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1.  Co-benefits of Global Greenhouse Gas Mitigation for Future Air Quality and Human Health 
Nature climate change  2013;3(10):885-889.
Actions to reduce greenhouse gas (GHG) emissions often reduce co-emitted air pollutants, bringing co-benefits for air quality and human health. Past studies1–6 typically evaluated near-term and local co-benefits, neglecting the long-range transport of air pollutants7–9, long-term demographic changes, and the influence of climate change on air quality10–12. Here we simulate the co-benefits of global GHG reductions on air quality and human health using a global atmospheric model and consistent future scenarios, via two mechanisms: a) reducing co-emitted air pollutants, and b) slowing climate change and its effect on air quality. We use new relationships between chronic mortality and exposure to fine particulate matter13 and ozone14, global modeling methods15, and new future scenarios16. Relative to a reference scenario, global GHG mitigation avoids 0.5±0.2, 1.3±0.5, and 2.2±0.8 million premature deaths in 2030, 2050, and 2100. Global average marginal co-benefits of avoided mortality are $50–380 (ton CO2)−1, which exceed previous estimates, exceed marginal abatement costs in 2030 and 2050, and are within the low range of costs in 2100. East Asian co-benefits are 10–70 times the marginal cost in 2030. Air quality and health co-benefits, especially as they are mainly local and near-term, provide strong additional motivation for transitioning to a low-carbon future.
PMCID: PMC4051351  PMID: 24926321
2.  Alterations in oestrogen metabolism: implications for higher penetrance of familial pulmonary arterial hypertension in females 
The European respiratory journal  2009;34(5):1093-1099.
Mutations in bone morphogenetic protein receptor type 2 (BMPR2) cause familial pulmonary arterial hypertension (FPAH), but the penetrance is reduced and females are significantly overrepresented. In addition, gene expression data implicating the oestrogen-metabolising enzyme CYP1B1 suggests a detrimental role of oestrogens or oestrogen metabolites. We examined genetic and metabolic markers of altered oestrogen metabolism in subjects with a BMPR2 mutation.
Genotypes for CYP1B1 Asn453Ser (N453S) were determined for 140 BMPR2 mutation carriers (86 females and 54 males). Nested from those subjects, a case–control study of urinary oestrogen metabolite levels (2-hydroxyoestrogen (2-OHE) and 16α-hydroxyoestrone (16α-OHE1)) was conducted in females (five affected mutation carriers versus six unaffected mutation carriers).
Among females, there was four-fold higher penetrance among subjects homozygous for the wild-type genotype (N/N) than those with N/S or S/S genotypes (p=0.005). Consistent with this finding, the 2-OHE/16α-OHE1 ratio was 2.3-fold lower in affected mutation carriers compared to unaffected mutation carriers (p=0.006).
Our findings suggest that variations in oestrogens and oestrogen metabolism modify FPAH risk. Further investigation of the role of oestrogens in this disease with profound sex bias may yield new insights and, perhaps, therapeutic interventions.
PMCID: PMC3742124  PMID: 19357154
Bone morphogenetic protein receptor 2; CYP1B1; genetic polymorphism; oestrogen; pulmonary hypertension; sex
3.  Effects of N-acetylcysteine on matrix metalloproteinase-9 secretion and cell migration of human corneal epithelial cells 
Eye  2012;26(8):1138-1144.
Matrix metalloproteinase-9 (MMP-9) secreted by corneal epithelial cells has a role in the remodelling of extracellular matrix and migration of epithelial cells. Elevated levels of MMP-9 activity in the ocular surface may be involved in the pathogenesis of corneal diseases. N-acetylcysteine (NAC) has been used to treat corneal diseases, including recurrent epithelial erosions. In this study, its effects on the MMP-9 secretion and human corneal epithelial (HCE) cell migration were evaluated in vitro.
Confluent HCE cell cultures were treated with 0–20 mM NAC, and tested for MMP-9 secretion and epithelial cell migration by gelatin zymography and scratch wound assay, respectively. Comparisons between different treatment groups were made using analysis of variance, followed by multiple pairwise comparisons.
Twenty mM NAC inhibited the secretion of MMP-9 significantly. Cell migration, assessed after 24 h of wounding, showed a highly significant dose-dependent inhibitory effect.
This study shows that NAC reduces MMP-9 production by HCE cells and inhibits cell migration in vitro. This information helps to elucidate the mechanisms by which NAC may be beneficial therapeutically and suggests that NAC may be useful for managing corneal erosions and related conditions.
PMCID: PMC3420048  PMID: 22766540
cornea; epithelium; healing; recurrent corneal erosions (RCE); N-acetylcysteine (NAC)
4.  Older adults with cognitive complaints show brain atrophy similar to that of amnestic MCI 
Neurology  2006;67(5):834-842.
To examine the neural basis of cognitive complaints in healthy older adults in the absence of memory impairment and to determine whether there are medial temporal lobe (MTL) gray matter (GM) changes as reported in Alzheimer disease (AD) and amnestic mild cognitive impairment (MCI).
Participants were 40 euthymic individuals with cognitive complaints (CCs) who had normal neuropsychological test performance. The authors compared their structural brain MRI scans to those of 40 patients with amnestic MCI and 40 healthy controls (HCs) using voxel-based morphometry and hippocampal volume analysis.
The CC and MCI groups showed similar patterns of decreased GM relative to the HC group on whole brain analysis, with differences evident in the MTL, frontotemporal, and other neocortical regions. The degree of GM loss was associated with extent of both memory complaints and performance deficits. Manually segmented hippocampal volumes, adjusted for age and intracranial volume, were significantly reduced only in the MCI group, with the CC group showing an intermediate level.
Cognitive complaints in older adults may indicate underlying neurodegenerative changes even when unaccompanied by deficits on formal testing. The cognitive complaint group may represent a pre–mild cognitive impairment stage and may provide an earlier therapeutic opportunity than mild cognitive impairment. MRI analysis approaches incorporating signal intensity may have greater sensitivity in early preclinical stages than volumetric methods.
PMCID: PMC3488276  PMID: 16966547
5.  Global Air Quality and Health Co-benefits of Mitigating Near-Term Climate Change through Methane and Black Carbon Emission Controls 
Environmental Health Perspectives  2012;120(6):831-839.
Background: Tropospheric ozone and black carbon (BC), a component of fine particulate matter (PM ≤ 2.5 µm in aerodynamic diameter; PM2.5), are associated with premature mortality and they disrupt global and regional climate.
Objectives: We examined the air quality and health benefits of 14 specific emission control measures targeting BC and methane, an ozone precursor, that were selected because of their potential to reduce the rate of climate change over the next 20–40 years.
Methods: We simulated the impacts of mitigation measures on outdoor concentrations of PM2.5 and ozone using two composition-climate models, and calculated associated changes in premature PM2.5- and ozone-related deaths using epidemiologically derived concentration–response functions.
Results: We estimated that, for PM2.5 and ozone, respectively, fully implementing these measures could reduce global population-weighted average surface concentrations by 23–34% and 7–17% and avoid 0.6–4.4 and 0.04–0.52 million annual premature deaths globally in 2030. More than 80% of the health benefits are estimated to occur in Asia. We estimated that BC mitigation measures would achieve approximately 98% of the deaths that would be avoided if all BC and methane mitigation measures were implemented, due to reduced BC and associated reductions of nonmethane ozone precursor and organic carbon emissions as well as stronger mortality relationships for PM2.5 relative to ozone. Although subject to large uncertainty, these estimates and conclusions are not strongly dependent on assumptions for the concentration–response function.
Conclusions: In addition to climate benefits, our findings indicate that the methane and BC emission control measures would have substantial co-benefits for air quality and public health worldwide, potentially reversing trends of increasing air pollution concentrations and mortality in Africa and South, West, and Central Asia. These projected benefits are independent of carbon dioxide mitigation measures. Benefits of BC measures are underestimated because we did not account for benefits from reduced indoor exposures and because outdoor exposure estimates were limited by model spatial resolution.
PMCID: PMC3385429  PMID: 22418651
air quality; climate change; health impact analysis; outdoor air; particulate matter
6.  Abnormal error-related antisaccade activation in premanifest and early manifest Huntington disease 
Neuropsychology  2011;25(3):306-318.
Individuals with the trinucleotide CAG expansion (CAG+) that causes Huntington disease (HD) have impaired performance on antisaccade (AS) tasks that require directing gaze in the mirror opposite direction of visual targets. This study aimed to identify the neural substrates underlying altered antisaccadic performance.
Three groups of participants were recruited: 1) Imminent and early manifest HD (early HD, n=8); 2) premanifest (presymptomatic) CAG+ (preHD, n=10); and 3) CAG unexpanded (CAG−) controls (n=12). All participants completed a uniform study visit that included a neurological evaluation, neuropsychological battery, molecular testing, and functional magnetic resonance imaging during an AS task. The blood oxygenation level dependent (BOLD) response was obtained during saccade preparation and saccade execution for both correct and incorrect responses using regression analysis.
Significant group differences in BOLD response were observed when comparing incorrect AS to correct AS execution. Specifically, as the percentage of incorrect AS increased, BOLD responses in the CAG− group decreased progressively in a well-documented reward detection network that includes the pre-supplementary motor area and dorsal anterior cingulate cortex. In contrast, AS errors in the preHD and early HD groups lacked this relationship with BOLD signal in the error detection network, and BOLD responses to AS errors were smaller in the two CAG+ groups as compared with the CAG− group.
These results are the first to suggest that abnormalities in an error-related response network may underlie early changes in AS eye movements in premanifest and early manifest HD.
PMCID: PMC3086952  PMID: 21401260
Huntington disease; premanifest; saccades; functional MRI; error monitoring
7.  The Pathology of Bleomycin induced Fibrosis is Associated with Loss of Resident Lung Mesenchymal Stem cells which Regulate Effector T-cell Proliferation 
Stem Cells (Dayton, Ohio)  2011;29(4):725-735.
Tissue resident mesenchymal stem cells (MSC) are important regulators of tissue repair or regeneration, fibrosis, inflammation, angiogenesis and tumor formation. Here we define a population of resident lung mesenchymal stem cells (luMSC) that function to regulate the severity of bleomycin injury via modulation of the T-cell response. Bleomycin induced loss of these endogenous luMSC and elicited fibrosis (PF), inflammation and pulmonary arterial hypertension (PAH). Replacement of resident stem cells by administration of isolated luMSC attenuated the bleomycin-associated pathology and mitigated the development of PAH. In addition, luMSC modulated a decrease in numbers of lymphocytes and granulocytes in bronchoalveolar fluid and demonstrated an inhibition of effector T cell proliferation in vitro. Global gene expression analysis indicated that the luMSC are a unique stromal population differing from lung fibroblasts in terms of proinflammatory mediators and pro-fibrotic pathways. Our results demonstrate that luMSCs function to protect lung integrity following injury however when endogenous MSC are lost this function is compromised illustrating the importance of this novel population during lung injury. The definition of this population in vivo in both murine and human pulmonary tissue facilitates the development of a therapeutic strategy directed at the rescue of endogenous cells to facilitate lung repair during injury.
PMCID: PMC3322548  PMID: 21312316
resident lung mesenchymal stem cells; pulmonary fibrosis; pulmonary hypertension; stem cells
9.  An Estimate of the Global Burden of Anthropogenic Ozone and Fine Particulate Matter on Premature Human Mortality Using Atmospheric Modeling 
Environmental Health Perspectives  2010;118(9):1189-1195.
Ground-level concentrations of ozone (O3) and fine particulate matter [≤ 2.5 μm in aerodynamic diameter (PM2.5)] have increased since preindustrial times in urban and rural regions and are associated with cardiovascular and respiratory mortality.
We estimated the global burden of mortality due to O3 and PM2.5 from anthropogenic emissions using global atmospheric chemical transport model simulations of preindustrial and present-day (2000) concentrations to derive exposure estimates.
Attributable mortalities were estimated using health impact functions based on long-term relative risk estimates for O3 and PM2.5 from the epidemiology literature. Using simulated concentrations rather than previous methods based on measurements allows the inclusion of rural areas where measurements are often unavailable and avoids making assumptions for background air pollution.
Anthropogenic O3 was associated with an estimated 0.7 ± 0.3 million respiratory mortalities (6.3 ± 3.0 million years of life lost) annually. Anthropogenic PM2.5 was associated with 3.5 ± 0.9 million cardiopulmonary and 220,000 ± 80,000 lung cancer mortalities (30 ± 7.6 million years of life lost) annually. Mortality estimates were reduced approximately 30% when we assumed low-concentration thresholds of 33.3 ppb for O3 and 5.8 μg/m3 for PM2.5. These estimates were sensitive to concentration thresholds and concentration–mortality relationships, often by > 50%.
Anthropogenic O3 and PM2.5 contribute substantially to global premature mortality. PM2.5 mortality estimates are about 50% higher than previous measurement-based estimates based on common assumptions, mainly because of methodologic differences. Specifically, we included rural populations, suggesting higher estimates; however, the coarse resolution of the global atmospheric model may underestimate urban PM2.5 exposures.
PMCID: PMC2944076  PMID: 20382579
air pollution; atmospheric chemistry model; health effects of air pollution; health impact analysis; ozone; particulate matter
10.  Peroxisome Proliferator-Activated Receptor-γ Agonist Treatment Increases Septation and Angiogenesis and Decreases Airway Hyperresponsiveness in a Model of Experimental Neonatal Chronic Lung Disease 
Chronic lung disease (CLD) affects premature newborns requiring supplemental oxygen and results in impaired lung development and subsequent airway hyperreactivity. We hypothesized that the maintenance of peroxisome proliferator-activated receptor gamma (PPARγ) signaling is important for normal lung morphogenesis and treatment with PPARγ agonists could protect against CLD and airway hyperreactivity (AHR) following chronic hyperoxic exposure. This was tested in an established hyperoxic murine model of experimental CLD. Newborn mice and mothers were exposed to room air (RA) or moderate hyperoxia (70% oxygen) for 10 days and fed a standard diet or chow impregnated with the PPARγ agonist rosiglitazone (ROSI) for the duration of study. Following hyperoxic exposure (HE) animals were returned to RA until postnatal day (P) 13 or P41. The accumulation of ROSI in neonatal and adult tissue was confirmed by mass spectrometry. Analyses of body weight and lung histology were performed on P13 and P41 to localize and quantitate PPARγ expression, determine alveolar and microvessel density, proliferation and alpha-smooth muscle actin (α-SMA) levels as a measure of myofibroblast differentiation. Microarray analyses were conducted on P13 to examine transcriptional changes in whole lung. Pulmonary function and airway responsiveness were analyzed at P55. ROSI treatment during HE preserved septation and vascular density. Key array results revealed ontogeny groups differentially affected by hyperoxia including cell cycle, angiogenesis, matrix and muscle differentiation/contraction. These results were further confirmed by histological evaluation of myofibroblast and collagen accumulation. Late AHR to methacholine was present in mice following HE and attenuated with ROSI treatment. These findings suggest that rosiglitazone maintains downstream PPARγ effects and may be beneficial in the prevention of severe CLD with AHR.
PMCID: PMC2873208  PMID: 19484746
Chronic Lung Disease (CLD); Rosiglitazone; PPAR gamma; Lung simplification; airway hyperresonsiveness (AHR)
11.  Author's reply 
Gut  2007;56(2):310-311.
PMCID: PMC1856768
12.  The antecedents of biliary cancer: a primary care case–control study in the United Kingdom 
British Journal of Cancer  2008;100(1):178-180.
In a case–control study using a large UK primary care database, we found that non-steroidal anti-inflammatory drugs had no protective effect against biliary carcinomas (cholangiocarcinoma and gall bladder cancer). Increased risks were observed for cigarette smoking, diabetes, gallstone disease and obesity.
PMCID: PMC2634685  PMID: 19018260
cholangiocarcinoma; gall bladder cancer; risk factors; non-steroidal anti-inflammatory drugs; database study
13.  Coeliac disease and risk of tuberculosis: a population‐based cohort study 
Thorax  2007;62(1):1-2.
Are patients with coeliac disease at higher risk of tuberculosis?
PMCID: PMC2111272  PMID: 17189527
14.  Incidence and mortality of idiopathic pulmonary fibrosis and sarcoidosis in the UK 
Thorax  2006;61(11):980-985.
Idiopathic pulmonary fibrosis (IPF) and sarcoidosis are common diagnoses in patients attending chest clinics, but little is known about the epidemiology of these diseases. We used data from a general practice database to provide information on the current incidence of IPF and sarcoidosis in the UK.
Data were extracted for all patients with a diagnosis of IPF or sarcoidosis between 1991 and 2003. The whole population of the database was used to calculate disease incidence stratified by age, sex, region, and time period. Poisson regression was used to compare the incidence between populations and Cox regression was used to compare survival between populations.
920 cases of IPF (mean age 71 years, 62% male) and 1019 cases of sarcoidosis (mean age 47 years, 47% male) were identified. The overall incidence rate per 100 000 person‐years was 4.6 for IPF and 5.0 for sarcoidosis. The incidence of IPF increased progressively between 1991 and 2003 (p<0.00001), and was highest in Northern England and Scotland (p<0.0001). The survival of patients with IPF was stable over time. In contrast, the incidence of sarcoidosis was highest in London, West Midlands and Northern Ireland and remained stable over time.
The incidence of IPF has more than doubled between 1990 and 2003; this is not due to the ageing of the UK population or an increased ascertainment of milder cases. The incidence of sarcoidosis has not changed during this time period. Our findings suggest that more than 4000 new cases of IPF and 3000 new cases of sarcoidosis are currently diagnosed each year in the UK.
PMCID: PMC2121155  PMID: 16844727
idiopathic pulmonary fibrosis; sarcoidosis; epidemiology
15.  Vulnerability of pulmonary capillaries during severe exercise 
The pulmonary capillaries are vulnerable to mechanical failure during strenuous exercise
PMCID: PMC2465077  PMID: 17021008
pulmonary capillaries; pulmonary haemorrhage; strenuous exercise
16.  Is an internal comparison better than using national data when estimating mortality in longitudinal studies? 
Discrepancies between the results of different studies looking at mortality in similar disease cohorts led us to consider the impact of methodology upon outcome.
Cohort studies were carried out using age, sex, practice, and calendar time matched control groups in the general practice research database. Data were used on all subjects with inflammatory bowel disease, coeliac disease, or Barrett's oesophagus. Mortality data for the population of England and Wales were obtained from the UK Office for National Statistics. The study compared hazard ratios (HR) for mortality using the matched controls to those found when an indirect standardisation to the mortality experience of England and Wales was carried out.
For all three conditions the mortality risk was slightly lower when the national population data were used compared with the internal comparison group (coeliac disease HR 1.33 v standardised mortality ratios (SMR) 1.25, Barrett's oesophagus HR 1.32 v SMR 1.32, inflammatory bowel disease HR 1.50 v SMR 1.34).
A bias was found towards underestimating mortality risk when cohort studies use national population death rates as a comparator. Estimates obtained when an internal comparison group has been used are probably more appropriate.
PMCID: PMC2566035  PMID: 16905729
inflammatory bowel disease; Barrett's oesophagus; coeliac disease; cohort studies; standardised mortality ratio; Cox regression
17.  Recent advances in coeliac disease 
Gut  2006;55(7):1037-1046.
PMCID: PMC1856316  PMID: 16766754
coeliac disease; recent advances
18.  Cardiac Cycle Dependent Left Atrial Dynamics: Implications for Catheter Ablation of Atrial Fibrillation 
Left atrial volume (LAV) determines prognosis and response to therapy in atrial fibrillation. Integration of electro-anatomical maps with 3D-images rendered from CT and MRI is used to facilitate atrial fibrillation ablation.
We measured LAV changes and regional motion during the cardiac cycle that might affect the accuracy of image integration and determined their relationship to standard LAV measurements.
MRI was performed in thirty patients with paroxysmal atrial fibrillation. Left atrial time-volume curves were generated and used to divide the left atrial function (LAEF) into pumping (PEF) and conduit (CEF) fractions and to determine the maximum LAV (LAMAX) and the pre-atrial contraction volume (PACV). LAV was measured using an MRI angiogram and traditional geometric models from echocardiography (area-length and ellipsoid). The in-plane displacement of the pulmonary veins, anterior left atrium, mitral annulus, and left atrial appendage was measured.
LAMAX was 107±36ml and occurred at 42±5% of the RR interval. PACV was 86 ±34ml and occurred at 81±4% of the RR interval. LAEF was 45±10% and PEF was 31±10%. LAV measurements made from the MRI angiogram, area-length and ellipsoid models underestimated LAMAX by 21±25ml, 16±26ml, and 35±22ml, respectively. The anterior LA, mitral annulus, and left atrial appendage were significantly displaced during the cardiac cycle (8.8±2.0mm, 13.2±3.8mm, and 10.2±3.4mm, respectively); the pulmonary veins were not.
LAV changes significantly during the cardiac cycle and substantial regional variation in left atrial motion exists. Standard measurements of left atrial volume significantly underestimate LAMAX when compared to the gold standard measure of 3D-volumetrics.
PMCID: PMC2527027  PMID: 18486563
Atrial fibrillation; magnetic resonance imaging; MR imaging; atrial anatomy; atrial morphology; atrial mapping; atrial fibrillation ablation; left atrium
19.  Oral and inhaled corticosteroids and adrenal insufficiency: a case‐control study 
Thorax  2006;61(5):405-408.
Adrenal insufficiency, a well recognised complication of treatment with oral corticosteroids, has been described in association with inhaled corticosteroid use in over 60 case reports. The risk of adrenal insufficiency in people prescribed an oral or inhaled corticosteroid in the general population is not known. A study was undertaken to quantify the association between adrenal insufficiency and oral and inhaled corticosteroid exposure.
A case‐control study was performed using computerised general practice data from The Health Improvement Network.
From a cohort of 2.4 million people, 154 cases of adrenal insufficiency and 870 controls were identified. There was a dose related increased risk of adrenal insufficiency in people prescribed an oral corticosteroid with an odds ratio of 2.0 (95% CI 1.6 to 2.5) per course of treatment per year. Adrenal insufficiency was associated with a prescription for an inhaled corticosteroid during the 90 day period before the diagnosis with an odds ratio of 3.4 (95% CI 1.9 to 5.9) and this effect was dose related (p for trend <0.001). After adjusting for oral corticosteroid exposure, this odds ratio was reduced to 1.6 (95% CI 0.8 to 3.2) although the dose relation remained (p for trend 0.036).
People prescribed an oral or inhaled corticosteroid are at a dose related increased risk of adrenal insufficiency although the absolute risk is small. This analysis suggests that the increased risk in people prescribed an inhaled corticosteroid is largely due to oral corticosteroid exposure, but inhaled corticosteroids may have an effect when they are taken at higher doses.
PMCID: PMC2111185  PMID: 16517576
inhaled corticosteroids; adrenal insufficiency
20.  Hospital Costs of Colorectal Cancer Care 
In a hospital based setting, identify factors which influence the cost of colorectal cancer care?
Retrospective case note review
Nottingham, United Kingdom
227 patients treated for colorectal cancer
Retrospective review of the hospital records provided the primary data for the costing study and included all CRC related resource consumption over the study period.
Of 700 people identified, 227 (32%) sets of hospital notes were reviewed. The median age of the study group was 70.3 (IQR 11.3) years and there were 128 (56%) males. At two years, there was a significant difference in costs between Dukes D cancers (£3641) and the other stages (£3776 Dukes A; £4921 Dukes B). Using univariate and multivariate regression, the year of diagnosis, Dukes stage of disease, intensive nursing care, stoma requirements and recurrent disease all significantly affected the total cost of care.
CRC remains costly with no significant difference in costs if diagnosed before compared to after 1992. Very early and very late stage cancers remain the least costly stage of cancers to treat. Other significant effectors of hospital costs were the site of cancer (rectal), intensive nursing care, recurrent disease and the need for a stoma.
PMCID: PMC2872591  PMID: 20689608
colorectal cancer; cost; hospital; Dukes stage; screening
21.  Treated Colorectal Cancer: What is the Cost to Primary Care? 
Colorectal cancer is the second commonest cause of cancer death and the cost to primary care has not been estimated.
To determine the direct primary care costs of colorectal cancer care.
Retrospective case note review.
Nottingham, United Kingdom.
We identified people with colorectal cancer between 1995 and 1998, from computerised pathology records. Colorectal cancer related resources consumed in primary care, from hospital discharge to death, were identified from retrospective notes review. Outcome measures were costs incurred by the General Practitioner (GP) and the total cost to primary care. We used multiple linear regression to identify predictors of cost.
Of 416 people identified from pathology records, the median age at primary operation of the 135 (33%) people we selected was 74.2 (IQR 14.4) years, 75 (56%) were male. The median GP cost was: Dukes A £61.0 (IQR 516.2) and Dukes D £936.2 (1196.2) p < 0.01. The geometric mean ratio found Dukes D cancers to be 10 times as costly as Dukes A. The median total cost was: Dukes A £1038.3 (IQR 5090.6) and Dukes D £1815.2 (2092.5) p = 0.06. Using multivariate analysis, Dukes stage was the most important predictor of GP costs. For total costs, the presence of a permanent stoma was the most predictive variable, followed by adjuvant therapy and advanced Dukes stage (Dukes C and D).
Contrary to hospital based care costs, late stage disease (Dukes D) costs substantially more to general practice than any other stage. Stoma care products are the most costly prescribable item. Costs savings may be realised in primary care by screening detection of early stage colorectal cancers.
PMCID: PMC2872599  PMID: 20689603
colorectal cancer; cost; general practice; Dukes stage; stoma
22.  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.
PMCID: PMC1747199  PMID: 16055620
23.  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.
PMCID: PMC2483869  PMID: 18614511
24.  Do clinical trials improve quality of care? A comparison of clinical processes and outcomes in patients in a clinical trial and similar patients outside a trial where both groups are managed according to a strict protocol 
Quality & safety in health care  2005;14(3):175-178.
Background: The conventional view that participants in randomised controlled trials sacrifice themselves for the good of future patients is challenged by increasing evidence to suggest that individual patients benefit from participation in trials.
Objective: To test the hypothesis that trial participants receive higher quality care and, as a consequence, have better outcomes than patients receiving guideline driven routine care.
Methods: Retrospective comparative study of 408 women with pre-eclampsia all managed according to a strict protocol. Trial participants were 86 women who participated in a multicentre randomised controlled trial of magnesium sulphate for the treatment of pre-eclampsia (Magpie Trial); 322 non-participants formed the control group. Indicators of the process of care and clinical outcomes were compared between the two groups.
Results: Trial participants were significantly more likely to have received daily blood tests (odds ratio (OR) 6.82, 95% CI 1.62 to 28.72) and had their respiration rate measured hourly (OR 3.42, 95% CI 1.69 to 6.92) than control patients. There were no significant differences in other markers of clinical process and no significant difference in clinical outcomes.
Conclusion: This study shows minor differences in process markers and no difference in clinical outcomes between patients in a clinical trial and patients receiving protocol driven care. The benefits of improved clinical care that have previously been associated with being in a trial may be explained by the use of clear clinical protocols. In routine practice, patients may be well advised to insist on treatment as part of a protocol.
PMCID: PMC1744006  PMID: 15933313
25.  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.
PMCID: PMC1768803  PMID: 15772201
myocardial infarction; tricyclic antidepressant; TCA; selective serotonin reuptake inhibitor; SSRI; case–control study; self controlled case series

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