Objective
To estimate the effect of estrogen‐only and combined hormone replacement therapy (HRT) on the hazards of overall and age‐specific all‐cause mortality in healthy women aged 46–65 at first ...prescription.
Design
Matched cohort study.
Setting
Electronic primary care records from The Health Improvement Network (THIN) database, UK (1984−2017).
Population
105 199 HRT users (cases) and 224 643 non‐users (controls) matched on age and general practice.
Methods
Weibull‐Double‐Cox regression models adjusted for age at first treatment, birth cohort, type 2 diabetes, hypertension and hypertension treatment, coronary heart disease, oophorectomy, hysterectomy, body mass index, smoking and deprivation status.
Main outcome measures
All‐cause mortality.
Results
A total of 21 751 women died over an average of 13.5 years follow‐up per participant, of whom 6329 were users and 15 422 non‐users. The adjusted hazard ratio (HR) of overall all‐cause mortality in combined HRT users was 0.91 (95% CI 0.88−0.94), and in estrogen‐only users was 0.99 (0.93−1.07), compared with non‐users. Age‐specific adjusted HRs for participants aged 46–50, 51–55, 56–60 and 61–65 years at first treatment were 0.98 (0.92−1.04), 0.87 (0.82−0.92), 0.88 (0.82−0.93) and 0.92 (0.85−0.98) for combined HRT users compared with non‐users, and 1.01 (0.84−1.21), 1.03 (0.89−1.18), 0.98 (0.86−1.12) and 0.93 (0.81−1.07) for estrogen‐only users, respectively.
Conclusions
Combined HRT was associated with a 9% lower risk of all‐cause mortality and estrogen‐only formulation was not associated with any significant changes.
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Estrogen‐only HRT is not associated with all‐cause mortality and combined HRT reduces the risks.
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Estrogen‐only HRT is not associated with all‐cause mortality and combined HRT reduces the risks.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Abstract Purpose Primary care practices in the United Kingdom have received substantial financial rewards for achieving standards set out in the Quality and Outcomes Framework since April 2004. This ...article reviews the growing evidence for the impact of the framework on the quality of primary medical care. Methods Five hundred seventy-five articles were identified by searching the MEDLINE, EMBASE, and PsycINFO databases, and from the reference lists of published reviews and articles. One hundred twenty-four relevant articles were assessed using a modified Downs and Black rating scale for 110 observational studies and a Critical Appraisal Skills Programme rating scale for 14 qualitative studies. Ninety-four studies were included in the review. Results Quality of care for incentivized conditions during the first year of the framework improved at a faster rate than the preintervention trend and subsequently returned to prior rates of improvement. There were modest cost-effective reductions in mortality and hospital admissions in some domains. Differences in performance narrowed in deprived areas compared with nondeprived areas. Achievement for conditions outside the framework was lower initially and has worsened in relative terms since inception. Some doctors reported improved data recording and teamwork, and nurses enhanced specialist skills. Both groups believed that the person-centeredness of consultations and continuity were negatively affected. Patients' satisfaction with continuity declined, with little change in other domains of patient experience. Conclusions Observed improvements in quality of care for chronic diseases in the framework were modest, and the impact on costs, professional behavior, and patient experience remains uncertain. Further research is needed into how to improve quality across different domains, while minimizing costs and any unintended adverse effects of payment for performance schemes. Health care organizations should remain cautious about the benefits of similar schemes.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
In horses/ponies with pituitary pars intermedia dysfunction (PPID), pergolide mesylate treatment, with monitoring of therapeutic response, is recommended by contemporaneous literature and equine ...endocrinologists. However, it is unknown whether these recommendations are adhered to in private practice. This clinical audit aimed to compare treatment and monitoring of PPID cases in veterinary practice against available recommendations. Case data and basal plasma adrenocorticotropic hormone (ACTH) concentrations from all equids tested for PPID between 2012 and 2016 from a single veterinary practice in the UK were obtained. Records were reviewed and information on treatment and monitoring over the subsequent 2–6 years was extracted and compared with published recommendations. After exclusions, the audit population was 480 animals (median age, 20 years). The most common presenting signs were laminitis and/or historical laminitis (51.2%) and hypertrichosis and/or delayed coat shedding (24.5%). Based on seasonally adjusted reference intervals for basal ACTH concentration, 51.7% (n = 248) of animals were classified as positive, 37.1% (n = 178) as negative and 11.3% (n = 54) as equivocal for PPID. Records were available for 459 animals; of which pergolide treatment was initiated in 78.7% (n = 185/235) of positive cases, 19.2% (n = 10/52) of equivocal cases and 6.4% (n = 11/172) of cases classified as negative. Overall, 87.2% (n = 129/148) of cases commenced treatment as per recommendations. Only 77.7% (n = 160/206) of pergolide-treated animals had documented PPID monitoring and of these, only 48.1% (n = 77/160) had follow-up basal ACTH testing in the first 1–3 months following diagnosis. The findings confirm that management of PPID in veterinary practice fell below contemporaneous recommendations, especially for monitoring.
•First audit of management of equine pituitary pars intermedia dysfunction (PPID).•87.2% of cases were initially treated as per recommendations.•Only 77.7% of pergolide-treated animals had documented PPID monitoring.•Only 48.1% were monitored using endocrine tests within 1–3 months of diagnosis.•Monitoring of PPID in veterinary practice fell below recommendations.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
There is a high prevalence of COVID-19 in university-age students, who are returning to campuses. There is little evidence regarding the feasibility of universal, asymptomatic testing to help control ...outbreaks in this population. This study aimed to pilot mass COVID-19 testing on a university research park, to assess the feasibility and acceptability of scaling up testing to all staff and students.
This was a cross-sectional feasibility study on a university research park in the East of England. All staff and students (5625) were eligible to participate. All participants were offered four PCR swabs, which they self-administered over two weeks. Outcome measures included uptake, drop-out rate, positivity rates, participant acceptability measures, laboratory processing measures, data collection and management measures.
798 (76%) of 1053 who registered provided at least one swab; 687 (86%) provided all four; 792 (99%) of 798 who submitted at least one swab had all negative results and 6 participants had one inconclusive result. There were no positive results. 458 (57%) of 798 participants responded to a post-testing survey, demonstrating a mean acceptability score of 4.51/5, with five being the most positive.
Repeated self-testing for COVID-19 using PCR is feasible and acceptable to a university population.
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NUK, OILJ, UL, UM, UPUK, VSZLJ
Inequalities in life events can lead to inequalities in older age. This research aimed to explore associations between life events reported by older people and quality of life (QoL) and functional ...ability.
Participants were grouped according to eight life events: parental closeness, educational opportunities in childhood, financial hardship, loss of an unborn child, bereavement due to war, involvement in conflict, violence and experiencing a natural disaster. Linear and logistic regressions were used to explore associations between these groups and the main outcomes of functional ability and QoL.
7555 participants were allocated to four LCA groups: 'few life events' (n = 6,250), 'emotionally cold mother' (n = 724), 'violence in combat' (n = 274) and 'many life events' (n = 307). Reduced QoL was reported in the 'many life events' (coefficient - 5.33, 95%CI -6.61 to -4.05), 'emotionally cold mother' (-1.89, -2.62 to 1.15) and 'violence in combat' (-1.95, -3.08 to -0.82) groups, compared to the 'few life events' group. The 'many life events' group also reported more difficulty with activities of daily living.
Policies aimed at reducing inequalities in older age should consider events across the life course.
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NUK, OILJ, UL, UM, UPUK, VSZLJ
The number of displaced people, including asylum seekers and refugees, in the UK continues to rise. This article highlights findings from two participatory community listening exercises on the topic ...of health of displaced people.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Aims Diabetes UK estimates a quarter of UK cases of diabetes are undiagnosed; 750 000 people have undiagnosed diabetes in addition to 2.25 million with known diabetes, but research studies examining ...this are contradictory. The aim was to determine the prevalence of, and risk factors for, undiagnosed diabetes in the population of England aged > 50 years and to calculate the percentage of cases of undiagnosed diabetes.
Methods This was a cross‐sectional study in a nationally representative sample of 6739 people aged 52–79 years from the English Longitudinal Study of Ageing (ELSA) 2004/2005. Diabetes cases were ascertained by self‐reported doctor diagnosis of diabetes. A fasting plasma glucose measurement after a minimum of 8‐h fast was available for 2387 (38% of the participants without diabetes). Undiagnosed diabetes cases were based on a fasting plasma glucose ≥ 7.0 mmol/l.
Results The overall weighted prevalence of diabetes was 9.1%; 502 people (7.5%) had self‐reported diabetes (9.0% of men and 6.0% of women); 36 (1.7%) had undiagnosed diabetes (2.6% of men and 0.8% of women). Of cases of diabetes, 18.5% were undiagnosed (22% in men, 12% in women). Significant risk factors for undiagnosed diabetes were male sex, higher body mass index, waist circumference, systolic blood pressure and triglycerides.
Conclusions In 2004 the prevalence of undiagnosed diabetes, and the proportion of cases of diabetes that were undiagnosed, appear smaller than in previous studies. This is likely to be due to increased awareness of diabetes and improved clinical care resulting in many of those with previously undetected disease having been diagnosed.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Abstract Objective To compare the outcomes of patients with cervical adenocarcinoma in situ (ACIS) treated with cold knife cone (CKC) biopsy or loop electrosurgical excision procedure (LEEP) for the ...treatment of cervical adenocarcinoma in situ (ACIS). Study design This is a retrospective, population-based cohort study of Western Australian patients with ACIS diagnosed between 2001 and 2012. Outcomes included pathological margin status and the incidence of persistent or recurrent endocervical neoplasia (ACIS and adenocarcinoma) during follow-up (< 12 months) and surveillance (≥ 12 months) periods. Results The study group comprised 338 patients including 107 (32%) treated initially by LEEP and 231 (68%) treated by CKC biopsy. The mean age was 33.2 years (range 18 to 76 years) and median follow-up interval was 3.6 years (range < 1 year to 11.8 years). Overall, 27 (8.0%) patients had ACIS persistence/recurrence while 9 (2.7%) were diagnosed with adenocarcinoma during the follow-up and surveillance periods. No patient died of cervical cancer within the study period. There were no significant differences in the incidence of persistent and/or recurrent endocervical neoplasia according to the type of excisional procedure. Patients with positive biopsy margins were 3.4 times more likely to have disease persistence or recurrence. Conclusion(s) LEEP and CKC biopsy appear equally effective in the treatment of ACIS for women wishing to preserve fertility. Patients undergoing conservative management for ACIS should be closely monitored, particularly if biopsy margins are positive in initial excision specimens. Patients and their clinicians should be aware of the potential risks of residual and recurrent disease.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Variable Members of the public (n=100) Practice nurses (n=39) General practitioners (n=39) Consultant physicians (n=39) No (%) responding 58 (58) 32 (82) 30 (77) 29 (74) Age group by No (%): <40 ...years 14 (25) 15 (47) (47) 7 (24) 41-65 years 25 (45) 16 (50) (53) 22 (76) >65 years 17 (30) 1 (3) (0) 0 (0) Ratio of men:women (%) 42:58 3:97 70:30 86:14 Odds ratio (95% CI) adjusted for age and sex, with consultants as reference group 0.12 (0.03 to 0.42) 0.08 (0.02 to 0.35) 0.27 (0.08 to 0.96) - Median NNT threshold chosen (interquartile range): <40 years 50 33 50 or 100 250 41-65 years 12 12 or 33 33 50 >65 years 50 33 - - Men 50 33 50 100 Women 33 33 50 250 All respondents 33 (12-250) 33 (<12-50) 50 (33-100) 100 (50-250) Comment Treating hypertension entails combining evidence with judgment about risk. The thresholds chosen by the groups might depend on whether the question was real or hypothetical, or whether the benefits were expressed as reduction of absolute risk (such as numbers needed to treat) or relative risk. Because all groups faced the same question, however, valid comparisons can be made between them.
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BFBNIB, CMK, NMLJ, NUK, PNG, SAZU, UL, UM, UPUK
Objective
To compare outcomes of patients with pure adenocarcinoma‐in‐situ (AIS) and mixed AIS/CIN 2/3 lesions including the incidence of AIS persistence, recurrence and progression to ...adenocarcinoma.
Design
Retrospective cohort study.
Setting
Statewide population in Western Australia.
Population
Women diagnosed with AIS between 2001 and 2012.
Methods
We conducted a retrospective, population‐based cohort study.
Main outcome measures
De‐identified linked data were utilised to ascertain the association between patient age at excisional treatment, margin status, lesion type, lesion size, and risk of persistent AIS (defined as the presence of AIS <12 months from treatment), recurrent AIS (≥12 months post‐treatment), and adenocarcinoma.
Results
636 patients were eligible for analysis. The mean age was 32.3 years and median follow‐up interval was 2.5 years. Within the study cohort, 266 patients (41.8%) had pure AIS and 370 (58.2%) had mixed AIS/CIN 2/3. Overall, 47 patients (7.4%) had AIS persistence/recurrence and 12 (1.9%) had adenocarcinoma. Factors associated with persistence/recurrence were pure AIS (hazard ratio (HR) 2.3; 95%CI 1.28–3.94; P = 0.005), age >30 years (HR 2.1; 95%CI 1.16–3.81; P = 0.015), positive endocervical margins (HR 5.8; 95%CI 3.05–10.92; P = <0.001) and AIS lesions >8 mm (HR 2.5; 95%CI 1.00–6.20; P = 0.049). A histologically positive AIS ectocervical margin was not associated with persistence/recurrence.
Conclusion
In this study, pure AIS was associated with greater risk of persistence/recurrence than was mixed AIS/CIN 2/3. AIS lesions >8 mm and positive endocervical margins were significant predictors for persistent or recurrent disease.
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Pure cervical adenocarcinoma‐in‐situ (AIS) may have greater risk of recurrence than AIS co‐existing with CIN 2/3.
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Pure cervical adenocarcinoma‐in‐situ (AIS) may have greater risk of recurrence than AIS co‐existing with CIN 2/3.
This paper includes Author Insights, a video available at https://vimeo.com/rcog/authorinsights14808.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
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