Temporal Risk of Nonfatal Cardiovascular Events After Chronic Obstructive Pulmonary Disease Exacerbation: A Population-based Study.

Rationale: Cardiovascular events after chronic obstructive pulmonary disease (COPD) exacerbations are recognized. Studies to date have been post hoc analyses of trials, did not differentiate exacerbation severity, included death in the cardiovascular outcome, or had insufficient power to explore individual outcomes temporally.Objectives: We explore temporal relationships between moderate and severe exacerbations and incident, nonfatal hospitalized cardiovascular events in a primary care-derived COPD cohort.Methods: We included people with COPD in England from 2014 to 2020, from the Clinical Practice Research Datalink Aurum primary care database. The index date was the date of first COPD exacerbation or, for those without exacerbations, date upon eligibility. We determined composite and individual cardiovascular events (acute coronary syndrome, arrhythmia, heart failure, ischemic stroke, and pulmonary hypertension) from linked hospital data. Adjusted Cox regression models were used to estimate average and time-stratified adjusted hazard ratios (aHRs).Measurements and Main Results: Among 213,466 patients, 146,448 (68.6%) had any exacerbation; 119,124 (55.8%) had moderate exacerbations, and 27,324 (12.8%) had severe exacerbations. A total of 40,773 cardiovascular events were recorded. There was an immediate period of cardiovascular relative rate after any exacerbation (1-14 d; aHR, 3.19 [95% confidence interval (CI), 2.71-3.76]), followed by progressively declining yet maintained effects, elevated after one year (aHR, 1.84 [95% CI, 1.78-1.91]). Hazard ratios were highest 1-14 days after severe exacerbations (aHR, 14.5 [95% CI, 12.2-17.3]) but highest 14-30 days after moderate exacerbations (aHR, 1.94 [95% CI, 1.63-2.31]). Cardiovascular outcomes with the greatest two-week effects after a severe exacerbation were arrhythmia (aHR, 12.7 [95% CI, 10.3-15.7]) and heart failure (aHR, 8.31 [95% CI, 6.79-10.2]).Conclusions: Cardiovascular events after moderate COPD exacerbations occur slightly later than after severe exacerbations; heightened relative rates remain beyond one year irrespective of severity. The period immediately after an exacerbation presents a critical opportunity for clinical intervention and treatment optimization to prevent future cardiovascular events.

Factors associated with non-fatal heart failure and atrial fibrillation or flutter within the first 30 days post COPD exacerbation: a nested case-control study.

BACKGROUND: An immediate, temporal risk of heart failure and arrhythmias after a Chronic Obstructive Pulmonary Disease (COPD) exacerbation has been demonstrated, particularly in the first month post-exacerbation. However, the clinical profile of patients who develop heart failure (HF) or atrial fibrillation/flutter (AF) following exacerbation is unclear. Therefore we examined factors associated with people being hospitalized for HF or AF, respectively, following a COPD exacerbation. METHODS: We conducted two nested case-control studies, using primary care electronic healthcare records from the Clinical Practice Research Datalink Aurum linked to Hospital Episode Statistics, Office for National Statistics for mortality, and socioeconomic data (2014-2020). Cases had hospitalization for HF or AF within 30 days of a COPD exacerbation, with controls matched by GP practice (HF 2:1;AF 3:1). We used conditional logistic regression to explore demographic and clinical factors associated with HF and AF hospitalization. RESULTS: Odds of HF hospitalization (1,569 cases, 3,138 controls) increased with age, type II diabetes, obesity, HF and arrhythmia history, exacerbation severity (hospitalization), most cardiovascular medications, GOLD airflow obstruction, MRC dyspnea score, and chronic kidney disease. Strongest associations were for severe exacerbations (adjusted odds ratio (aOR)=6.25, 95%CI 5.10-7.66), prior HF (aOR=2.57, 95%CI 1.73-3.83), age≥80 years (aOR=2.41, 95%CI 1.88-3.09), and prior diuretics prescription (aOR=2.81, 95%CI 2.29-3.45). Odds of AF hospitalization (841 cases, 2,523 controls) increased with age, male sex, severe exacerbation, arrhythmia and pulmonary hypertension history and most cardiovascular medications. Strongest associations were for severe exacerbations (aOR=5.78, 95%CI 4.45-7.50), age≥80 years (aOR=3.15, 95%CI 2.26-4.40), arrhythmia (aOR=3.55, 95%CI 2.53-4.98), pulmonary hypertension (aOR=3.05, 95%CI 1.21-7.68), and prescription of anticoagulants (aOR=3.81, 95%CI 2.57-5.64), positive inotropes (aOR=2.29, 95%CI 1.41-3.74) and anti-arrhythmic drugs (aOR=2.14, 95%CI 1.10-4.15). CONCLUSIONS: Cardiopulmonary factors were associated with hospitalization for HF in the 30 days following a COPD exacerbation, while only cardiovascular-related factors and exacerbation severity were associated with AF hospitalization. Understanding factors will help target people for prevention.

Relationship between asthma and severe COVID-19: a national cohort study.

BACKGROUND: We aimed to determine whether children and adults with poorly controlled or more severe asthma have greater risk of hospitalisation and/or death from COVID-19. METHODS: We used individual-level data from the Office for National Statistics Public Health Data Asset, based on the 2011 census in England, and the General Practice Extraction Service data for pandemic planning and research linked to death registration records and Hospital Episode Statistics admission data. Adults were followed from 1 January 2020 to 30 September 2021 for hospitalisation or death from COVID-19. For children, only hospitalisation was included. RESULTS: Our cohort comprised 35 202 533 adults and 2 996 503 children aged 12-17 years. After controlling for sociodemographic factors, pre-existing health conditions and vaccine status, the risk of death involving COVID-19 for adults with asthma prescribed low dose inhaled corticosteroids (ICS) was not significantly different from those without asthma. Adults with asthma prescribed medium and high dosage ICS had an elevated risk of COVID-19 death; HRs 1.18 (95% CI 1.14 to 1.23) and 1.36 (95% CI 1.28 to 1.44), respectively. A similar pattern was observed for COVID-19 hospitalisation; fully adjusted HRs 1.53 (95% CI 1.50 to 1.56) and 1.52 (95% CI 1.46 to 1.56) for adults with asthma prescribed medium and high-dosage ICS, respectively. Risk of hospitalisation was greater for children with asthma prescribed one (2.58 (95% CI 1.82 to 3.66)) or two or more (3.80 (95% CI 2.41 to 5.95)) courses of oral corticosteroids in the year prior to the pandemic. DISCUSSION: People with mild and/or well-controlled asthma are neither at significantly increased risk of hospitalisation with nor more likely to die from COVID-19 than adults without asthma.

Recent trends in asthma diagnosis, preschool wheeze diagnosis and asthma exacerbations in English children and adolescents: a SABINA Jr study.

BACKGROUND: Asthma-related burden remains poorly characterised in children in the UK. We quantified recent trends in asthma prevalence and burden in a UK population-based cohort (1‒17-year-olds). METHODS: The Clinical Practice Research Datalink Aurum database (2008‒2018) was used to assess annual asthma incidence and prevalence in 1‒17-year-olds and preschool wheeze in 1‒5-year-olds, stratified by sex and age. During the same period, annual asthma exacerbation rates were assessed in those with either a diagnosis of preschool wheeze or asthma. RESULTS: Annual asthma incidence rates decreased by 51% from 1403.4 (95% CI 1383.7 to 1423.2) in 2008 to 688.0 (95% CI 676.3 to 699.9) per 105 person-years (PYs) in 2018, with the most pronounced decrease observed in 1‒5-year olds (decreasing by 65%, from 2556.9 (95% CI 2509.8 to 2604.7) to 892.3 (95% CI 866.9 to 918.3) per 105 PYs). The corresponding decreases for the 6‒11- and 12‒17-year-olds were 36% (1139.9 (95% CI 1110.6 to 1169.7) to 739.9 (95% CI 720.5 to 759.8)) and 20% (572.3 (95% CI 550.4 to 594.9) to 459.5 (95% CI 442.9 to 476.4)) per 105 PYs, respectively. The incidence of preschool wheeze decreased over time and was slightly more pronounced in the 1‒3 year-olds than in the 4-year-olds. Prevalence of asthma and preschool wheeze also decreased over time, from 18.0% overall in 2008 to 10.2% in 2018 for asthma. Exacerbation rates increased over time from 1.33 (95% CI 1.31 to 1.35) per 10 PYs in 2008 to 1.81 (95% CI 1.78 to 1.83) per 10 PYs in 2018. CONCLUSION: Paediatric asthma incidence decreased in the UK since 2008, particularly in 1-5-year-olds; this was accompanied by a decline in asthma prevalence. Preschool wheeze incidence also decreased in this age group. However, exacerbation rates have been increasing.

Left-sided heart failure burden and mortality in idiopathic pulmonary fibrosis: a population-based study.

BACKGROUND: Cardiovascular disease is prevalent in idiopathic pulmonary fibrosis (IPF), yet the extent of left-sided heart failure (HF) burden, whether this has changed with time and whether HF impacts mortality risk in these patients are unknown. The aims of this study were therefore to determine the temporal trends in incidence and prevalence of left-sided HF in patients with IPF in England and compare these to published estimates in the general population and those with comparable chronic respiratory conditions such as chronic obstructive pulmonary disease (COPD), as well as determine the risk of all-cause and cause-specific mortality in patients with comorbid left-sided HF and IPF at population-level using electronic healthcare data. METHODS: Clinical Practice Research Datalink (CPRD) Aurum primary-care data linked to mortality and secondary-care data was used to identify IPF patients in England. Left-sided HF prevalence and incidence rates were calculated for each calendar year between 2010 and 2019, stratified by age and sex. Risk of all-cause, cardiovascular and IPF-specific mortality was calculated using multivariate Cox regression. RESULTS: From 40,577patients with an IPF code in CPRD Aurum, 25, 341 IPF patients met inclusion criteria. Left-sided HF prevalence decreased from 33.4% (95% CI 32.2-34.6) in 2010 to 20.9% (20.0-21.7) in 2019. Left-sided HF incidence rate per 100 person-years (95% CI) remained stable between 2010 and 2017 but decreased from 4.3 (3.9-4.8) in 2017 to 3.4 (3.0-3.9) in 2019. Throughout follow-up, prevalence and incidence were higher in men and with increasing age. Comorbid HF was associated with poorer survival (adjusted HR (95%CI) 1.08 (1.03-1.14) for all-cause mortality; 1.32 (1.09-1.59) for cardiovascular mortality). CONCLUSION: Left-sided HF burden in IPF patients in England remains high, with incidence almost 4 times higher than in COPD, a comparable lung disease with similar cardiovascular risk factors. Comorbid left-sided HF is also a poor prognostic marker. More substantial reduction in left-sided HF prevalence than incidence suggests persistently high IPF mortality. Given rising IPF incidence in the UK, this calls for better management of comorbidities such as left-sided HF to help optimise IPF survival.

Gang membership and sexual violence: associations with childhood maltreatment and psychiatric morbidity.

BACKGROUND: Gang members engage in many high-risk sexual activities that may be associated with psychiatric morbidity. Victim-focused research finds high prevalence of sexual violence towards women affiliated with gangs. AIMS: To investigate associations between childhood maltreatment and psychiatric morbidity on coercive and high-risk sexual behaviour among gang members. METHOD: Cross-sectional survey of 4665 men 18-34 years in Great Britain using random location sampling. The survey oversampled men from areas with high levels of violence and gang membership. Participants completed questionnaires covering violent and sexual behaviours, experiences of childhood disadvantage and trauma, and psychiatric diagnoses using standardised instruments. RESULTS: Antisocial men and gang members had high levels of sexual violence and multiple risk behaviours for sexually transmitted infections, childhood maltreatment and mental disorders, including addictions. Physical, sexual and emotional trauma were strongly associated with adult sexual behaviour and more prevalent among gang members. Other violent behaviour, psychiatric morbidity and addictions accounted for high-risk and compulsive sexual behaviours among gang members but not antisocial men. Gang members showed precursors before age 15 years of adult preference for coercive rather than consenting sexual behaviour. CONCLUSIONS: Gang members show inordinately high levels of childhood trauma and disadvantage, sexual and non-sexual violence, and psychiatric disorders, which are interrelated. The public health problem of sexual victimisation of affiliated women is explained by these findings. Healthcare professionals may have difficulties promoting desistance from adverse health-related behaviours among gang members whose multiple high-risk and violent sexual behaviours are associated with psychiatric morbidity, particularly addictions.

Ethnic disparities in psychotic experiences explained by area-level syndemic effects.

BACKGROUND: Ethnic inequalities in health outcomes are often explained by socioeconomic status and concentrated poverty. However, ethnic disparities in psychotic experiences are not completely attenuated by these factors. AIMS: We investigated whether disparities are better explained by interactions between individual risk factors and place-based clustering of disadvantage, termed a syndemic. METHOD: We performed a cross-sectional survey of 3750 UK men, aged 18-34 years, oversampling Black and minority ethnic (BME) men nationally, together with men residing in London Borough of Hackney. Participants completed questionnaires covering psychiatric symptoms, substance misuse, crime and violence, and risky sexual health behaviours. We included five psychotic experiences and a categorical measure of psychosis based on the Psychosis Screening Questionnaire. RESULTS: At national level, more Black men reported psychotic experiences but disparities disappeared following statistical adjustment for social position. However, large disparities for psychotic experiences in Hackney were not attenuated by adjustment for social factors in Black men (adjusted odds ratio, 3.24; 95% CI 2.14-4.91; P < 0.002), but were for South Asian men. A syndemic model of joint effects, adducing a four-component latent variable (psychotic experiences and anxiety, substance dependence, high-risk sexual behaviour and violence and criminality) showed synergy between components and explained persistent disparities in psychotic experiences. A further interaction confirmed area-level effects (Black ethnicity × Hackney residence, 0.834; P < 0.001). CONCLUSIONS: Syndemic effects result in higher rates of non-affective psychosis among BME persons in certain inner-urban settings. Further research should investigate how syndemics raise levels of psychotic experiences and related health conditions in Black men in specific places with multiple deprivations.

Evidence of concurrent and prospective associations between early maltreatment and ADHD through childhood and adolescence.

PURPOSE: An emerging body of work suggests a link between childhood maltreatment and attention-deficit hyperactivity disorder (ADHD). However, research examining the role of maltreatment in the early course of the disorder lacks robust evidence from longitudinal studies. Our aim was to examine concurrent and prospective associations between maltreatment experiences and ADHD diagnosis and sex differences, and to estimate the association between repetitive maltreatment exposure and ADHD through childhood and adolescence. METHODS: Data were obtained from the Boricua Youth Study, a longitudinal study of 2480 children and adolescents of Puerto Rican background. Neglect, physical, emotional and sexual abuse, and foster placement were regressed on ADHD diagnosis measured at each of three waves using the Diagnostic Interview Schedule for Children-IV. Multilevel regressions estimated the effects of exposure on ADHD, adjusted by age, sex, income, household education, parental psychopathology, comorbidity and ADHD medication status. RESULTS: Emotional abuse and foster placement had robust associations with ADHD diagnosis. For girls, physical abuse had a threefold increase in the odds of having ADHD diagnosis; for boys, associations were observed only for emotional abuse. Prospective models examining the risk of ADHD following maltreatment provided initial evidence for the effects of physical abuse on ADHD, and a linear trend for repetitive exposure suggested increased probability for disorder persistence. CONCLUSIONS: Associations between early maltreatment and ADHD were robust. Different categories of maltreatment increase the likelihood of ADHD for girls and boys. Increased exposure to maltreatment may predict symptom persistence. Interventions addressing ADHD must consider the effects of both sex and family environment.

Shifts in positive and negative psychotic symptoms and anger: effects on violence.

BACKGROUND: Changes in positive and negative symptom profiles during acute psychotic episodes may be key drivers in the pathway to violence. Acute episodes are often preceded by fluctuations in affect before psychotic symptoms appear and affective symptoms may play a more important role in the pathway than previously recognised. METHODS: We carried out a prospective cohort study of 409 male and female patients discharged from medium secure services in England and Wales to the community. Measures were taken at baseline (pre-discharge), 6 and 12 months post-discharge using the Positive and Negative Syndrome Scale. Information on violence was obtained using the McArthur Community Violence Instrument and Police National Computer. RESULTS: The larger the shift in positive symptoms the more likely violence occurred in each 6-month period. However, shifts in angry affect were the main driving factor for positive symptom shifts associated with violence. Shifts in negative symptoms co-occurred with positive and conveyed protective effects, but these were overcome by co-occurring shifts in anger. Severe but stable delusions were independently associated with violence. CONCLUSIONS: Intensification of angry affect during acute episodes of psychosis indicates the need for interventions to prevent violence and is a key driver of associated positive symptoms in the pathway to violence. Protective effects against violence exerted by negative symptoms are not clinically observable during symptom shifts because they are overcome by co-occurring anger.

A cross-national comparison of violence among young men in China and the UK: psychiatric and cultural explanations.

PURPOSE: Public health psychiatry has a key role in violence prevention. Cross-national comparisons of violence and associated psychiatric morbidity can indicate targets for preventive interventions. METHOD: Data on young adult men in households, 18-34 years, were drawn from the Second Men's Modern Lifestyles survey in Great Britain (n = 2046) and from a corresponding survey in Chengdu, China (n = 4132), using a translated questionnaire. Binary logistic regression models were carried out to estimate the cross-national differences for different types of violence and to identify explanatory variables. RESULTS: Chinese men were less likely to report violence in the past 5 years (AOR 0.59, 95% CI 0.48-0.72, P < 0.001). All levels of violence were lower among Chinese men except intimate partner violence (AOR 2.43, 95% CI 1.65-3.59, P < 0.001) and a higher proportion of Chinese men were only violent towards their partners (AOR 7.90, 95% CI 3.27-19.07, P < 0.001). CONCLUSIONS: Cross-national differences were explained by British men's reports of early violence persisting into adulthood, confidence in fighting ability, perception that violence is acceptable behaviour, and experience of violent victimization. More British men screened positive for antisocial personality disorder and substance misuse. Attitudes which condone violence and a serious problem of alcohol-related, male-on-male violence are key targets for preventive interventions among British men. The higher prevalence of life course-persistent antisocial behaviour among British men is of concern and requires further investigation. Higher prevalence of intimate partner violence among Chinese men reflects patriarchal approaches to conflict resolution and confirms an important public health problem in China which requires further cross-national investigation.

Extremism, religion and psychiatric morbidity in a population-based sample of young men.

BACKGROUND: There is growing risk from terrorism following radicalisation of young men. It is unclear whether psychopathology is associated. AIMS: To investigate the population distribution of extremist views among UK men. METHOD: Cross-sectional study of 3679 men, 18-34 years, in Great Britain. Multivariate analyses of attitudes, psychiatric morbidity, ethnicity and religion. RESULTS: Pro-British men were more likely to be White, UK born, not religious; anti-British were Muslim, religious, of Pakistani origin, from deprived areas. Pro- and anti-British views were linearly associated with violence (adjusted odds ratio (OR) = 1.51, 95% CI 1.38-1.64, P<0.001, adjusted OR = 1.33, 95% CI 1.13-1.58, P<0.001, respectively) and negatively with depression (adjusted OR = 0.72, 95% CI 0.61-0.85, P<0.001, adjusted OR = 0.64, 95% CI 0.48-0.86, P = 0.003, respectively). CONCLUSIONS: Men at risk of depression may experience protection from strong cultural or religious identity. Antisocial behaviour increases with extremism. Religion is protective but may determine targets of violence following radicalisation.

Borderline personality disorder and violence in the UK population: categorical and dimensional trait assessment.

BACKGROUND: Borderline personality disorder (BPD) is characterised by difficulties with impulse control and affective dysregulation. It is unclear whether BPD contributes to the perpetration of violence or whether this is explained by comorbidity. We explored independent associations between categorical and dimensional representations of BPD and violence in the general population, and differential associations from individual BPD criteria. METHODS: We used a representative combined sample of 14,753 men and women from two British national surveys of adults (≥16 years). BPD was assessed using the Structured Clinical Interview II- Questionnaire. We measured self-reported violent behaviour in the past 5 years, including severity, victims and locations of incidents. Associations for binary, dimensional and trait-level exposures were performed using weighted logistic regression, adjusted for demography and comorbid psychopathology. RESULTS: Categorical diagnosis of BPD was associated only with intimate partner violence (IPV). Associations with serious violence leading to injuries and repetitive violence were better explained by comorbid substance misuse, anxiety and antisocial personality disorder (ASPD). However, anger and impulsivity BPD items were independently associated with most violent outcomes including severity, repetition and injury; suicidal behaviours and affective instability were not associated with violence. Both trait-level and severity-dimensional analyses showed that BPD symptoms might impact males and females differently in terms of violence. CONCLUSIONS: For individuals diagnosed BPD, violence is better explained by comorbidity. However, BPD individual traits show different pathways to violence at the population level. Gender differences in BPD traits and their severity indicate distinct, underlying mechanisms towards violence. BPD and traits should be evaluated in perpetrators of IPV.

Criminal justice pathways to psychiatric care for psychosis.

BACKGROUND: Some patients are at higher risk of contact with criminal justice agencies when experiencing a first episode of psychosis. AIMS: To investigate whether violence explains criminal justice pathways (CJPs) for psychosis in general, and ethnic vulnerability to CJPs. METHOD: Two-year population-based survey of people presenting with a first-episode of psychosis. A total of 481 patients provided information on pathways to psychiatric care. The main outcome was a CJP at first contact compared with other services on the care pathway. RESULTS: CJPs were more common if there was violence at first presentation (odds ratio (OR) = 4.23, 95% CI 2.74-6.54, P<0.001), drug use in the previous year (OR = 2.28, 95% CI 1.50-3.48, P<0.001) and for high psychopathy scores (OR = 2.54, 95% CI 1.43-4.53, P = 0.002). Compared with White British, CJPs were more common among Black Caribbean (OR = 2.97, 95% CI 1.54-5.72, P<0.001) and Black African patients (OR = 1.95, 95% CI 1.02-3.72, P = 0.01). Violence mediated 30.2% of the association for Black Caribbeans, but was not a mediator for Black African patients. These findings were sustained after adjustment for age, marital status, gender and employment. CONCLUSIONS: CJPs were more common in violent presentations, for greater psychopathy levels and drug use. Violence presentations did not fully explain ethnic vulnerability to CJPs.

Accuracy of the recording of pneumonia events in English electronic healthcare record data in patients with chronic obstructive pulmonary disease.

BACKGROUND: In primary care, identifying pneumonia events in people with chronic obstructive pulmonary disease (COPD) may be challenging due to similarities in symptoms with COPD exacerbations and lack of diagnostic testing. This study explored the accuracy of pneumonia diagnosis coded in primary care by comparing diagnosis in primary care with diagnosis in hospital. METHODS: A study population of people with COPD in England was created using the Clinical Practice Research Datalink Aurum database linked with Hospital Episode Statistics inpatient data. Pneumonia codes only, and pneumonia code with associated clinical and/or treatment codes (chest x-ray, symptoms, antibiotics, sputum and blood culture) were used to determine pneumonia events in primary care. Events that were followed by hospitalisation within 7 days were used to estimate the positive predictive value (PPV) of pneumonia coding in primary care, using primary diagnosis of pneumonia in secondary care as the gold standard. The PPV of primary care recording of hospitalised pneumonia was also calculated. RESULTS: Two hundred seventy-four thousand one hundred fifty-six COPD patients were eligible for inclusion, of whom 7,560 had an eligible pneumonia event in primary care diagnosed between 2015-2019 which was not 'hospital-acquired' and was diagnosed and entered on the same day. Of the 2,094 events which were followed by hospitalisation within 7 days, 1,208 had a primary diagnosis of pneumonia in hospital, representing a PPV of pneumonia coding in primary care of 57.7% (95% CI 55.6%-59.8%). Another 284 (13.6%) were diagnosed as a COPD exacerbation and 114 (5.4%) were diagnosed as another respiratory disease. Use of additional pneumonia clinical and treatment codes had a modest effect on the PPV but substantially lowered the number of events. Of the 33,603 eligible pneumonia events identified in secondary care, only 11,445 were recorded in primary care within 42 days, representing a sensitivity of 34.1% (95% CI 33.6%-34.6%). CONCLUSIONS: Use of primary care pneumonia codes and associated clinical and treatment codes to determine pneumonia is not recommended due to significant levels of misdiagnosis and many hospitalised events failing to be recorded in primary care.

A Harmonised Approach to Curating Research-Ready Datasets for Asthma, Chronic Obstructive Pulmonary Disease (COPD) and Interstitial Lung Disease (ILD) in England, Wales and Scotland Using Clinical Practice Research Datalink (CPRD), Secure Anonymised Information Linkage (SAIL) Databank and DataLoch.

Background: Electronic healthcare records (EHRs) are an important resource for health research that can be used to improve patient outcomes in chronic respiratory diseases. However, consistent approaches in the analysis of these datasets are needed for coherent messaging, and when undertaking comparative studies across different populations. Methods and Results: We developed a harmonised curation approach to generate comparable patient cohorts for asthma, chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD) using datasets from within Clinical Practice Research Datalink (CPRD; for England), Secure Anonymised Information Linkage (SAIL; for Wales) and DataLoch (for Scotland) by defining commonly derived variables consistently between the datasets. By working in parallel on the curation methodology used for CPRD, SAIL and DataLoch for asthma, COPD and ILD, we were able to highlight key differences in coding and recording between the databases and identify solutions to enable valid comparisons. Conclusion: Codelists and metadata generated have been made available to help re-create the asthma, COPD and ILD cohorts in CPRD, SAIL and DataLoch for different time periods, and provide a starting point for the curation of respiratory datasets in other EHR databases, expediting further comparable respiratory research.

Risk of cardiovascular events following COVID-19 in people with and without pre-existing chronic respiratory disease.

BACKGROUND: COVID-19 is associated with cardiovascular outcomes in the general population, but it is unknown whether people with chronic respiratory disease (CRD) have a higher risk of cardiovascular events post-COVID-19 compared with the general population and, if so, what respiratory-related factors may modify this risk in these people. METHODS: Primary and secondary care data from the National Health Service England were used to define a population of adults in England with COVID-19 (index date) between 1 January 2020 and 30 November 2021. Adjusted Cox proportional hazard regression was used to quantify the association between CRD, asthma-related factors, chronic obstructive pulmonary disease (COPD)-related factors, and risk of cardiovascular events. Asthma-specific factors included baseline asthma control, exacerbations, and inhaled corticosteroid (ICS) dose. COPD-specific risk factors included baseline ICS and exacerbations. Secondary objectives quantified the impact of COVID-19 hospitalisation and vaccine dose on cardiovascular outcomes. RESULTS: Of 3 670 455 people, those with CRD had a higher risk of cardiovascular events [adjusted hazard ratio (HRadj), 1.08; 95% confidence interval (CI) 1.06-1.11], heart failure (HRadj, 1.17; 95% CI, 1.12-1.22), angina (HRadj, 1.13; 95% CI, 1.06-1.20) and pulmonary emboli (HRadj, 1.24; 95% CI, 1.15-1.33) compared with people without CRD. In people with asthma or COPD, baseline exacerbations were associated with a higher risk of cardiovascular outcomes (HRadj, 1.36; 95% CI, 1.27-1.00 and HRadj, 1.35; 95% CI, 1.24-1.46, respectively). Regardless of CRD, the risk of cardiovascular events was lower with increasing COVID-19 vaccine dose. CONCLUSIONS: Higher risk of cardiovascular events post-COVID-19 might be explained by the underlying severity of the CRD, and COVID-19 vaccines were beneficial to both people with and those without CRD with regards to cardiovascualr events.

Strictly lobar microbleeds are associated with executive impairment in patients with ischemic stroke or transient ischemic attack.

BACKGROUND AND PURPOSE: Cerebral microbleeds (CMBs) are a marker of small vessel diseases, including hypertensive arteriopathy and cerebral amyloid angiopathy, and may be associated with cognitive impairment. The relationship between CMBs and cognitive function in ischemic cerebrovascular disease remains uncertain. We, therefore, investigated the cognitive impact of CMBs in a cohort of patients with ischemic stroke or transient ischemic attack. METHODS: All patients underwent detailed and comprehensive neuropsychological testing and standardized MRI, including fluid attenuation inversion recovery, T1, T2, and gradient-recalled echo T2*-weighted sequences. CMBs, white matter changes, lacunes, and territorial cortical infarcts (defined by standardized criteria) were identified, and associations with cognition assessed. RESULTS: Three hundred twenty patients with a diagnosis of ischemic stroke or transient ischemic attack were included. Of these, 72 (22.5%) had at least 1 CMB. Of all the cognitive domains tested, only executive impairment was more prevalent in patients with CMBs than without (38% versus 25%; P=0.039). In univariate analysis, the presence of strictly lobar (but not deep) CMBs was associated with executive impairment (odds ratio, 2.49; 95% confidence interval, 1.16-5.36; P=0.019). In adjusted multivariate analyses, the presence (OR, 2.34; 95% confidence interval, 1.08-5.09; P=0.031) and number (OR, 1.33; 95% confidence interval, 1.04-1.69; P=0.022) of strictly lobar CMBs were significantly associated with executive impairment. CMBs were not associated with impairment in other cognitive domains. CONCLUSIONS: Strictly lobar CMBs are independently associated with executive dysfunction in patients with ischemic stroke or transient ischemic attack. Our findings suggest that a microangiopathy related to strictly lobar CMBs (eg, cerebral amyloid angiopathy) contributes to cognitive impairment in this population.

Predicting future violence among individuals with psychopathy.

Structured risk assessment aims to help clinicians classify offenders according to likelihood of future violent and criminal behaviour. We investigated how confident clinicians can be using three commonly used instruments (HCR-20, VRAG, OGRS-II) in individuals with different diagnoses. Moderate to good predictive accuracy for future violence was achieved for released prisoners with no mental disorder, low to moderate for clinical syndromes and personality disorder, but accuracy was no better than chance for individuals with psychopathy. Comprehensive diagnostic assessment should precede an assessment of risk. Risk assessment instruments cannot be relied upon when managing public risk from individuals with psychopathy.

Prevalence of Poorly Controlled Asthma and Factors Associated with Specialist Referral in Those with Poorly Controlled Asthma in a Paediatric Asthma Population.

Background: Significant morbidity and mortality are associated with poor asthma control. The aim of this study was to determine factors associated with poor control and referral to specialist secondary care services. Methods: We used primary care data from the Clinical Practice Research Datalink Aurum (CPRD) linked with Hospital Episode Statistics (HES) records from 1st January 2007 to 31st December 2019. We selected patients aged 6-17 years old. Poor control was defined as six or more prescriptions of short-acting beta-agonist (SABA) inhalers, two or more courses of oral corticosteroids (OCS), an Asthma Control test (ACT) or childhood ACT <20, one hospital admission for asthma, or one visit to Accident & Emergency (A&E) department for asthma-related episodes in the 12 months following asthma diagnosis. Asthma severity was defined following GINA guidelines 2021. Results: About 17.6% of children aged between 6 and 17 years with active asthma had poor control. Severe asthma, eczema, food allergies, increased BMI and living in deprived areas were identified as risk factors for poor control. Among those with poor control, referral rates to specialist care were extremely low, only 2% overall. Those with severe asthma were three-times more likely to be referred than those with mild-to-moderate asthma [HRcrude = 4.04 (95% CI, 3.35-4.87); HRadj = 2.72 (95% CI: 2.13-3.49)]. Other factors associated with referral were food allergy and living in a more deprived area. Conclusion: Around 1 in 6 children and adolescents with active asthma are not achieving adequate control of their symptoms. Among the subset of 6-17-year olds with poorly controlled asthma, timely referral for specialist advice in secondary care is rare, especially in those with so-called mild asthma who nevertheless are at significant risk for poor asthma outcomes.

Development of an Asthma Exacerbation Risk Prediction Model for Conversational Use by Adults in England.

Background: Improving accurate risk assessment of asthma exacerbations, and reduction via relevant behaviour change among people with asthma could save lives and reduce health care costs. We developed a simple personalised risk prediction model for asthma exacerbations using factors collected in routine healthcare data for use in a risk modelling feature for automated conversational systems. Methods: We used pseudonymised primary care electronic healthcare records from the Clinical Practice Research Datalink (CPRD) Aurum database in England. We combined variables for prediction of asthma exacerbations using logistic regression including age, gender, ethnicity, Index of Multiple Deprivation, geographical region and clinical variables related to asthma events. Results: We included 1,203,741 patients divided into three cohorts to implement temporal validation: 898,763 (74.7%) in the training sample, 226,754 (18.8%) in the testing sample and 78,224 (6.5%) in the validation sample. The Area under the ROC curve (AUC) for the full model was 0.72 and for the restricted model was 0.71. Using a cut-off point of 0.1, approximately 27 asthma reviews by clinicians per 100 patients would be prevented compared with a strategy that all patients are regarded as high risk. Compared with patients without an exacerbation, patients who exacerbated were older, more likely to be female, prescribed more SABA and ICS in the preceding 12 months, have history of GORD, COPD, anxiety, depression, live in very deprived areas and have more severe disease. Conclusion: Using information available from routinely collected electronic healthcare record data, we developed a model that has moderate ability to separate patients who had an asthma exacerbation within 3 months from their index date from patients who did not. When comparing this model with a simplified model with variables that can easily be self-reported through a WhatsApp chatbot, we have shown that the predictive performance of the model is not substantially different.