Recent changes to diagnostic criteria for depression in DSM-5 remove the bereavement exclusion, allowing earlier diagnosis following bereavement. Evaluation of the potential effect of this change requires an understanding of existing psychotropic medication prescribing by non-specialists after bereavement.
To describe initiation of psychotropic medication in the first year after partner bereavement.
In a UK primary care database, we identified 21,122 individuals aged 60 and over with partner bereavement and no psychotropic drug use in the previous year. Prescribing (anxiolytic/hypnotic, antidepressant, antipsychotic) after bereavement was compared to age, sex and practice matched controls.
The risks of receiving a new psychotropic prescription within two and twelve months of bereavement were 9.5% (95% CI 9.1 to 9.9%) and 17.9% (17.3 to 18.4%) respectively; an excess risk of initiation in the first year of 12.4% compared to non-bereaved controls. Anxiolytic/hypnotic and antidepressant initiation rates were highest in the first two months. In this period, the hazard ratio for initiation of anxiolytics/hypnotics was 16.7 (95% CI 14.7 to 18.9) and for antidepressants was 5.6 (4.7 to 6.7) compared to non-bereaved controls. 13.3% of those started on anxiolytics/hypnotics within two months continued to receive this drug class at one year. The marked variation in background family practice prescribing of anxiolytics/hypnotics was the strongest determinant of their initiation in the first two months after bereavement.
Almost one in five older people received a new psychotropic drug prescription in the year after bereavement. The early increase and trend in antidepressant use after bereavement suggests some clinicians did not adhere to the bereavement exclusion, with implications for its recent removal in DSM-5. Family practice variation in use of anxiolytics/hypnotics suggests uncertainty over their role in bereavement with the potential for inappropriate long term use.
Comparisons of the same patient data in 2004 and 2006 downloads of the DIN-LINK UK primary care database demonstrated unexpected differences in the rates of coronary heart disease between the datasets. Incidence rates were lower between 1996–2003 in the new (2006) download. Patient record checks demonstrated that coronary heart disease codes had been removed in the new download during the run-up to the new contract. Planners need to be aware of such issues when evaluating trends in CHD or other similar conditions.
coronary heart disease; electronic patient records; primary care database; quality and outcomes framework
Care home residents are vulnerable to the adverse effects of prescribing but there is limited monitoring in the UK.
To compare prescribing quality in care homes in England and Wales with the community and with US nursing homes.
Design and setting
Cross-sectional analysis of a UK primary care database and comparison with the US National Nursing Home Survey including 326 general practices in 2008–2009 in England and Wales, with 10 387 care home and 403 259 community residents aged 65 to 104 years.
Comparison of age- and sex-standardised use of ‘concern’ and common drug groups in the last 90 days and potentially inappropriate prescribing based on a consensus list of medications best avoided in older people (Beers criteria).
Compared to the community, care home residents were more likely to receive ‘concern’ drugs, including benzodiazepines (relative risk (RR) = 2.05, 95% confidence interval (CI) = 1.90 to 2.22), anticholinergic antihistamines (RR = 2.78, 95% CI = 2.38 to 3.23), loop diuretics (RR = 1.47, 95% CI = 1.41 to 1.53), and antipsychotics (RR = 22.7, 95% CI = 20.6 to 24.9). Use of several common drug groups, including laxatives, antidepressants, and antibiotics, was higher, but use of cardiovascular medication was lower. Thirty-three per cent (95% CI = 31.7% to 34.3%) of care home residents in England and Wales received potentially inappropriate medication, compared to 21.4% (95% CI = 20.9% to 21.8%) in the community. The potentially inappropriate prescribing rate in US nursing homes was similar to England and Wales.
Care home prescribing has the potential for improvement. High use of anticholinergic and psychotropic medication may contribute to functional and cognitive decline. The targeting and effectiveness of medication reviews in care homes needs to be improved.
community; inappropriate prescribing; nursing homes; prescribing patterns; primary care
L-ascorbic acid is an essential part of the human diet and has been associated with a wide-range of chronic complex diseases including cardiovascular outcomes. To date, there are no confirmed genetic correlates of circulating levels of L-ascorbic acid.
We aimed to confirm the existence of association between common variation at the SLC23A1 gene locus and circulating levels of L-ascorbic acid.
We employed a two-stage design which used a discovery cohort (the British Women’s Heart and Health Study) and a series of follow-up cohorts and meta-analysis (totalling 15087 participants) to assess the relationship between variation at SLC23A1 and circulating levels of L-ascorbic acid.
In the discovery cohort, variation at rs33972313 was associated with a reduction in circulating levels of L-ascorbic acid (−4.15μmol/L (95%CI −0.49, −7.81), p=0.03 reduction per minor allele). Pooled analysis of the relationship between rs33972313 and circulating L-ascorbic acid across all studies confirmed this, showing that each additional rare allele was associated with a reduction in circulating levels of L-ascorbic acid of −5.98μmol/L (95%CI −8.23, −3.73), p=2.0×10−7 per minor allele.
Work here has identified a genetic variant (rs33972313) in the SLC23A1 vitamin C active transporter locus that is reliably associated with circulating levels of L-ascorbic acid in the general population. This finding has implications more generally for the epidemiological investigation of relationships between circulating L-ascorbic acid and health outcomes.
Vitamin C; genotype; L-ascorbic acid
An increased risk of death in persons who have suffered spousal bereavement has been described in many populations. The impact of modifying factors, such as chronic disease and material circumstances, is less well understood. The authors followed 171,120 couples 60 years of age or older in a United Kingdom primary care database between 2005 and 2010 for an average of 4 years. A total of 26,646 (15.5%) couples experienced bereavement, with mean follow up after bereavement of 2 years. In a model adjusted for age, sex, comorbid conditions at baseline, material deprivation based on area of residence, season, and smoking status, the hazard ratio for mortality in the first year after bereavement was 1.25 (95% confidence interval: 1.18, 1.33). Further adjustment for changes in comorbid conditions throughout follow up did not alter the hazard ratio for bereavement (hazard ratio = 1.27, 95% confidence interval: 1.19, 1.35). The association was strongest in individuals with no significant chronic comorbid conditions throughout follow up (hazard ratio = 1.50, 95% confidence interval: 1.28, 1.77) and in more affluent couples (P = 0.035). In the first year after bereavement, the association between bereavement and death is not primarily mediated through worsening or new onset of chronic disease. Good health and material circumstances do not protect individuals from increased mortality rates after bereavement.
aged; bereavement; comorbid conditions; mortality
Socio-economic position (SEP) and ethnicity influence type 2 diabetes mellitus (T2DM) risk in adults. However, the influence of SEP on emerging T2DM risks in different ethnic groups and the contribution of SEP to ethnic differences in T2DM risk in young people have been little studied. We examined the relationships between SEP and T2DM risk factors in UK children of South Asian, black African-Caribbean and white European origin, using the official UK National Statistics Socio-economic Classification (NS-SEC) and assessed the extent to which NS-SEC explained ethnic differences in T2DM risk factors.
Methods and Findings
Cross-sectional school-based study of 4,804 UK children aged 9–10 years, including anthropometry and fasting blood analytes (response rates 70%, 68% and 58% for schools, individuals and blood measurements). Assessment of SEP was based on parental occupation defined using NS-SEC and ethnicity on parental self-report. Associations between NS-SEC and adiposity, insulin resistance (IR) and triglyceride differed between ethnic groups. In white Europeans, lower NS-SEC status was related to higher ponderal index (PI), fat mass index, IR and triglyceride (increases per NS-SEC decrement [95%CI] were 1.71% [0.75, 2.68], 4.32% [1.24, 7.48], 5.69% [2.01, 9.51] and 3.17% [0.96, 5.42], respectively). In black African-Caribbeans, lower NS-SEC was associated with lower PI (−1.12%; [−2.01, −0.21]), IR and triglyceride, while in South Asians there were no consistent associations between NS-SEC and T2DM risk factors. Adjustment for NS-SEC did not appear to explain ethnic differences in T2DM risk factors, which were particularly marked in high NS-SEC groups.
SEP is associated with T2DM risk factors in children but patterns of association differ by ethnic groups. Consequently, ethnic differences (which tend to be largest in affluent socio-economic groups) are not explained by NS-SEC. This suggests that strategies aimed at reducing social inequalities in T2DM risk are unlikely to reduce emerging ethnic differences in T2DM risk.
UK estimates of age related macular degeneration (AMD) occurrence vary.
To estimate prevalence, number and incidence of AMD by type in the UK population aged ≥50 years.
Age-specific prevalence rates of AMD obtained from a Bayesian meta-analysis of AMD prevalence were applied to UK 2007–2009 population data. Incidence was estimated from modelled age-specific prevalence.
Overall prevalence of late AMD was 2.4% (95% credible interval (CrI) 1.7% to 3.3%), equivalent to 513 000 cases (95% CrI 363 000 to 699 000); estimated to increase to 679 000 cases by 2020. Prevalences were 4.8% aged ≥65 years, 12.2% aged ≥80 years. Geographical atrophy (GA) prevalence rates were 1.3% (95% CrI 0.9% to 1.9%), 2.6% (95% CrI 1.8% to 3.7%) and 6.7% (95% CrI 4.6% to 9.6%); neovascular AMD (NVAMD) 1.2% (95% CrI 0.9% to 1.7%), 2.5% (95% CrI 1.8% to 3.4%) and 6.3% (95% CrI 4.5% to 8.6%), respectively. The estimated number of prevalent cases of late AMD were 60% higher in women versus men (314 000 cases in women, 192 000 men). Annual incidence of late AMD, GA and NVAMD per 1000 women was 4.1 (95% CrI 2.4% to 6.8%), 2.4 (95% CrI 1.5% to 3.9%) and 2.3 (95% CrI 1.4% to 4.0%); in men 2.6 (95% CrI 1.5% to 4.4%), 1.7 (95% CrI 1.0% to 2.8%) and 1.4 (95% CrI 0.8% to 2.4%), respectively. 71 000 new cases of late AMD were estimated per year.
These estimates will guide health and social service provision for those with late AMD and enable estimation of the cost of introducing new treatments.
Prevalence; incidence; AMD; UK; epidemiology; clinical trial
In a national primary care database sample of older people (≥65 years), 81% (83 588/103 821) of community and 58% (1702/2940) of care home residents with diabetes or heart disease had depression case finding recently recorded; 66% (1418/2145) of community and 22% (26/118) of care home residents with a new depression episode had a depression-severity assessment recorded. Age, sex, and higher care home dementia prevalence did not explain these differences. Case finding and assessment of depression need to be improved in older people, particularly care home residents.
depression; homes for the aged; elderly; quality indicators, health care
Background The objective of this study was to examine adiposity patterns in UK South Asian, black African–Caribbean and white European children using a range of adiposity markers. A cross-sectional survey in London, Birmingham and Leicester primary schools was conducted. Weight, height, waist circumference, skinfold thickness values (biceps, triceps, subscapular and suprailiac) were measured. Fat mass was derived from bioimpedance; optimally height-standardized indices were derived for all adiposity markers. Ethnic origin was based on parental self-report. Multilevel models were used to obtain adjusted means and ethnic differences adjusted for gender, age, month, observer and school (fitted as a random effect). A total of 5887 children aged 9–10 years participated (response rate 68%), including 1345 white Europeans, 1523 South Asians and 1570 black African–Caribbeans.
Results Compared with white Europeans, South Asians had a higher sum of all skinfolds and fat mass percentage, and their body mass index (BMI) was lower. South Asians were slightly shorter but use of optimally height-standardized indices did not materially affect these comparisons. At any given fat mass, BMI was lower in South Asians than white Europeans. In similar comparisons, black African–Caribbeans had a lower sum of all skinfolds but a higher fat mass percentage, and their BMI was higher. Black African–Caribbeans were markedly taller. Use of optimally height-standardized indices yielded markedly different findings; sum of skinfolds index was markedly lower, whereas fat mass index and weight-for-height index were similar. At any given fat mass, BMI was similar in black African–Caribbeans and white Europeans.
Conclusions UK South Asian children have higher adiposity levels and black African–Caribbeans have similar or lower adiposity levels when compared with white Europeans. However, these differences are not well represented by comparisons based on BMI, which systematically underestimates adiposity in South Asians, and in black African–Caribbeans it overestimates adiposity because of its association with height.
Ethnicity; South Asian; African–Caribbean; adiposity; obesity; body mass index
To examine the association between cardiovascular risk factors and retinal arteriolar tortuosity in a multiethnic child-population.
Cross sectional study of 986 UK primary-school children of South Asian, black African Caribbean, and white European origin aged 10-11 years. Anthropometric measurements and retinal imaging, were carried out and a fasting blood sample collected. Digital images of retinal arterioles were analysed using a validated semi-automated measure of tortuosity. Associations between tortuosity and cardiometabolic risk factors were analysed using multilevel linear regression, adjusted for gender, age, ethnicity, arteriole branch status, month and school.
Levels of arteriolar tortuosity were similar in boys and girls, and in different ethnic groups. Retinal arteriolar tortuosity was positively associated with levels of triglyceride, total and LDL cholesterol, systolic and diastolic blood pressure. One standard deviation increases in these risk factors were associated with 3.7% (95% CI 1.2, 6.4%), 3.3% (0.9, 5.8%), 3.1% (0.6, 5.6%), 2.0% (−0.3, 4.2%) and 2.3% (0.1, 4.6%) increases in tortuosity respectively. Adiposity, insulin resistance and blood glucose showed no associations with tortuosity.
Established cardiovascular risk factors, strongly linked to coronary heart disease in adulthood, may influence retinal arteriolar tortuosity at the end of the first decade of life.
Retina; arteriolar tortuosity; cardiovascular risk
In children from similar sociodemographic backgrounds attending the same schools, South Asian children were nine times more likely to be myopic and black African Caribbeans three times more likely, compared with white Europeans. Ethnic differences in environmental susceptibility to myopia may be explained by genetics or early life exposures.
Ethnic differences in childhood prevalence of myopia have not been well characterized in the United Kingdom. In this study, ethnic differences in refractive status and ocular biometry were examined in a multiethnic sample of British children.
This was a cross-sectional study of 10- and 11-year-old school children of South Asian, black African Caribbean, and white European ethnic origin. Vision, open-field autorefraction (without cycloplegia), and ocular biometry were measured in each eye. Myopia was defined as spherical equivalent refraction of −0.50 D with unaided vision of 20/30 or worse (in one or both eyes). Ethnic differences in the prevalence of myopia were examined by using logistic regression, and multiple linear regression was used for ethnic differences in ocular biometry. All models were adjusted for age, sex, and clustering within school.
Data were available for 1179 children. The prevalence of myopia was 25.2%, 10.0%, and 3.4%, respectively, in the South Asian, black African Caribbean, and white European children. Adjusted odds ratios (ORs) of myopia compared with the white European children were 8.9 (95% confidence interval [CI] 4.0 to 19.4) in the South Asian and 3.2 (95% CI, 1.4 to 7.2) in black African Caribbean children. Ethnic differences in the prevalence of myopia were largely accounted for by ethnic differences in axial length. The South Asian and black African Caribbean children had longer axial lengths (0.44 mm; 95% CI, 0.30 to 0.57 mm and 0.30 mm; 95% CI, 0.16 to 0.44 mm, respectively).
Among British children exposed to the same schooling environment, the South Asians had the highest prevalence of myopia, followed by the black African Caribbeans compared with the white Europeans. A quarter of British South Asian children were myopic, which is strongly related to increased axial length.
Passive smoke exposure increases the risk of lower respiratory infection (LRI) in infants, but the extensive literature on this association has not been systematically reviewed for nearly ten years. The aim of this paper is to provide an updated systematic review and meta-analysis of studies of the association between passive smoking and LRI, and with diagnostic subcategories including bronchiolitis, in infants aged two years and under.
We searched MEDLINE and EMBASE (to November 2010), reference lists from publications and abstracts from major conference proceedings to identify all relevant publications. Random effect pooled odds ratios (OR) with 95% confidence intervals (CI) were estimated.
We identified 60 studies suitable for inclusion in the meta-analysis. Smoking by either parent or other household members significantly increased the risk of LRI; odds ratios (OR) were 1.22 (95% CI 1.10 to 1.35) for paternal smoking, 1.62 (95% CI 1.38 to 1.89) if both parents smoked, and 1.54 (95% CI 1.40 to 1.69) for any household member smoking. Pre-natal maternal smoking (OR 1.24, 95% CI 1.11 to 1.38) had a weaker effect than post-natal smoking (OR 1.58, 95% CI 1.45 to 1.73). The strongest effect was on bronchiolitis, where the risk of any household smoking was increased by an OR of 2.51 (95% CI 1.96 to 3.21).
Passive smoking in the family home is a major influence on the risk of LRI in infants, and especially on bronchiolitis. Risk is particularly strong in relation to post-natal maternal smoking. Strategies to prevent passive smoke exposure in young children are an urgent public and child health priority.
Background Ethnic differences in physical activity in children in the UK have not been accurately assessed. We made objective measurements of physical activity in 9–10-year-old British children of South Asian, black African–Caribbean and white European origin.
Methods Cross-sectional study of urban primary school children (2006–07). Actigraph-GT1M activity monitors were worn by 2071 children during waking hours on at least 1 full day. Ethnic differences in mean daily activity [counts, counts per minute of registered time (CPM) and steps] were adjusted for age, gender, day of week and month. Multilevel modelling allowed for repeated days within individual and clustering within school.
Results In white Europeans, mean daily counts, CPM and mean daily steps were 394 785, 498 and 10 220, respectively. South Asian and black Caribbean children recorded more registered time per day than white Europeans (34 and 36 min, respectively). Compared with white Europeans, South Asians recorded 18 789 fewer counts [95% confidence interval (CI) 6390–31 187], 41 fewer CPM 95% CI 26–57) and 905 fewer steps (95% CI 624–1187). Black African–Caribbeans recorded 25 359 more counts (95% CI 14 273–36 445), and similar CPM, but fewer steps than white Europeans. Girls recorded less activity than boys in all ethnic groups, with 74 782 fewer counts (95% CI 66 665–82 899), 84 fewer CPM (95% CI 74–95) and 1484 fewer steps (95% CI 1301–1668).
Conclusion British South Asian children have lower objectively measured physical activity levels than European whites and black African–Caribbeans.
Ethnic differences; childhood; physical activity
Treatment with specific beta-blockers reduces mortality and hospitalisation in heart failure.
To describe trends and inequities in beta-blocker prescribing for heart failure.
Design of study
Repeated cross-sectional analysis of a nationally representative primary care database (DIN-LINK).
A total of 152 UK general practices.
Prescribing of beta-blockers between 2000 and 2005 was examined among a yearly average of 7294 patients aged ≥50 years who had actively managed heart failure — defined as a recorded diagnosis of heart failure and two prescriptions of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker during the calendar year. The main outcome was the prescription of a guideline-recommended beta-blocker (bisoprolol, carvedilol, metoprolol, or nebivolol) in the year. Determinants of beta-blocker prescribing were analysed using logistic regression.
Between 2000 and 2005, age-adjusted use of recommended beta-blockers rose from 6.1% to 27.0% in men, and from 4.2% to 21.5% in women. In 2005, younger patients were more likely to be treated; the fully adjusted odds ratio was 4.83 (95% confidence interval = 3.78 to 6.17) for patients aged 60–64 years compared with those aged 85 years. Women and patients living in areas of socioeconomic deprivation were less likely to be treated. In 2005, in addition to treatment with guideline-recommended beta-blockers, a further 11.7% of men and 12.5% of women were prescribed other beta-blockers.
Recommended beta-blocker use has risen in the UK but remains low and inequitable, with many patients still treated with beta-blockers that are not recommended in guidelines. This suggests further improvements in prescribing are still possible.
adrenergic; beta-blockers; equity; heart failure
Higher exposure to outdoor air pollution is associated with increased cardiopulmonary deaths, but there is limited evidence about the association between outdoor air pollution and diagnosed cardiovascular disease. Our study aimed to estimate the size of the association between long term exposure to outdoor air pollution and prevalent cardiovascular disease.
We carried out a cross-sectional analysis of data on more than 19,000 white adults aged 45 and older who participated in three representative surveys of the English population in 1994, 1998 and 2003, examining the relationship between self-reported doctor-diagnosed cardiovascular disease and exposure to outdoor air pollutants using multilevel regression techniques and meta-analysis.
The combined estimates suggested that an increase of 1 μg m-3 in concentration of particulate matter less than 10 microns in diameter was associated with an increase of 2.9% (95% CI -0.6% to 6.5%) in prevalence of cardiovascular disease in men, and an increase of 1.6% (95%CI -2.1% to 5.5%) in women. The year-specific analyses showed strongly positive associations in 2003 between odds of cardiovascular disease in both men and women and exposure to particulate matter but not in 1994 or 1998. We found no consistent associations between exposure to gaseous air pollutants and doctor-diagnosed cardiovascular disease.
The associations of prevalent cardiovascular disease with concentration of particulate matter less than 10 microns in diameter, while only weakly positive, were consistent with the effects reported in cohort studies. The results provide evidence of the size of the association between particulate air pollution and the prevalence of cardiovascular disease but no evidence for an association with gaseous pollutants. We found strongly positive associations between particulate matter and cardiovascular disease in 2003 only, which highlights the importance of replicating findings in more than one population.
To examine long-term changes in environmental tobacco smoke (ETS) exposure in British men between 1978 and 2000, using serum cotinine.
Prospective cohort: British Regional Heart Study.
General practices in 24 towns in England, Wales and Scotland.
Non-smoking men: 2125 studied at baseline [questionnaire (Q1): 1978–80, aged 40–59 years], 3046 studied 20 years later (Q20: 1998–2000, aged 60–79 years) and 1208 studied at both times. Non-smokers were men reporting no current smoking with cotinine < 15 ng/ml at Q1 and/or Q20.
Serum cotinine to assess ETS exposure.
In cross-sectional analysis, geometric mean cotinine level declined from 1.36 ng/ml [95% confidence interval (CI): 1.31, 1.42] at Q1 to 0.19 ng/ml (95% CI: 0.18, 0.19) at Q20. The prevalence of cotinine levels ≤ 0.7 ng/ml [associated with low coronary heart disease (CHD) risk] rose from 27.1% at Q1 to 83.3% at Q20. Manual social class and northern region of residence were associated with higher mean cotinine levels both at Q1 and Q20; older age was associated with lower cotinine level at Q20 only. Among 1208 persistent non-smokers, cotinine fell by 1.47 ng/ml (95% CI: 1.37, 1.57), 86% decline. Absolute falls in cotinine were greater in manual occupational groups, in the Midlands and Scotland compared to southern England, although percentage decline was very similar across groups.
A marked decline in ETS exposure occurred in Britain between 1978 and 2000, which is likely to have reduced ETS-related disease risks appreciably before the introduction of legislation banning smoking in public places.
Cohort study; cotinine; environmental tobacco smoke; tobacco; trend
Physical activity studies in older people experience poor recruitment. We wished to assess the influence of activity levels and health status on recruitment to a physical activity study in older people.
Comparison of participants and non-participants to a physical activity study using accelerometers in patients aged ≥ 65 years registered with a UK primary care centre. Logistic regression was used to calculate odds ratios (OR) of participants in the accelerometer study with various adjustments. Analyses were initially adjusted for age, sex and household clustering; the health variables were then adjusted for physical activity levels and vice versa to look for independent effects.
43%(240/560) participated in the physical activity study. Age had no effect but males were more likely to participate than females OR 1.4(1.1–1.8). 46% (76/164) of non-participants sent the questionnaire returned it. The 240 participants reported greater physical activity than the 76 non-participants on all measures, eg faster walking OR 3.2(1.4–7.7), or 10.4(3.2–33.3) after adjustment for health variables. Participants reported more health problems; this effect became statistically significant after controlling for physical activity, eg disability OR 2.4(1.1–5.1).
Physical activity studies on older primary care patients may experience both a strong bias towards participants being more active and a weaker bias towards participants having more health problems and therefore primary care contact. The latter bias could be advantageous for physical activity intervention studies, where those with health problems need targeting.
Despite high consultation rates, little is known about predictors of primary care use by older people. A survey of patients aged ≥65 years from two London practices included details on physical health and functioning, psychological measures, social support, and socioeconomic measures. The response rate was 75% (1704/2276). We obtained consent to link the survey data to subjects' computerised primary care records for 92% (1565/1704) of responders. Individual factors (physical ill health, anxiety, female sex), social factors (frequent telephone contact with friends or family), and practice factors independently predicted consultation in the year post survey. Although physical ill health was the most important, the other factors had independent effects and may be useful in understanding the increase in consulting by older people.
health services for the aged; medical record linkage; primary care; surveys
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.
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.
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).
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.
Objective To examine the associations between a biomarker of overall passive exposure to tobacco smoke (serum cotinine concentration) and risk of coronary heart disease and stroke.
Design Prospective population based study in general practice (the British regional heart study).
Participants 4729 men in 18 towns who provided baseline blood samples (for cotinine assay) and a detailed smoking history in 1978-80.
Main outcome measure Major coronary heart disease and stroke events (fatal and non-fatal) during 20 years of follow up.
Results 2105 men who said they did not smoke and who had cotinine concentrations < 14.1 ng/ml were divided into four equal sized groups on the basis of cotinine concentrations. Relative hazards (95% confidence intervals) for coronary heart disease in the second (0.8-1.4 ng/ml), third (1.5-2.7 ng/ml), and fourth (2.8-14.0 ng/ml) quarters of cotinine concentration compared with the first (≥ 0.7 ng/ml) were 1.45 (1.01 to 2.08), 1.49 (1.03 to 2.14), and 1.57 (1.08 to 2.28), respectively, after adjustment for established risk factors for coronary heart disease. Hazard ratios (for cotinine 0.8-14.0 ν ≥ 0.7 ng/ml) were particularly increased during the first (3.73, 1.32 to 10.58) and second five year follow up periods (1.95, 1.09 to 3.48) compared with later periods. There was no consistent association between cotinine concentration and risk of stroke.
Conclusion Studies based on reports of smoking in a partner alone seem to underestimate the risks of exposure to passive smoking. Further prospective studies relating biomarkers of passive smoking to risk of coronary heart disease are needed.
Objective To determine whether breast feeding in infancy compared with bottle feeding formula milk is associated with lower mean blood pressure at different ages.
Design Systematic review.
Data sources Embase, Medline, and Web of Science databases.
Study selection Studies showing the effects of feeding in infancy on blood pressure at different ages.
Data extraction Pooled mean differences in blood pressure between breast fed infants and those bottle fed formula milk, based on random effects models.
Data synthesis The pooled mean difference in systolic blood pressure was -1.10 mm Hg (95% confidence interval -1.79 to -0.42 mm Hg) but with significant heterogeneity between estimates (P < 0.001). The difference was largest in studies of < 300 participants (-2.05 mm Hg, -3.30 to -0.80 mm Hg), intermediate in studies of 300-1000 participants (1.13 mm Hg, -2.53 to 0.27 mm Hg), and smallest in studies of > 1000 participants (-0.16 mm Hg, -0.60 to 0.28 mm Hg). An Egger test but not Begg test was statistically significant for publication bias. The difference was unaltered by adjustment for current size and was independent of age at measurement of blood pressure and year of birth. Diastolic blood pressure was not significantly related to type of feeding in infancy.
Conclusions Selective publication of small studies with positive findings may have exaggerated claims that breast feeding in infancy reduces systolic blood pressure in later life. The results of larger studies suggest that feeding in infancy has at most a modest effect on blood pressure, which is of limited clinical or public health importance.
The General Practice Research Database (GPRD) and Doctor's Independent Network Database (DIN), are large electronic primary care databases compiled in the UK during the 1990s. They provide a valuable resource for epidemiological and health services research. GPRD (based on VAMP) presents notes as a series of discrete episodes, whereas DIN is based on a system (MEDITEL) that used a Problem Orientated Medical Record (POMR) which links prescriptions to diagnostic problems. We have examined the implications for research of these different underlying philosophies.
Records of 40,183 children from 141 practices in DIN and 76,310 from 464 practices in GRPD who were followed to age 5 were used to compare the volume of recording of prescribing and diagnostic codes in the two databases. To assess the importance and additional value of the POMR within DIN, the appropriateness of diagnostic linking to skin emollient prescriptions was investigated.
Variation between practices for both the number of days on which prescriptions were issued and diagnoses were recorded was marked in both databases. Mean number of "prescription days" during the first 5 years of life was similar in DIN (19.5) and in GPRD (19.8), but the average number of "diagnostic days" was lower in DIN (15.8) than in GPRD (22.9). Adjustment for linkage increased the average "diagnostic days" to 23.1 in DIN. 32.7% of emollient prescriptions in GPRD appeared with an eczema diagnosis on the same day compared to only 19.4% in DIN; however, 86.4% of prescriptions in DIN were linked to an earlier eczema diagnosis. More specifically 83% of emollient prescriptions appeared under a problem heading of eczema in the 121 practices that were using problem headings satisfactorily.
Prescribing records in DIN and GPRD are very similar, but the usage of diagnostic codes is more parsimonious in DIN because of its POMR structure. Period prevalence rates will be underestimated in DIN unless this structure is taken into account. The advantage of the POMR is that in 121 of 141 practices using problem headings as intended, most prescriptions can be linked to a problem heading providing a specific reason for their issue.
To examine whether British South Asian children differ in insulin resistance, adiposity, and cardiovascular risk profile from white children.
Cross sectional study.
Primary schools in 10 British towns.
British children aged 8 to 11 years (227 South Asian and 3415 white); 73 South Asian and 1287 white children aged 10 and 11 years provided blood samples (half fasting, half after glucose load).
Main outcome measures
Insulin concentrations, anthropometric measures, established cardiovascular risk factors.
Mean ponderal index was lower in South Asian children than in white children (mean difference −0.43 kg/m3, 95% confidence interval −0.13 kg/m3 to −0.73 kg/m3). Mean waist circumferences and waist:hip ratios were similar. Mean insulin concentrations were higher in South Asian children (percentage difference was 53%, 14% to 106%, after fasting and 54%, 19% to 99%, after glucose load), though glucose concentrations were similar. Mean heart rate and triglyceride and fibrinogen concentrations were higher among South Asian children; serum total, low density lipoprotein, and high density lipoprotein cholesterol concentrations were similar in the two groups. Differences in insulin concentrations remained after adjustment for adiposity and other potential confounders. However, the relations between adiposity and insulin concentrations (particularly fasting insulin) were much stronger among South Asian children than among white children.
The tendency to insulin resistance observed in British South Asian adults is apparent in children, in whom it may reflect an increased sensitivity to adiposity. Action to prevent non-insulin dependent diabetes in South Asian adults may need to begin during childhood.
What is already known on this topicCompared with white people British South Asians are at increased risk of coronary heart disease, stroke, and non-insulin dependent diabetesThere is evidence that these conditions originate in early lifeWhat this study addsBritish South Asian children show higher average levels of insulin and insulin resistance than white childrenThese ethnic differences in insulin resistance in childhood are not associated with corresponding differences in adiposity, particularly central adiposityInsulin metabolism seems to be more sensitive to a given degree of adiposity among the South Asian children compared with white childrenThe prevention of insulin resistance and its consequences may need to begin during childhood, particularly in South Asians
To determine whether children's exposure to passive smoking has changed since the late 1980s.
Cross sectional surveys of nationally representative samples of secondary school children carried out between 1988 and 1998 by Office for National Statistics.
Secondary school children aged 11-15.
Main outcome measures
Salivary cotinine concentrations in non-smoking children.
Cotinine concentrations in all non-smoking children almost halved between 1988 and 1998, from a geometric mean of 0.96 (95% confidence interval 0.83 to 1.11) ng/ml in 1988 to 0.52 (0.43 to 0.62) ng/ml in 1998. This reduction was largely due to reductions in exposure in children from non-smoking households and to decreases in the percentage of parents who smoked. Children living with mothers or fathers who smoked experienced little reduction in exposure.
Exposure to passive smoking among children in England has approximately halved since the late 1980s. This reduction is partly explained by the fall in the percentage of both mothers and fathers who smoke and is also likely to reflect reductions of smoking in public places. However, there is only limited evidence that children from smoking households have experienced a reduction in exposure through parents' avoidance of smoking in their presence.