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1.  Maternal depression, antidepressant prescriptions, and congenital anomaly risk in offspring: a population-based cohort study 
Bjog  2014;121(12):1471-1481.
Objective
To estimate risks of major congenital anomaly (MCA) among children of mothers prescribed antidepressants during early pregnancy or diagnosed with depression but without antidepressant prescriptions.
Design
Population-based cohort study.
Setting
Linked UK maternal–child primary care records.
Population
A total of 349 127 singletons liveborn between 1990 and 2009.
Methods
Odds ratios adjusted for maternal sociodemographics and comorbidities (aORs) were calculated for MCAs, comparing women with first-trimester selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs) and women with diagnosed but unmedicated depression, or women without diagnosed depression.
Main outcome measures
Fourteen system-specific MCA groups classified according to the European Surveillance of Congenital Anomalies and five specific heart anomaly groups.
Results
Absolute risks of MCA were 2.7% (95% confidence interval, 95% CI, 2.6–2.8%) in children of mothers without diagnosed depression, 2.8% (95% CI 2.5–3.2%) in children of mothers with unmedicated depression, and 2.7% (95% CI 2.2–3.2%) and 3.1% (95% CI 2.2–4.1%) in children of mothers with SSRIs or TCAs, respectively. Compared with women without depression, MCA overall was not associated with unmedicated depression (aOR 1.07, 95% CI 0.96–1.18), SSRIs (aOR 1.01, 95% CI 0.88–1.17), or TCAs (aOR 1.09, 95% CI 0.87–1.38). Paroxetine was associated with increased heart anomalies (absolute risk 1.4% in the exposed group compared with 0.8% in women without depression; aOR 1.78, 95% CI 1.09–2.88), which decreased marginally when compared with women with diagnosed but unmedicated depression (aOR 1.67, 95% CI 1.00–2.80).
Conclusions
Overall MCA risk did not increase with maternal depression or with antidepressant prescriptions. Paroxetine was associated with increases of heart anomalies, although this could represent a chance finding from a large number of comparisons undertaken.
doi:10.1111/1471-0528.12682
PMCID: PMC4232879  PMID: 24612301
Antidepressants; congenital anomaly; depression; SSRIs; TCAs
2.  A Review of Population-Based Studies on Hypertension in Ghana 
Ghana Medical Journal  2012;46(2 Suppl):4-11.
Summary
Background
Hypertension is becoming a common health problem worldwide with increasing life expectancy and increasing prevalence of risk factors. Epidemiological data on hypertension in Ghana is necessary to guide policy and develop effective interventions.
Methods
A review of population-based studies on hypertension in Ghana was conducted by a search of the PUBMED database, supplemented by a manual search of bibliographies of the identified articles and through the Ghana Medical Journal. A single reviewer extracted data using standard data collection forms.
Results
Eleven studies published on hypertension with surveys conducted between 1973 and 2009 were identified. The prevalence of hypertension was higher in urban than rural areas in studies that covered both types of area and increased with increasing age (prevalence ranging from 19.3% in rural to 54.6% in urban areas). Factors associated with high blood pressure included increasing body mass index, increased salt consumption, family history of hypertension and excessive alcohol intake. The levels of hypertension detection, treatment and control were generally low (control rates ranged from 1.7% to 12.7%).
Conclusion
An increased burden of hypertension should be expected in Ghana as life expectancy increases and with rapid urbanisation. Without adequate detection and control, this will translate into a higher incidence of stroke and other adverse health outcomes for which hypertension is an established risk factor. Prevention and control of hypertension in Ghana is thus imperative and any delays in instituting preventive measures would most likely pose a greater challenge on the already overburdened health system.
PMCID: PMC3645150  PMID: 23661811
hypertension; salt consumption; alcohol intake; urbanization; Ghana
3.  Constituent country inequalities in myocardial infarction incidence and case fatality in men and women in the United Kingdom, 1996–2005 
Background
Understanding myocardial infarction (MI) incidence and case fatality trends across the four UK constituent countries is of importance following devolution of the government of health-care services.
Methods
Retrospective cohort study using a primary care database (5.19 million patients) examining trends in incidence of first MI and 30-day case fatality.
Results
From 1996 to 2005, the incidence of MI decreased in all countries, but reductions were greater in England (men, −3.1%; women, −2.8%) and Wales (men, −3.3%; women, −4.6%) than in Scotland (men, −1.9%; women, −0.6%) and Northern Ireland (men no change, women, −0.8%) (average annual percentage change). Greater reductions in England and Wales than Scotland and Northern Ireland meant a widening of north–south difference in MI incidence over the study period. Downward trends in 30-day case fatality were found in each country but less regional variation was evident (England men, −12.0%, women, −11.0%; Wales men, −18.4%, women, −12.6%; Scotland men, −9.5%, women, −9.0%; Northern Ireland men, −8.6%, women, −13.0%).
Conclusion
From 1996 to 2005, downward trends in the incidence of first MI and 30-day case fatality were evident in each constituent country. Greater improvements in case fatality, compared with incidence, were found within each country.
doi:10.1093/pubmed/fdq049
PMCID: PMC3043643  PMID: 20634202
case fatality; incidence; myocardial infarction; trends; United Kingdom
4.  Incidence of diagnosed polymyalgia rheumatica and temporal arteritis in the United Kingdom, 1990–2001 
Annals of the Rheumatic Diseases  2006;65(8):1093-1098.
Objective
To investigate time trends, geographical variation, and seasonality in the incidence of diagnosis of polymyalgia rheumatica (PMR) and temporal arteritis (TA) in the United Kingdom.
Methods
Analysis of computerised medical records from UK general practices. Participants were registered with a practice contributing to the General Practice Research Database during the period 1990–2001. The main outcome measures were rates of diagnosis by year, age, sex, geographical region, and calendar month.
Results
15 013 people had a first diagnosis of PMR and 3928 a first diagnosis of TA during 17 830 028 person‐years of observation. The age adjusted incidence rate of PMR was 8.4/10 000 person‐years (95% CI 8.3 to 8.6), rising from 6.9/10 000 person‐years in 1990 to 9.3/10 000 in 2001. The age adjusted incidence rate of TA was 2.2/10 000 person‐years (95% CI 2.1 to 2.3) with no increase observed. Both PMR and TA were more common in the south than in the north of the UK, and both were more commonly diagnosed in the summer months.
Conclusions
The explanation for the findings is unclear. Variations in diagnostic practice and accuracy are likely to have contributed in part to the patterns seen. However, the findings are also likely to reflect, at least in part, variations in the incidence of disease. The striking geographical pattern may be partly attributable to a risk factor which is more prevalent in the south and east of the United Kingdom.
doi:10.1136/ard.2005.046912
PMCID: PMC1798240  PMID: 16414971
incidence; polymyalgia rheumatica; temporal arteritis; United Kingdom
6.  Use of nicotine replacement therapy and the risk of acute myocardial infarction, stroke, and death 
Tobacco Control  2005;14(6):416-421.
Objective: To determine whether nicotine replacement therapy (NRT) is associated with an increased risk of acute myocardial infarction, acute stroke, or death.
Design: Self control case series analysis of data from The Health Improvement Network (THIN) to estimate the relative incidence of myocardial infarction and stroke in four 14 day periods before and after the first prescription for NRT.
Setting: THIN is a computerised general practice database.
Subjects: Patients contributing data to THIN.
Interventions: Observational study of NRT.
Main outcomes: Acute myocardial infarction, acute stroke, and death.
Results: 33 247 individuals had been prescribed NRT, of whom 861 had had a myocardial infarction and 506 a stroke. There was a progressive increase in the incidence of first myocardial infarction in the 56 days leading up to the first NRT prescription (overall incidence ratio 5.55, 95% confidence interval (CI) 4.42 to 6.98), but the incidence fell after this time and was not increased in the 56 days after starting NRT (incidence ratio 1.27, 95% CI 0.82 to 1.97). The results were similar for second myocardial infarction and stroke, and for subgroups of people with pre-existing angina and hypertension. There were 960 deaths in our cohort during a mean follow up period of 2.6 years after starting NRT, with no evidence of an increased mortality in the 56 days after the NRT prescription (incidence ratio 0.86, 95% CI 0.60 to 1.23).
Conclusions: The use of NRT is not associated with any increase in the risk of myocardial infarction, stroke, or death.
doi:10.1136/tc.2005.011387
PMCID: PMC1748112  PMID: 16319366
7.  Bupropion and the risk of sudden death: a self-controlled case-series analysis using The Health Improvement Network 
Thorax  2005;60(10):848-850.
Background: Bupropion is an effective smoking cessation therapy but its use in the UK has been limited by concerns that it may increase the risk of sudden death.
Methods: Data for all patients prescribed bupropion within The Health Improvement Network (a computerised general practice database) were extracted and the self-controlled case-series method was used to estimate the relative incidence of death during the first 28 days of treatment. The incidence of seizures, a recognised adverse effect of bupropion, was also investigated during this period.
Results: A total of 9329 individuals had been prescribed bupropion (mean age 44 years, 48% male). The total person-time after the first prescription for bupropion was 17 586 years, and during this time 121 people died. Two people died within the first 28 days of treatment, which was less than expected in comparison with the remaining observation period by an incidence ratio of 0.50 (95% confidence interval (CI) 0.12 to 2.05). Twenty eight people were recorded as having a total of 45 seizures (23 before starting bupropion, two in the first 28 days of treatment, and 20 at a later point). The relative incidence of seizures during the first 28 days of treatment was 3.62 (95% CI 0.87 to 15.09), equivalent to one additional seizure per 6219 first time bupropion users.
Conclusions: Bupropion use is probably associated with an increased risk of seizures, but no evidence was found to suggest that the drug is associated with an increased risk of sudden death.
doi:10.1136/thx.2005.041798
PMCID: PMC1747199  PMID: 16055620
8.  A case control study of age related macular degeneration and use of statins 
The British Journal of Ophthalmology  2005;89(9):1171-1175.
Aims: Age related macular degeneration (AMD) is the leading cause of blindness in industrialised countries. Previous studies have suggested that statins may have a protective effect against the disease; however, existing studies have had limited power to reliably detect or exclude an effect and have produced conflicting results. The authors assessed the risk of AMD associated with the use of statins.
Methods: Population based case control study using the United Kingdom General Practice Research Database. 18 007 people with diagnosed AMD were compared with 86 169 controls matched on age, sex, and general practice. The primary outcome was the odds ratio for the association between exposure to statins and AMD.
Results: The crude odds ratio for the association between any recorded exposure to statins and AMD was 1.32 (95% CI 1.17 to 1.48), but this reduced to 0.93 (95% CI 0.81 to 1.07, p = 0.33) after adjustment for consultation rate, smoking, alcohol intake, body mass index, atherosclerotic disease, hyperlipidaemia, heart failure, diabetes mellitus, hypertension, use of other cardiovascular drugs, and use of fibrates. There was no evidence that the risk varied by dose of statin, duration of use, or that the risk varied for individual statins.
Conclusion: In the short and medium term statin use is not associated with a decreased risk of AMD. Whether subgroups of patients with specific forms of AMD (particularly choroidal neovascularisation) benefit from statin therapy remains a possibility.
doi:10.1136/bjo.2004.064477
PMCID: PMC1772815  PMID: 16113375
age related macular degeneration; statins; case control
9.  Bullous pemphigoid and pemphigus vulgaris—incidence and mortality in the UK: population based cohort study 
BMJ : British Medical Journal  2008;337(7662):160-163.
Objective To determine the incidence of and mortality from bullous pemphigoid and pemphigus vulgaris in the United Kingdom.
Design Retrospective historical cohort study.
Setting Computerised medical records from the health improvement network, a large population based UK general practice database.
Participants Patients with pemphigus vulgaris and bullous pemphigoid diagnostic codes and age, sex, and practice matched controls.
Main outcome measures Incidence and mortality compared with the control population by calendar period, age group, sex, geographical region, and degree of social deprivation.
Results 869 people with bullous pemphigoid and 138 people with pemphigus vulgaris were identified. The median age at presentation for bullous pemphigoid was 80 (range 23-102) years, and 534 (61%) patients were female. The median age at presentation for pemphigus vulgaris was 71 (21-102) years, and 91 (66%) patients were female. Incidences of bullous pemphigoid and pemphigus vulgaris were 4.3 (95% confidence interval 4.0 to 4.6) and 0.7 (0.6 to 0.8) per 100 000 person years. The incidence of bullous pemphigoid increased over time; the average yearly increase was 17% (incidence rate ratio=1.2, 95% confidence interval 1.1 to 1.2). An average yearly increase in incidence of pemphigus vulgaris of 11% (incidence rate ratio=1.1, 1.0 to 1.2) occurred. The risk of death for patients with bullous pemphigoid was twice as great as for controls (adjusted hazard ratio=2.3, 95% confidence interval 2.0 to 2.7). For pemphigus vulgaris, the risk of death was three times greater than for controls (adjusted hazard ratio=3.3, 2.2 to 5.2).
Conclusions Incidences of bullous pemphigoid and pemphigus vulgaris are increasing. The reasons for the changes in incidence are not clearly understood but have implications for identifying causative factors. Both disorders are associated with a high risk of death. Previous estimates may have underestimated the risk of death associated with these diseases.
doi:10.1136/bmj.a180
PMCID: PMC2483869  PMID: 18614511
10.  General population based study of the impact of tricyclic and selective serotonin reuptake inhibitor antidepressants on the risk of acute myocardial infarction 
Heart  2005;91(4):465-471.
Objective: To investigate the impact of tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) on the risk of first acute myocardial infarction (MI).
Design: Case–control analysis and a self controlled case series.
Setting: 644 general practices throughout England, Scotland, Wales, and Northern Ireland.
Patients: Over 60 000 cases of MI and 360 000 age, sex, and practice matched controls randomly selected from the UK General Practice Research Database.
Main outcome measures: Matched odds ratios and incidence rate ratios estimating whether there is an acute or prolonged increased risk of MI after exposure to TCA and SSRI drugs and individual drugs within these families.
Results: Case–control analysis found an initial increased risk of MI after TCA exposure (for example, at 1–7 days after the first dothiepin prescription: odds ratio (OR) 1.90, 95% confidence interval (CI) 1.15 to 3.14) or SSRI exposure (for example, at 1–7 days after first fluoxetine prescription: OR 2.59, 95% CI 1.44 to 4.66). In the self controlled analysis the equivalent risk estimates were an incidence rate ratio of 1.43, 95% CI 0.92 to 2.22 for dothiepin and an incidence rate ratio of 1.66, 95% CI 1.01 to 2.71 for fluoxetine.
Conclusions: Antidepressant prescriptions are associated with an increased risk of MI. The size of these effects is similar for TCA and SSRI exposures; however, the lack of specificity between types of antidepressants and the lower risks found in the self controlled analysis suggest that these associations are more likely due to factors relating to underlying depression and health services utilisation than to specific adverse drug effects.
doi:10.1136/hrt.2004.037457
PMCID: PMC1768803  PMID: 15772201
myocardial infarction; tricyclic antidepressant; TCA; selective serotonin reuptake inhibitor; SSRI; case–control study; self controlled case series
11.  Respiratory symptoms in older people and their association with mortality 
Thorax  2005;60(4):331-334.
Methods: A total of 14 458 people aged 75 years and over participating in a trial of health screening of older people in general practice answered questions on three respiratory symptoms: cough, sputum production, and wheeze. The association of symptoms with mortality was examined for all cause and respiratory causes of death taking account of potential confounders.
Results: Coughing up phlegm in winter mornings had a prevalence of 27.0% (95% confidence interval (CI) 26.8 to 27.2). Those with this symptom had an adjusted hazard ratio for all cause mortality of 1.35 (95% CI 1.21 to 1.50), p<0.001 and for respiratory specific mortality of 2.01 (95% CI 1.66 to 2.41), p<0.001. Phlegm at any time of the day in winter had a prevalence of 16.5% (95% CI 16.3 to 16.7) with hazard ratios for all cause and respiratory specific mortality of 1.28 (95% CI 1.15 to 1.42) and 2.28 (95% CI 1.92 to 2.70), p<0.001. Wheeze or whistling from the chest had a prevalence of 14.3% (95% CI 14.1 to 14.5) with hazard ratios of 1.45 (95% CI 1.31 to 1.61) and 2.86 (95% CI 2.45 to 3.35), p<0.001.
Conclusions: The prevalence of respiratory symptoms is widespread among elderly people and their presence is a strong predictor of mortality.
doi:10.1136/thx.2004.029579
PMCID: PMC1747384  PMID: 15790990
12.  Bullous pemphigoid and pemphigus vulgaris—incidence and mortality in the UK: population based cohort study 
Objective To determine the incidence of and mortality from bullous pemphigoid and pemphigus vulgaris in the United Kingdom.
Design Retrospective historical cohort study.
Setting Computerised medical records from the health improvement network, a large population based UK general practice database.
Participants Patients with pemphigus vulgaris and bullous pemphigoid diagnostic codes and age, sex, and practice matched controls.
Main outcome measures Incidence and mortality compared with the control population by calendar period, age group, sex, geographical region, and degree of social deprivation.
Results 869 people with bullous pemphigoid and 138 people with pemphigus vulgaris were identified. The median age at presentation for bullous pemphigoid was 80 (range 23-102) years, and 534 (61%) patients were female. The median age at presentation for pemphigus vulgaris was 71 (21-102) years, and 91 (66%) patients were female. Incidences of bullous pemphigoid and pemphigus vulgaris were 4.3 (95% confidence interval 4.0 to 4.6) and 0.7 (0.6 to 0.8) per 100 000 person years. The incidence of bullous pemphigoid increased over time; the average yearly increase was 17% (incidence rate ratio=1.2, 95% confidence interval 1.1 to 1.2). An average yearly increase in incidence of pemphigus vulgaris of 11% (incidence rate ratio=1.1, 1.0 to 1.2) occurred. The risk of death for patients with bullous pemphigoid was twice as great as for controls (adjusted hazard ratio=2.3, 95% confidence interval 2.0 to 2.7). For pemphigus vulgaris, the risk of death was three times greater than for controls (adjusted hazard ratio=3.3, 2.2 to 5.2).
Conclusions Incidences of bullous pemphigoid and pemphigus vulgaris are increasing. The reasons for the changes in incidence are not clearly understood but have implications for identifying causative factors. Both disorders are associated with a high risk of death. Previous estimates may have underestimated the risk of death associated with these diseases.
doi:10.1136/bmj.a180
PMCID: PMC2483869  PMID: 18614511
13.  A population based case-control study of cataract and inhaled corticosteroids 
The British Journal of Ophthalmology  2003;87(10):1247-1251.
Background/aims: Exposure to systemic corticosteroid use is known to be associated with a risk of cataract. Whether low doses of inhaled corticosteroids are associated with an increased risk of cataract is not known. This study was undertaken to quantify the risk of cataract associated with the use of inhaled corticosteroids and assess whether there is a dose-response relation.
Methods: A population based case-control study based on the General Practice Research Database in the United Kingdom. 15 479 people with cataract and 15 479 controls were matched for age, sex, practice, and observation period.
Results: The crude odds ratio for the association between any recorded exposure to inhaled corticosteroids and cataract was 1.58 (95% CI 1.46 to 1.71), reduced to 1.10 (95% CI 1.00 to 1.20) after adjustment for systemic corticosteroid exposure and consultation rate. There was a dose-response relation, the adjusted odds ratio rising from 0.99 (95% CI 0.87 to 1.13) at daily doses up to 400 μg to 1.69 (95% CI 1.17 to 2.43) for daily doses greater than 1600 μg. The association was also stronger with increasing duration of use.
Conclusion: Higher doses and longer duration of exposure to inhaled corticosteroids are associated with an increased risk of cataract. The lowest doses compatible with good control of airways disease should be used. The risk of cataract associated with high doses of inhaled corticosteroids needs to be more widely appreciated.
PMCID: PMC1920769  PMID: 14507760
cataract; corticosteroids
14.  Prevalence of visual impairment in people aged 75 years and older in Britain: results from the MRC trial of assessment and management of older people in the community 
Aims: To measure the prevalence of visual impairment in a large representative sample of people aged 75 years and over participating in the MRC trial of assessment and management of older people in the community.
Methods: 53 practices in the MRC general practice research framework. Data were obtained from 14 600 participants aged 75 years and older. Prevalence of visual impairment overall (binocular visual acuity <6/18) which was categorised separately into low vision (binocular visual acuity <6/18–3/60) or blindness (binocular visual acuity of <3/60). The prevalence of binocular acuity <6/12 was presented for comparison with other studies. Visual acuity was measured using Glasgow acuity charts; glasses, if worn, were not removed.
Results: Visual acuity was available for 14 600 people out of 21 241 invited (69%). Among people with visual acuity data, 12.4% overall (1803) were visually impaired (95% confidence intervals 10.8% to 13.9%); 1501 (10.3%) were categorised as having low vision (8.7% to 11.8%), and 302 (2.1%) were blind (1.8% to 2.4%). At ages 75–79, 6.2% of the cohort were visually impaired (5.1% to 7.3%) with 36.9% at age 90+ (32.5% to 41.3%). At ages 75–79, 0.6% (0.4% to 0.8%) of the study population were blind, with 6.9% (4.8% to 9.0%) at age 90+. In multivariate regression, controlling for age, women had significant excess risk of visual impairment (odds ratio 1.43, 95% confidence interval 1.29 to 1.58). Overall, 19.9% of study participants had a binocular acuity of less than 6/12 (17.8% to 22.0%).
Conclusion: The results from this large study show that visual impairment is common in the older population and that this risk increases rapidly with advancing age, especially for women. A relatively conservative measure of visual impairment was used. If visual impairment had been defined as visual acuity of <6/12 (American definition of visual impairment), the age specific prevalence estimates would have increased by 60%.
PMCID: PMC1771210  PMID: 12084753
visual impairment; blindness; prevalence; elderly
16.  Time for evidence-based screening? 
PMCID: PMC1296804  PMID: 9771490
19.  Acute infections and venous thromboembolism 
Journal of Internal Medicine  2011;271(6):608-618.
Abstract
Schmidt M, Horvath-Puho E, Thomsen RW, Smeeth L, Sørensen HT (Department of Clinical Epidemiology, Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark; and Department of Non-Communicable Epidemiology, London School of Hygiene and Tropical Medicine, London, UK). Acute infections and venous thromboembolism. J Intern Med 2012; 271: 608–618.
Background
Data on the association between acute infections and venous thromboembolism (VTE) are sparse. We examined whether various hospital-diagnosed infections or infections treated in the community increase the risk of VTE.
Methods
We conducted this population-based case–control study in Northern Denmark (population 1.8 million) using medical databases. We identified all patients with a first hospital-diagnosed VTE during the period 1999–2009 (n = 15 009). For each case, we selected 10 controls from the general population matched for age, gender and county of residence (n = 150 074). We identified all hospital-diagnosed infections and community prescriptions for antibiotics 1 year predating VTE. We used odds ratios from a conditional logistic regression model to estimate incidence rate ratios (IRRs) of VTE within different time intervals of the first year after infection, controlling for confounding.
Results
Respiratory tract, urinary tract, skin, intra-abdominal and bacteraemic infections diagnosed in hospital or treated in the community were associated with a greater than equal to twofold increased VTE risk. The association was strongest within the first 2 weeks after infection onset, gradually declining thereafter. Compared with individuals without infection during the year before VTE, the IRR for VTE within the first 3 months after infection was 12.5 (95% confidence interval (CI): 11.3–13.9) for patients with hospital-diagnosed infection and 4.0 (95% CI: 3.8–4.1) for patients treated with antibiotics in the community. Adjustment for VTE risk factors reduced these IRRs to 3.3 (95% CI: 2.9–3.8) and 2.6 (95% CI: 2.5–2.8), respectively. Similar associations were found for unprovoked VTE and for deep venous thrombosis and pulmonary embolism individually.
Conclusions
Infections are a risk factor for VTE.
doi:10.1111/j.1365-2796.2011.02473.x
PMCID: PMC3505369  PMID: 22026462
antibacterial agents; deep venous thrombosis; infections; pulmonary embolism; venous thromboembolism
20.  Self management and patient understanding of diabetes in the older person 
Diabetic Medicine  2010;28(1):117-122.
Abstract
Aim
To examine knowledge and management of diabetes by older people.
Methods
A representative sample of 1047 people with Type 2 diabetes, aged 75 years and over, were asked a series of questions relating to their diabetes management and their understanding of self management. The impact of cognitive impairment and socio-economic status were assessed.
Results
The majority of people, 1015 (96.9%), were under the care of a health professional and 1018 (97.2%) were taking insulin, tablets, controlling their diet or a combination. Cognitive impairment (Mini-Mental State Examination ≤ 23) was found in 235 (22.5%) people. Recent eye, foot and dietician assessment was reported by 813 (77.7%), 836 (79.7%) and 326 (31.1%) people, respectively. A quarter overall and 70% of those taking insulin tested their blood glucose. In the insulin group, 78 (54.2%) reported hypoglycaemia and those with cognitive impairment gave more incorrect responses when asked about diabetes management. Socio-economic status made very little difference to any of these outcomes.
Conclusions
Most older people with diabetes, regardless of their socio-economic status, are under the care of a healthcare professional and use medication or diet to manage their disease. Large numbers also attend foot and eye examinations. However, over one fifth of older people with diabetes have cognitive impairment. Older people had a reasonable understanding of their diabetes management but this was worse in those people with cognitive impairment.
Diabet. Med. 28, 117–122 (2011)
doi:10.1111/j.1464-5491.2010.03142.x
PMCID: PMC3588140  PMID: 21166853
cognitive impairment; elderly; self management; understanding
21.  Effect of β blockers on mortality after myocardial infarction in adults with COPD: population based cohort study of UK electronic healthcare records 
Objectives To investigate whether the use and timing of prescription of β blockers in patients with chronic obstructive pulmonary disease (COPD) having a first myocardial infarction was associated with survival and to identify factors related to their use.
Design Population based cohort study in England.
Setting UK national registry of myocardial infarction (Myocardial Ischaemia National Audit Project (MINAP)) linked to the General Practice Research Database (GPRD), 2003-11.
Participants Patients with COPD with a first myocardial infarction in 1 January 2003 to 31 December 2008 as recorded in MINAP, who had no previous evidence of myocardial infarction in their GPRD or MINAP record. Data were provided by the Cardiovascular Disease Research using Linked Bespoke studies and Electronic Health Records (CALIBER) group at University College London.
Main outcome measure Cox proportional hazards ratio for mortality after myocardial infarction in patients with COPD in those prescribed β blockers or not, corrected for covariates including age, sex, smoking status, drugs, comorbidities, type of myocardial infarction, and severity of infarct.
Results Among 1063 patients with COPD, treatment with β blockers started during the hospital admission for myocardial infarction was associated with substantial survival benefits (fully adjusted hazard ratio 0.50, 95% confidence interval 0.36 to 0.69; P<0.001; median follow-up time 2.9 years). Patients already taking a β blocker before their myocardial infarction also had a survival benefit (0.59, 0.44 to 0.79; P<0.001). Similar results were obtained with propensity scores as an alternative method to adjust for differences between those prescribed and not prescribed β blockers. With follow-up started from date of discharge from hospital, the effect size was slightly attenuated but there was a similar protective effect of treatment with β blockers started during hospital admission for myocardial infarction (0.64, 0.44 to 0.94; P=0.02).
Conclusions The use of β blockers started either at the time of hospital admission for myocardial infarction or before a myocardial infarction is associated with improved survival after myocardial infarction in patients with COPD.
Registration NCT01335672.
doi:10.1136/bmj.f6650
PMCID: PMC3898388  PMID: 24270505

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