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.
Sub-Saharan Africa is undergoing health transition as increased globalization and accompanying urbanization are causing a double burden of communicable and noncommunicable diseases. Rates of ...communicable diseases such as HIV/AIDS, tuberculosis and malaria in Africa are the highest in the world. The impact of noncommunicable diseases is also increasing. For example, age-standardized mortality from cardiovascular disease may be up to three times higher in some African than in some European countries. As the entry point into the health service for most people, primary care plays a key role in delivering communicable disease prevention and care interventions. This role could be extended to focus on noncommunicable diseases as well, within the context of efforts to strengthen health systems by improving primary-care delivery. We put forward practical policy proposals to improve the primary-care response to the problems posed by health transition: (i) improving data on communicable and noncommunicable diseases; (ii) implementing a structured approach to the improved delivery of primary care; (iii) putting the spotlight on quality of clinical care; (iv) aligning the response to health transition with health system strengthening; and (v) capitalizing on a favourable global policy environment. Although these proposals are aimed at primary care in sub-Saharan Africa, they may well be relevant to other regions also facing the challenges of health transition. Implementing these proposals requires action by national and international alliances in mobilizing the necessary investments for improved health of people in developing countries in Africa undergoing health transition.
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.
While the effects of weather and, in particular, ambient temperature on overall mortality are well documented, the strength of the evidence base for the effects on acute myocardial infarction (MI) ...are less clear.
To systematically review studies specifically focusing on the effects of temperature on MI.
Medline, Embase, and GeoBase publication databases, as well as reference lists, and the websites of a number of relevant public organisations.
Studies of original data in which ambient temperature was an exposure of interest and MI a specific outcome were selected.
The reported effects of ambient temperature on the risk of MI, including effect sizes and confidence intervals, where possible, were recorded. Methodological details were also extracted, including study population, location and setting, ascertainment of MI events, adjustment for potential confounders and consideration of lagged effects.
19 studies were identified, of which 14 considered the short-term effects of temperature on a daily timescale, the remainder looking at longer-term effects. Overall, 8 of the 12 studies which included relevant data from the winter season reported a statistically significant short-term increased risk of MI at lower temperatures, while increases in risk at higher temperatures were reported in 7 of the 13 studies with relevant data. A number of differences were identified between studies in the population included demographics, location, local climate, study design and statistical methodology.
A number of studies, including some that were large and relatively well controlled, suggested that both hot and cold weather had detrimental effects on the short-term risk of MI. However, further research with consistent methodology is needed to clarify the magnitude of these effects and to show which populations and individuals are vulnerable.
Acute infections and venous thromboembolism Schmidt, M.; Horvath-Puho, E.; Thomsen, R. W. ...
Journal of internal medicine,
June 2012, Volume:
271, Issue:
6
Journal Article
Peer reviewed
Open access
. 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.
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.
Summary
Background
Emerging evidence suggests an association between common inflammatory skin diseases and chronic kidney disease (CKD).
Objectives
To explore the association between CKD stages 3–5 ...(CKD3–5) and atopic eczema, psoriasis, rosacea and hidradenitis suppurativa.
Methods
We undertook two complementary analyses; a prevalent case–control study and a cohort study using routinely collected primary care data UK Clinical Practice Research Datalink (CPRD). We matched individuals with CKD3–5 in CPRD in March 2018 with up to five individuals without CKD for general practitioner practice, age and sex. We compared the prevalence of CKD3–5 among individuals with and without each inflammatory skin disease. We included individuals in CPRD with diabetes mellitus (2004–2018) in a cohort analysis to compare the incidence of CKD3–5 among people with and without atopic eczema and psoriasis.
Results
Our study included 56 602 cases with CKD3–5 and 268 305 controls. Cases were more likely than controls to have a history of atopic eczema odds ratio (OR) 1·14, 99% confidence interval (CI) 1·11–1·17, psoriasis (OR 1·13, 99% CI 1·08–1·19) or hidradenitis suppurativa (OR 1·49, 99% CI 1·19–1·85), but were slightly less likely to have been diagnosed with rosacea (OR 0·92, 99% CI 0·87–0·97), after adjusting for age, sex, practice (matching factors), index of multiple deprivation, diabetes, smoking, harmful alcohol use and obesity. Results remained similar after adjusting for hypertension and cardiovascular disease. In the cohort with diabetes (N = 335 827), there was no evidence that CKD3–5 incidence was associated with atopic eczema or psoriasis.
Conclusions
Atopic eczema, psoriasis and hidradenitis suppurativa are weakly associated with CKD3–5. Future research is needed to elucidate potential mechanisms and the clinical significance of our findings.
What is already known about this topic?
Emerging evidence supports an association between more common inflammatory skin diseases and chronic kidney disease (CKD), but the size and nature of this association remain unclear.
What does this study add?
People with CKD were more likely to have atopic eczema (14%), psoriasis (13%) and hidradenitis suppurativa (49%), compared with those without CKD.
The link between inflammatory skin diseases and CKD did not appear to be mediated through cardiovascular comorbidity, hypertension or nephrotoxic drugs.
A stronger association with CKD among those with severe atopic eczema and psoriasis was consistent with a dose–response association.
There was no evidence of CKD incidence being associated with atopic eczema or psoriasis in the cohort of people with diabetes.
Linked Comment: J. Wan and K. Abuabara. Br J Dermatol 2021; 185:693–694.
Plain language summary available online
•Non-white groups had better or equivalent capture of risk factors prior to diagnosis compared to white groups.•Risk factor levels at diagnosis were more favourable for south Asian and Black ...groups.•Initiation of diabetes therapy was faster for non-white groups relative to white groups.•Downstream inequalities in type 2 diabetes do not appear to stem from inequalities in initial diagnosis.
To characterize ethnic differences in the severity and clinical management of type 2 diabetes at initial diagnosis.
An observational cohort study of 179,886 people with incident type 2 diabetes between 2004 and 2017 in the Clinical Practice Research Datalink was undertaken; 63.4% of the cohort were of white ethnicity, 3.9% south Asian, and 1.6% black. Ethnic differences in clinical profile at diagnosis, consultation rates, and risk factor recording were derived from linear and logistic regression. Cox-proportional hazards regression was used to determine ethnic differences in time to initiation of therapeutic and non-therapeutic management following diagnosis. All analyses adjusted for age, sex, deprivation, and clustering by practice.
In the 12 months prior to diagnosis, non-white groups had fewer consultations compared to white groups, but risk factor recording was better than or equivalent to white groups for 9/10 risk factors for south Asian groups and 8/10 risk factors for black groups (p < 0.002). Blood pressure, BMI, cholesterol, eGFR, and CVD risk levels were more favourable in non-white groups, and prevalence of macrovascular disease was significantly lower (p < 0.003). Time to initiation of antidiabetic treatment and first risk assessment was faster in non-white groups relative to white groups, while time to risk factor measurement and diabetes review was slower.
We find limited evidence of systematic ethnic inequalities around the time of type 2 diabetes diagnosis. Ethnic disparities in downstream consequences may relate to genetic risk factors, or manifest later in the care pathway, potentially in relation to long-term risk factor control.
Chronic obstructive pulmonary disease (COPD) is a major cause of mortality. Patients with advanced disease often have a poor quality of life, such that guidelines recommend providing palliative care ...in their last year of life. Uptake and use of palliative care in advanced COPD is low; difficulty in predicting 1-year mortality is thought to be a major contributing factor.
We identified two primary care COPD cohorts using UK electronic healthcare records (Clinical Practice Research Datalink). The first cohort was randomised equally into training and test sets. An external dataset was drawn from a second cohort. A risk model to predict mortality within 12 months was derived from the training set using backwards elimination Cox regression. The model was given the acronym BARC based on putative prognostic factors including body mass index and blood results (B), age (A), respiratory variables (airflow obstruction, exacerbations, smoking) (R) and comorbidities (C). The BARC index predictive performance was validated in the test set and external dataset by assessing calibration and discrimination. The observed and expected probabilities of death were assessed for increasing quartiles of mortality risk (very low risk, low risk, moderate risk, high risk). The BARC index was compared to the established index scores body mass index, obstructive, dyspnoea and exacerbations (BODEx), dyspnoea, obstruction, smoking and exacerbations (DOSE) and age, dyspnoea and obstruction (ADO).
Fifty-four thousand nine hundred ninety patients were eligible from the first cohort and 4931 from the second cohort. Eighteen variables were included in the BARC, including age, airflow obstruction, body mass index, smoking, exacerbations and comorbidities. The risk model had acceptable predictive performance (test set: C-index = 0.79, 95% CI 0.78-0.81, D-statistic = 1.87, 95% CI 1.77-1.96, calibration slope = 0.95, 95% CI 0.9-0.99; external dataset: C-index = 0.67, 95% CI 0.65-0.7, D-statistic = 0.98, 95% CI 0.8-1.2, calibration slope = 0.54, 95% CI 0.45-0.64) and acceptable accuracy predicting the probability of death (probability of death in 1 year, n high-risk group, test set: expected = 0.31, observed = 0.30; external dataset: expected = 0.22, observed = 0.27). The BARC compared favourably to existing index scores that can also be applied without specialist respiratory variables (area under the curve: BARC = 0.78, 95% CI 0.76-0.79; BODEx = 0.48, 95% CI 0.45-0.51; DOSE = 0.60, 95% CI 0.57-0.61; ADO = 0.68, 95% CI 0.66-0.69, external dataset: BARC = 0.70, 95% CI 0.67-0.72; BODEx = 0.41, 95% CI 0.38-0.45; DOSE = 0.52, 95% CI 0.49-0.55; ADO = 0.57, 95% CI 0.54-0.60).
The BARC index performed better than existing tools in predicting 1-year mortality. Critically, the risk score only requires routinely collected non-specialist information which, therefore, could help identify patients seen in primary care that may benefit from palliative care.
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