, antiplatelet drugs and ulcer healing drugs were associated with reduced likelihood of receiving anticoagulants, as were peptic ulcers, chronic gut disorders, anaemias, psychoses and poor compliance. Anticoagulant treatment was associated with several cardiovascular co-morbidities and drugs, possibly due to secondary care treatment. Nevertheless, only 56.5% of patients at very high risk of stroke were taking anticoagulants in 2003, whereas 38.2% of patients at low risk of stroke received anticoagulants.

CONCLUSIONS

This study confirms previously observed trends of increasing AF prevalence and warfarin treatment. Many patients who may benefit from anticoagulation still do not receive it, whereas others at lower risk of stroke do. The lower likelihood of women receiving anticoagulants is of particular concern.

Mortality Among Adults With Intellectual Disability in England: Comparisons With the General Population

OBJECTIVES

To describe mortality among adults with intellectual disability in England in comparison with the general population.

METHODS

We conducted a cohort study from 2009 to 2013 using data from 343 general practices. Adults with intellectual disability (n = 16 666; 656 deaths) were compared with age-, gender-, and practice-matched controls (n = 113 562; 1358 deaths).

RESULTS

Adults with intellectual disability had higher mortality rates than controls (hazard ratio [HR] = 3.6; 95% confidence interval [CI] = 3.3, 3.9). This risk remained high after adjustment for comorbidity, smoking, and deprivation (HR = 3.1; 95% CI = 2.7, 3.4); it was even higher among adults with intellectual disability and Down syndrome or epilepsy. A total of 37.0% of all deaths among adults with intellectual disability were classified as being amenable to health care intervention, compared with 22.5% in the general population (HR = 5.9; 95% CI = 5.1, 6.8).

CONCLUSIONS

Mortality among adults with intellectual disability is markedly elevated in comparison with the general population, with more than a third of deaths potentially amenable to health care interventions. This mortality disparity suggests the need to improve access to, and quality of, health care among people with intellectual disability.

Evolution of statin prescribing 1994-2001: a case of agism but not of sexism?

OBJECTIVE

To study trends in the use of lipid lowering drugs in the UK, and to assess which patient factors influence prescribing.

METHODS

Routinely collected computerised medical data were analysed from 142 general practices across England and Wales that provide data for the Doctors' Independent Network database. Subjects included were people aged 35 years or more with treated ischaemic heart disease, averaging annually over 30,000. The temporal trend from 1994 to 2001 in prescription of lipid lowering drugs and daily statin dose and the odds ratios (ORs) for receiving a statin prescription in 1998 were examined.

RESULTS

Lipid lowering drug prescribing increased greatly over time, entirely because of statins, so that in 2001 56.3% of men and 41.1% of women with ischaemic heart disease received lipid lowering drugs. However, 33% of these patients were on a < 20 mg simvastatin daily equivalent. In 1998 the OR for receiving a statin fell from 1 at age 55-64 to 0.64 at 65-74 and 0.16 at 75-84 years. The age effect was similar in those without major comorbidity. Revascularised patients were much more likely to receive a statin than those with angina (OR 3.92, 95% confidence interval (CI) 3.57 to 4.31). Men were more likely to receive a statin than women (OR 1.62, 95% CI 1.54 to 1.71) but this difference disappeared after adjustment for age and severity of disease (OR 1.06). Geographical region had little effect but there was a very weak socioeconomic gradient.

CONCLUSIONS

Although prescribing has increased, many patients who may benefit from lipid lowering drugs either do not receive it or are undertreated, possibly because of lack of awareness of the relative potency of the different statins. Patients with angina and the elderly are less likely to receive treatment that may prevent a coronary event.

Effect of fresh fruit consumption on lung function and wheeze in children

BACKGROUND

Fresh fruit consumption and vitamin C intake have been associated with improved lung function in adults. Whether this is due to enhancement of lung growth, to a reduction in lung function decline, or to protection against bronchospasm is unclear.

METHODS

In a cross-sectional school based survey of 2650 children aged 8-11 from 10 towns in England and Wales the main outcome measure was forced expiratory volume in one second (FEV1) standardised for body size and sex. Exposure was assessed by a food frequency questionnaire to parents and by measurement of plasma levels of vitamin C in a subsample of 278 children.

RESULTS

FEV1 was positively associated with frequency of fresh fruit consumption. After adjustment for possible confounding variables including social class and passive smoking, those who never ate any fresh fruit had an estimated FEV1 some 79 ml (4.3%) lower than those who ate these items more than once a day (95% CI 22 to 136 ml). The association between FEV1 and fruit consumption was stronger in subjects with wheeze than in non-wheezers (p = 0.020 for difference in trend), though wheeze itself was not related to fresh fruit consumption. Frequency of consumption of salads and of green vegetables were both associated with FEV1 but the relationships were weaker than for fresh fruit. Plasma vitamin C levels were unrelated to FEV1 (r = -0.01, p = 0.92) or to wheeze and were only weakly related to fresh fruit consumption (r = 0.13, p = 0.055).

CONCLUSIONS

Fresh fruit consumption appears to have a beneficial effect on lung function in children. Further work is needed to confirm whether the effect is restricted to subjects who wheeze and to identify the specific nutrient involved.

Home environment and severe asthma in adolescence: a population based case-control study

OBJECTIVE

To investigate the effects of the home environment on the risk of severe asthma during adolescence.

DESIGN

A questionnaire based case-control study drawn from a cross sectional survey of allergic diseases among secondary school pupils in Sheffield in 1991.

SUBJECTS

763 children whose parents had reported that over the previous 12 months they had suffered either 12 or more wheezing attacks or a speech limiting attack of wheeze. A further 763 children were frequency matched for age and school class to act as controls. Analysis was restricted to 486 affected children and 475 others born between 1975 and 1980 who had lived at their present address for more than three years.

RESULTS

Independent associations with severe wheeze were seen for non-feather bedding, especially foam pillows (odds ratio 2.78; 95% confidence interval 1.89 to 4.17), and the ownership of furry pets now (1.51; 1.04 to 2.20) and at birth (1.70; 1.20 to 2.40). These estimates were derived from subjects whose parents denied making changes in the bedroom or avoiding having a pet because of allergy. Parental smoking, use of gas for cooking, age of mattress, and mould growth in the child's bedroom were not significantly associated with wheezing.

CONCLUSIONS

Either our study questionnaire failed to detect the avoidance or removal of feather bedding by allergic families or there is some undetermined hazard related to foam pillows. Synthetic bedding and furry pets were both widespread in this population and may represent remediable causes of childhood asthma.

Does β-adrenoceptor blocker therapy improve cancer survival? Findings from a population-based retrospective cohort study

AIMS

To examine the effect of β-adrenoceptor blocker treatment on cancer survival.

METHODS

In a UK primary care database, we compared patients with a new cancer diagnosis receiving β-adrenoceptor blockers regularly (n= 1406) with patients receiving other antihypertensive medication (n= 2056).

RESULTS

Compared with cancer patients receiving other antihypertensive medication, patients receiving β-adrenoceptor blocker therapy experienced slightly poorer survival (HR = 1.18, 95% CI 1.04, 1.33 for all β-adrenoceptor blockers; HR = 1.21, 95% CI 0.94, 1.55 for non-selective β-adrenoceptor blockers). This poorer overall survival was explained by patients with pancreatic and prostate cancer with no evidence of an effect on survival for patients with lung, breast or colorectal cancer. Analysis in a cancer-free matched parallel cohort did not suggest selection bias masked a beneficial effect.

CONCLUSION

Our study does not support the hypothesis that β-adrenoceptor blockers improve survival for common cancers.

Long-term exposure to outdoor air pollution and the incidence of chronic obstructive pulmonary disease in a national English cohort

Objectives

The role of outdoor air pollution in the incidence of chronic obstructive pulmonary disease (COPD) remains unclear. We investigated this question using a large, nationally representative cohort based on primary care records linked to hospital admissions.

Methods

A cohort of 812 063 patients aged 40–89 years registered with 205 English general practices in 2002 without a COPD diagnosis was followed from 2003 to 2007. First COPD diagnoses recorded either by a general practitioner (GP) or on admission to hospital were identified. Annual average concentrations in 2002 for particulate matter with an aerodynamic diameter <10 µm (PM₁₀) and <2.5 µm (PM_2.5), nitrogen dioxide (NO₂), ozone and sulfur dioxide (SO₂) at 1 km² resolution were estimated from emission-based dispersion models. Hazard ratios (HRs) per interquartile range change were estimated from Cox models adjusting for age, sex, smoking, body mass index and area-level deprivation.

Results

16 034 participants (1.92%) received a COPD diagnosis from their GP and 2910 participants (0.35%) were admitted to hospital for COPD. After adjustment, HRs for GP recorded COPD and PM₁₀, PM_2.5 and NO₂ were close to unity, positive for SO₂ (HR=1.07 (95% CI 1.03 to 1.11) per 2.2 µg/m³) and negative for ozone (HR=0.94 (0.89 to 1.00) per 3 µg/m³). For admissions HRs for PM_2.5 and NO₂ remained positive (HRs=1.05 (0.98 to 1.13) and 1.06 (0.98 to 1.15) per 1.9 µg/m³ and 10.7 µg/m³, respectively).

Conclusions

This large population-based cohort study found limited, inconclusive evidence for associations between air pollution and COPD incidence. Further work, utilising improved estimates of air pollution over time and enhanced socioeconomic indicators, is required to clarify the association between air pollution and COPD incidence.

Effects of changes in fresh fruit consumption on ventilatory function in healthy British adults

Cross-sectional studies have shown frequent fresh fruit consumption to be associated with higher lung function in both children and adults. This relationship is investigated longitudinally in a national sample of 2,171 British adults age 18 to 73 initially examined in 1984, who were reexamined 7 yr later, and had no reported history of chronic respiratory disease throughout. Outcome was assessed by change in forced expiratory volume in one second (FEV1) between the two examinations, standardized for age, height, and sex and related to fresh fruit consumption estimated by food frequency questionnaires at both examinations. After adjustment for region, social class, and smoking, changes in fresh fruit consumption levels were positively associated with changes in FEV1 (p = 0.002), highlighted by a more marked fall in FEV1 (107 ml; 95% confidence interval, 36 to 178 ml) in subjects who reduced their fresh fruit consumption the greatest compared with those with no change. In contrast, average levels of fruit intake were not associated with change in FEV1 (p = 0.695). The implication is that the cross-sectional effects of fresh fruit consumption on ventilatory function appear to be reversible and not progressive, such that consistently low levels of fresh fruit intake do not appear to increase lung function decline.

Trends in potentially inappropriate prescribing amongst older UK primary care patients

PURPOSE

To examine trends in UK primary care prescribing of medications potentially inappropriate for older people in the context of published international data.

METHODS

Analysis of routinely collected anonymised computerised patient records in 131 UK general practices (approximately 162,000 registered patients annually aged >or=65 years) providing data to the DIN-LINK database between 1994 and 2003. In each year, we identified patients prescribed drugs classified by the 2003 Beers criteria as potentially inappropriate for older people.

RESULTS

The level of potentially inappropriate prescribing remained steady over time: in 2003 32.2% of patients received any Beers drug, and 20.5% received a drug categorised as potentially "high risk"; percentages had been 32.9% and 21.4% respectively in 1994. In 2003, co-proxamol (93.7/1000 patients), benzodiazepines (52.4/1000 patients) and amitriptyline (45.4/1000, mainly at low doses) were the most frequently prescribed potentially inappropriate drugs. If co-proxamol (now being withdrawn) and low-dose amitriptyline (appropriate for neuropathic pain) are excluded, 24.8% of patients still received a potentially inappropriate prescription in 2003.

CONCLUSIONS

Prescription of potentially inappropriate medication, particularly benzodiazepines, to older people remains at a high level in the UK. Levels were higher than those seen in published data from the Netherlands, however the low rate of co-proxamol prescribing in the Netherlands explains much, but not all, of the difference. Future international comparisons, based on more careful delineation of the criteria, may play a valuable role in pharmaco-vigilance and can identify areas where regulation of prescribing may reduce risks to older patients.

Increased risk of acute cardiovascular events after partner bereavement: a matched cohort study

IMPORTANCE The period immediately after bereavement has been reported as a time of increased risk of cardiovascular events. However, this risk has not been well quantified, and few large population studies have examined partner bereavement. OBJECTIVE To compare the rate of cardiovascular events between older individuals whose partner dies with those of a matched control group of individuals whose partner was still alive on the same day. DESIGN, SETTING, AND PARTICIPANTS Matched cohort study using a UK primary care database containing availale data of 401 general practices from February 2005 through September 2012. In all, 30 447 individuals aged 60 to 89 years at study initiation who experienced partner bereavement during follow-up were matched by age, sex, and general practice with the nonbereaved control group (n = 83 588) at the time of bereavement. EXPOSURES Partner bereavement. MAIN OUTCOMES AND MEASURES The primary outcome was occurrence of a fatal or nonfatal myocardial infarction (MI) or stroke within 30 days of bereavement. Secondary outcomes were non-MI acute coronary syndrome and pulmonary embolism. All outcomes were compared between the groups during prespecified periods after bereavement (30, 90, and 365 days). Incidence rate ratios (IRRs) from a conditional Poisson model were adjusted for age, smoking status, deprivation, and history of cardiovascular disease. RESULTS Within 30 days of their partner's death, 50 of the bereaved group (0.16%) experienced an MI or a stroke compared with 67 of the matched nonbereaved controls (0.08%) during the same period (IRR, 2.20 [95% CI, 1.52-3.15]). The increased risk was seen in bereaved men and women and attenuated after 30 days. For individual outcomes, the increased risk was found separately for MI (IRR, 2.14 [95% CI, 1.20-3.81]) and stroke (2.40 [1.22-4.71]). Associations with rarer events were also seen after bereavement, including elevated risk of non-MI acute coronary syndrome (IRR, 2.20 [95% CI, 1.12-4.29]) and pulmonary embolism (2.37 [1.18-4.75]) in the first 90 days. CONCLUSIONS AND RELEVANCE This study provides further evidence that the death of a partner is associated with a range of major cardiovascular events in the immediate weeks and months after bereavement. Understanding psychosocial factors associated with acute cardiovascular events may provide opportunities for prevention and improved clinical care.

Maternal cotinine level during pregnancy and birthweight for gestational age

BACKGROUND

Recent studies have found that cotinine is a better predictor of birthweight than the number of cigarettes smoked in pregnancy. In this paper we test this hypothesis and use cotinine to explore the effect of environmental tobacco smoke (ETS) on birthweight.

METHODS

In all, 1254 white women were interviewed at booking, 28 and 36 weeks about the number and brand of cigarette smoked. Cotinine was assayed from blood samples taken on the day of interview. The outcome was birthweight for gestational age.

RESULTS

There was good agreement between self-reported smoker/non-smoker status and maternal cotinine with 1.3% women mis-reported as non-smokers at booking, 0.6% and 1.8% mis-reported at 28 and 36 weeks respectively. Among smokers, cotinine was more closely related to birthweight than the number of cigarettes smoked at all three time points (r = -0.25 versus r = -0.16 at booking). A reduction in cotinine between booking and 28 weeks was associated with increased birthweight but the effect was not statistically significant. Among non-smokers the association between birthweight and cotinine was not statistically significant after adjusting for maternal height, parity, sex and gestational age. Difference in mean birthweight between non-smokers in the lower and upper quintiles of cotinine was 0.2% (95% CI: -2.4, 2.8). Pooling the results of 10 studies plus our own gave an estimated difference in mean birthweight between women unexposed and exposed to passive smoke of 31 g (95% CI: 19, 44).

CONCLUSIONS

Cotinine is a better predictor of birthweight than the reported number of cigarettes smoked. If biochemical analysis is impossible, then self-reported smoking habit should be obtained prospectively using a structured approach. Any effect on birthweight of maternal passive smoking during pregnancy is small compared with the effects of maternal active smoking.

The effects of adiposity and weight change on forced expiratory volume decline in a longitudinal study of adults

OBJECTIVE

To investigate whether changes in anthropometric measures are related to lung function decline.

DESIGN

A national 7-y follow up study in Great Britain.

SUBJECTS

3391 adults aged 18-73 y at baseline.

MEASUREMENTS

The primary outcome measure was change in forced expiratory volume in one second (Delta FEV1), adjusted for age, height and sex. This was related to changes in weight, body mass index, waist circumference, hips circumference and waist to hip ratio.

RESULTS

Changes in weight, body mass and waist circumference, adjusted for confounders including mean level, were all associated with changes in FEV1 (P<0.001), with all effects stronger in men than women (P<0.05). Change in waist to hip ratio was related in men (P=0.01), but not in women (P=0.34). A 10 kg weight increase induced an additional fall in FEV1 of 96 ml (95% confidence interval (95% CI 65-127 ml) in men, and 51 ml (95% CI. 27-75 ml) in women. In men, the effect increased with average weight and obesity and was more pronounced in middle age. This phenomenon was not present in women, possibly due to gender differences in weight distribution in later adult life. Smoking did not appear to influence the magnitude of effect in either sex. The detrimental effect of weight gain on FEV1 in subjects that stopped smoking between studies appeared small in comparison to the benefit of smoking cessation.

CONCLUSION

Increases in adult body mass are predictors of FEV1 decline, especially among older and heavier men, where weight reduction may significantly slow lung function decline.

Mortality in older care home residents in England and Wales

BACKGROUND

mortality in UK care homes is not well described.

OBJECTIVE

to describe 1-year mortality and predictors in older care home residents compared with community residents.

METHOD

cohort study using the THIN primary care database with 9,772 care home and 354,306 community residents aged 65-104 years in 293 English and Welsh general practices in 2009.

RESULTS

a total of 2,558 (26.2%) care home and 11,602 (3.3%) community residents died within 1 year. The age and sex standardised mortality ratio for nursing homes was 419 (95% CI: 396-442) and for residential homes was 284 (266-302). Age-related increases in mortality were less marked in care homes than community. Comorbidities and identification as inappropriate for chronic disease management targets predicted mortality in both settings, but associations were weaker in care homes. The number of drug classes prescribed and primary care contact were the strongest clinical predictors of mortality in care homes.

CONCLUSIONS

older care home residents experience high mortality. Age and diagnostic characteristics are weaker predictors of risk of death within care homes than the community. Measures of primary care utilisation may be useful proxies for frailty and improve difficult end of life care decisions in care homes.

Trends in the prevalence and management of diagnosed type 2 diabetes 1994-2001 in England and Wales

BACKGROUND

Type 2 diabetes is an important cause of morbidity and mortality. Its prevalence appears to be increasing. Guidelines exist regarding its management. Recommendations regarding drug therapy have changed. Little is known about the influence of these guidelines and changed recommendations on the actual management of patients with type 2 diabetes. This study aims to document trends in the prevalence, drug treatment and recording of measures related to the management of type 2 diabetes; and to assess whether recommended targets can be met.

METHODS

The population comprised subjects registered between 1994 and 2001 with 74 general practices in England and Wales which routinely contribute to the Doctors' Independent Network database. Approximately 500,000 patients and 10,000 type 2 diabetics were registered in each year.

RESULTS

Type 2 diabetes prevalence rose from 17/1000 in 1994 to 25/1000 in 2001. Drug therapy has changed: use of long acting sulphonylureas is falling while that of short acting sulphonylureas, metformin and newer therapies including glitazones is increasing. Electronic recording of HbA1c, blood pressure, cholesterol and weight have risen steadily, and improvements in control of blood pressure and cholesterol levels have occurred. However, glycaemic control has not improved, and obesity has increased. The percentage with a BMI under 25 kg/m2 fell from 27.0% in 1994 to 19.4% in 2001 (p < 0.001).

CONCLUSION

Prevalence of type 2 diabetes is increasing. Its primary care management has changed in accordance with best evidence. Monitoring has improved, but further improvement is possible. Despite this, glycaemic control has not improved, while the prevalence of obesity in the diabetic population is rising.

Variability in Glycated Hemoglobin and Risk of Poor Outcomes Among People With Type 2 Diabetes in a Large Primary Care Cohort Study

OBJECTIVE

Diabetes guidelines focus on target glycated hemoglobin (HbA_1c) levels. Long-term variability in HbA_1c may be predictive of hospitalization or mortality, but its importance at different average levels or trajectories is unclear.

RESEARCH DESIGN AND METHODS

Using English primary care data, 58,832 patients with type 2 diabetes had HbA_1c average (mean of annual means), variability (coefficient of variation), and trajectory (annual regression slope) estimated during 2006-2009. Hazard ratios (HRs) for mortality and emergency hospitalization during 2010-2015, with adjustment for age, sex, smoking, BMI, duration of diabetes, and deprivation, were estimated using Cox regression. The simultaneous impact of HbA_1c average, variability, and trajectory was estimated using percentiles.

RESULTS

In mutually adjusted models, HbA_1c variability showed a consistent dose-response relationship with all-cause mortality, while average level was only important among individuals in the highest or lowest 10% of the distribution, and trajectory had no independent effect. Individuals with the most unstable HbA_1c (top 10%) were almost twice as likely to die (HR 1.93 [95% CI 1.72-2.16]) than were those with the most stable (bottom 10%)-an association attenuated but not explained by hypoglycemia. For emergency hospitalizations, similar trends were seen except for coronary artery disease (CAD) and ischemic stroke (IS), where increasing average rather than variability was predictive.

CONCLUSIONS

HbA_1c variability was strongly associated with overall mortality and emergency hospitalization and not explained by average HbA_1c or hypoglycemic episodes. Only for CAD and IS hospitalizations was no association found, with average HbA_1c strongly predictive. Targets should focus on both stability and absolute level of HbA_1c.

Relation of caffeine intake and blood caffeine concentrations during pregnancy to fetal growth: prospective population based study

OBJECTIVES

To examine the association of plasma caffeine concentrations during pregnancy with fetal growth and to compare this with relations with reported caffeine intake.

DESIGN

Prospective population based study.

SETTING

District general hospital, inner London.

SUBJECTS

Women booking for delivery between 1982 and 1984. Stored plasma was available for 1,500 women who had provided a blood sample on at least one occasion and for 640 women who had provided a sample on all three occasions (at booking, 28 weeks, and 36 weeks).

MAIN OUTCOME MEASURE

Birth weight adjusted for gestational age, maternal height, parity, and sex of infant. The exposures of interest were reported caffeine consumption and blood caffeine concentration. Cigarette smoking was assessed by blood cotinine concentration.

RESULTS

Caffeine intake showed no changes during pregnancy, but blood caffeine concentrations rose by 75%. Although caffeine intake increased steadily with increasing cotinine concentration above 15 ng/ml, blood caffeine concentrations fell. Caffeine consumption was inversely related to adjusted birth weight, the estimated effect being a 1.3% fall in birth weight for a 1,000 mg per week increase in intake (95% confidence interval 0.5% to 2.1%). The apparent caffeine effect was confined to cigarette smokers, among whom the estimated effect was-1.6%/1000 mg a week (-2.9% to -0.2%) after adjustment for cotinine and -1.3% (-2.7% to 0.1%) after further adjustment for social class and alcohol intake. Adjusted birth weight was unrelated to blood caffeine concentrations overall (P = 0.09, but a positive coefficient), after adjustment for cotinine (P = 0.73), or among current smokers (P = 0.45).

CONCLUSIONS

Smokers consume more caffeine than non-smokers. Blood caffeine concentrations during pregnancy are not related to fetal growth, but caffeine intake is negatively associated with birth weight, with this effect being apparent only in smokers. The effect remains of borderline significance after adjustment for other factors. Prudent advice for pregnant women would be to reduce caffeine intake in conjunction with stopping smoking.

The effect of unexpected bereavement on mortality in older couples

OBJECTIVES

We sought to determine whether unexpected bereavement has a greater impact on mortality in the surviving partner than death of a partner with preexisting chronic disease or disability.

METHODS

In a UK primary care database (The Health Improvement Network), we identified 171,720 couples aged 60 years and older. We compared the rise in mortality in the first year after bereavement in those whose partner died without recorded chronic disease (unexpected bereavement) to those whose deceased partner had a diagnosis of chronic disease (known morbidity).

RESULTS

For unexpected bereavement (13.4% of all bereavements), the adjusted hazard ratio for death in the first year after bereavement was 1.61 (95% confidence interval [CI] = 1.39, 1.86) compared with 1.21 (95% CI = 1.14, 1.30) where the partner had known morbidity. Differences between bereaved groups were significant (P = .001) and present for both men and women.

CONCLUSIONS

Unexpected bereavement has a greater relative mortality impact than bereavement preceded by chronic disease. Our findings highlight the potential value of preparing individuals for the death of a spouse with known morbidity and providing extra support after bereavement for those experiencing sudden unexpected bereavement.