Fall in population-based mortality from coronary heart disease negated in people with diabetes mellitus: data from England.

AIMS: Mortality rates for coronary heart disease (CHD) have declined substantially in developed countries. Diabetes mellitus is an important risk factor for CHD; its prevalence is increasing. We aimed to compare trends in population-based mortality for CHD without diabetes on the death certificate with trends for CHD with diabetes on the same certificate. METHODS: Analysis of an all-England dataset with multiple-cause coded mortality records from 1995 to 2010. Analysis of a similar dataset for Oxford, because it has the longest run of multiple-cause coded mortality in England, from 1979. Age-specific and age-standardized mortality rates were calculated. RESULTS: In the all-England dataset, there were 1 772 760 deaths with CHD and no mention of diabetes; and 173 184 deaths with CHD and diabetes on the same death certificate. Of deaths with CHD without a mention of diabetes, rates per million men fell by more than half from 2843 (95% confidence interval: 2822-2862) in 1995 to 1379 (1366-1391) in 2010; and those in women halved from 1324 (1314-1336) to 628 (621-635). Of deaths with CHD and diabetes, rates per million men increased from 194 (188-200) to 215 (210-220); and those for women fell, but only very slightly, from 114 (111-118) to 101 (98-104). The longer run in Oxford, from 1979, showed that rates in men and women without diabetes had fallen by two-thirds; but that rates for CHD with diabetes had not fallen. CONCLUSIONS: The fall in mortality from CHD without diabetes has been spectacular. There has been no comparable fall in mortality from CHD with diabetes.

Cancer in patients admitted to hospital with diabetes mellitus aged 30 years and over: record linkage studies.

AIMS/HYPOTHESIS: The aim of this study was to determine the risk of cancer in people admitted to hospital for diabetes mellitus when aged 30 or older. METHODS: This study involved the analysis of two statistical datasets of linked hospital and mortality data, in an area in southern England, between 1963 and 1998 (the Oxford Record Linkage Study, ORLS1) and between 1999 and 2008 (ORLS2). Rates of cancer in the diabetes cohorts were compared with rates of cancer in reference cohorts and expressed as rate ratios. RESULTS: The rate ratio for all cancer in people admitted to hospital with diabetes was 1.01 (95% CI 0.95-1.06, based on 15,898 people with diabetes) for the years 1963-1998; and 1.09 (1.00-1.19, based on 7,771 people with diabetes) in the years 1999-2008. In both datasets, there were significantly high rate ratios for cancers of the liver (ORLS1 and ORLS2, respectively, 2.0 [95% CI 1.4-2.9]; 2.5 [95% CI 1.3-4.3]), pancreas (2.2 [95% CI 1.8-2.7]; 3.5 [95% CI 2.5-4.8]) and uterus (1.5 [95% CI 1.0-2.2]; 2.6 [95% CI 1.4-4.5]). There were significantly low rate ratios for cancer of the prostate (0.6 [95% CI 0.5-0.7]; 0.7 [95% CI 0.5-0.9]) and non-melanoma skin cancer (0.6 [95% CI 0.5-0.8]; 0.8 [95% CI 0.6-0.96]). CONCLUSIONS/INTERPRETATION: Diabetes mellitus was associated with an elevated risk of some site-specific cancers and a reduction of risk of others. Considering the risk in diabetes of all cancers combined, the elevation of risk, if any, is likely to be small and numerically less important than other known complications of diabetes.

Benign breast disease and subsequent breast cancer: English record linkage studies.

BACKGROUND: Benign breast disease (BBD) increases the risk of breast cancer, but details of the relationship would benefit from further study in the UK. METHODS: Analysis of linked statistical abstracts of hospital data, including a cohort of 20 976 women with BBD in an Oxford data set and 89 268 such women in an English national data set. RESULTS: Rate ratios (RRs) for breast cancer, comparing BBD and comparison cohorts in these two data sets, were 2.3 (95% CI: 2.2-2.5) and 3.2 (3.0-3.3), respectively. RRs rose with increasing age at BBD diagnosis and remained elevated for at least 20 years after diagnosis. RRs were particularly high for a relatively small number of cancers occurring in the first few months after BBD diagnosis. CONCLUSIONS: Our findings accord well with those in other large studies, mostly done in the USA, in showing a sustained long-term cancer risk after BBD. They also demonstrate that known long-term risks of disease can be reliably identified from linked routine administrative hospital statistics. Most other studies omit cancers in the first few months after BBD. Such cases-presumably either misdiagnosed or miscoded-merit further study to determine whether in fact they include diagnoses of cancer that were initially missed.

Immune-mediated and chronic inflammatory disease in people with sarcoidosis: disease associations in a large UK database.

BACKGROUND: Sarcoidosis is a multi-system disorder characterised by non-caseating granulomas. Coexistence of sarcoidosis with immune-mediated and chronic inflammatory diseases has been described in case series. However, the coexistence of two different diseases in individuals can occur by chance, even if each of the diseases is rare. AIM: To determine whether sarcoidosis necessitating hospital admission or day-case care coexists with a range of immune-mediated and chronic inflammatory diseases more commonly than expected by chance. DESIGN: Analysis of an epidemiological database of hospital admission and day-case statistics, spanning 30 years. RESULTS: 1510 patients with sarcoidosis were identified (mean age 44 years, median follow-up 19 years) who had been admitted to hospital or day-case care. Significant associations in the sarcoidosis cohort were identified with systemic lupus erythematosus (odds ratio (OR) 8.3; 95% CI 2.7 to 19.4), autoimmune chronic hepatitis (OR 6.7; 95% CI 1.8 to 17.1), multiple sclerosis (OR 3.3; 95% CI 1.7 to 5.6), coeliac disease (OR 3.1; 95% CI 1.01 to 7.3), thyrotoxicosis (OR 2.5; 95% CI 1.4 to 4.0), myxoedema (OR 2.2; 95% CI 1.2 to 3.7) and ulcerative colitis (OR 2.1; 95% CI 1.1 to 3.7). Weaker associations were found for diabetes mellitus with a first admission aged 30-49 years (OR 2.9; 95% CI 2.1 to 4.0) or age >50 (OR 1.7; 95% CI 1.2 to 2.3), but not for people age <30. No significant association with Crohn's disease (OR 1.52; 95% CI 0.61 to 3.14) or primary biliary cirrhosis (OR 3.75; 95% CI 0.77 to 11.0),was found. When all immune-mediated and chronic inflammatory diseases for which associations were sought were combined, the overall rate ratio associated with sarcoidosis was 2.2 (95% CI 1.9 to 2.6). CONCLUSION: This study adds epidemiological evidence to information from clinical reports that there is a connection between sarcoidosis and other immune-mediated and chronic inflammatory diseases.

Cow's milk and the emergence of group B streptococcal disease in newborn babies.

BACKGROUND: Group B streptococcus (GBS), the most significant cause of neonatal bacterial sepsis, is thought to have emerged in the 1960s. GBS also causes mastitis in cows, and there is indirect evidence that human GBS is derived from a bovine ancestor. OBJECTIVE: A major change in the collection of milk from farms, using bulk tanks rather than churns, occurred in the 1960s. We sought to define the temporal relationship between this change in farming and the emergence of GBS neonatal disease. METHODS: We searched PubMed for reports of GBS disease from 1930 until 1980 to more exactly determine the time of emergence of neonatal infection and supported this data with UK hospital admission statistics for GBS infections. We identified the dates of the change from churns to bulk tanks by searching the internet and books for information on the history of milk transportation, farming and milk collection in the UK. RESULTS: There are no PubMed reports of neonatal GBS disease between 1930 and 1950, and reports from the UK only emerged in the mid-1960s, confirming the notion that GBS neonatal infection was a newly emergent disease in the 1960s. No national data on hospital admissions are available around this time, but the Oxford Record Linkage Study, with admission data available for Oxford from 1968, showed no cases of neonatal disease until 1974. Cow's milk collection in the UK switched to bulk tank between 1960 and 1979, and publications relating to GBS disease emerged soon after. CONCLUSIONS: There is a temporal relationship between the emergence of neonatal GBS disease reports in the UK in the 1960s and a change in cow's milk collection. This finding may be a temporal coincidence or may add support to the notion that human GBS was historically derived from a bovine ancestor.

Trends over time and geographical variation in admission rates for plastic surgery in England.

The epidemiology of provision of plastic surgical care is poorly understood. Anecdotally, plastic surgeons in England have reported an increasing volume of work. However, it is unclear how much the workload has increased, and whether there is much geographical variation in workload within a publicly funded healthcare system. Data from English national hospital statistics from 1968-2004 and the Oxford Record Linkage Study (ORLS) from 1963-2004 were analysed for plastic surgery to study long-term trends. Linkage enables analyses to be undertaken in which individuals are counted once only each year regardless of how many plastic surgical admissions they had in the year. In addition, linked hospital admission data for plastic surgery in England, available from 2001-2005, were analysed to study geographical variation. Admission rates increased very substantially over the last four decades: per 100,000 population, they were 71 per 100,000 in England in 1968 and 408 by 2004. Admission rates in the ORLS area, measured as episodes per 100,000, rose from 73 in 1963 to 452 in 2004; and the corresponding figures for person-based rates rose from 63 to 400. Thus the increase in admission rates was a genuine, substantial increase in numbers of people in receipt of Plastic surgical care and not simply an increase in multiple admissions per patient. Geographical analysis showed 4.6-fold variation in admission rates for residents of the health authority areas (range 154 (Hampshire and the Isle of Wight) to 716 (County Durham and Tees Valley) admissions per 100,000 population). We discuss implications of the findings for workforce planning and service design in Plastic surgery within the context of the NHS, and how they may be applied to plastic surgical healthcare models globally. Detailed analysis of case-mix in the speciality, aimed at increasing understanding of both trends and geographical variation, is warranted.

Associations between infectious mononucleosis and cancer: record-linkage studies.

Infection with Epstein-Barr virus (EBV) followed by infectious mononucleosis (IM) is now considered to be a risk factor for Hodgkin's disease (HD). It is less clear whether EBV infection and IM are associated with an increased risk of cancer generally. We used a longstanding record-linkage dataset in Oxford (years 1963-1998), and a more recent record-linkage dataset covering England (1999-2005), to compare rate ratios for cancer between people admitted to hospital for IM and a reference cohort. In the Oxford cohort, there was an increased risk of subsequent HD [rate ratio (RR) 6.0, 95% confidence interval (CI) 2.4-12.5] but not of other cancers combined (RR 0.85, 95% CI 0.57-1.23). In the England cohort, there were increased risks of HD (RR 3.2, 95% CI 1.2-7.0), non-Hodgkin's lymphoma (RR 5.6, 95% CI 2.9-9.8), and oropharyngeal cancer (RR 5.4, 95% CI 1.1-16.2), but no significant overall risk of cancer when lymphomas were excluded (RR 1.01, 95% CI 0.71-1.41). We confirm an association between IM and lymphoma; but the risk, if any, of cancer more generally is likely to be small.

Cancer and immune-mediated disease in people who have had meningococcal disease: record-linkage studies.

The mechanisms that cause susceptibility to invasive meningococcal disease are largely unknown, but are likely to have important genetic and immunological components. We postulated that susceptibility to meningococcal disease might be associated with altered risks of development of other clinical disease. We studied cancer and immune-mediated disease in people who have been hospitalized with meningococcal disease. In cohorts of people who had invasive meningococcal disease, compared with reference cohorts, the rate ratio for cancer in an Oxford dataset studied from 1963 to 1998 was 0.88 [95% confidence interval (CI) 0.42-1.61] and in an all-England dataset studied from 1999 to 2005 it was 1.02 (95% CI 0.80-1.27). The respective rate ratios for immune-mediated disease were 1.49 (95% CI 0.81-2.50) and 0.69 (95% CI 0.53-0.89). Susceptibility to meningococcal disease was not associated with an altered risk of cancer. Occurrence of immune-mediated disease was, if anything, low in the large all-England cohort of people who had meningococcal disease.

Risk of multiple sclerosis after head injury: record linkage study.

BACKGROUND: The possibility that head injury may influence the development of multiple sclerosis (MS) has been studied inconclusively in the past. OBJECTIVE: To determine whether head injury is associated with an increased risk of MS. METHOD: Analysis of database of linked hospital and death records, comparing the occurrence of MS in a cohort of people admitted to hospital with head injury and a reference cohort. RESULTS: The rate ratio for MS after head injury, compared with the reference cohort, was 1.1 (95% confidence interval, 0.88 to 1.36). There was no significant increase in the risk of MS at either short or long time periods after head injury. Using length of hospital stay as a proxy for severity of injury, there was no significant increase in the rate ratio for MS after head injuries with hospital stays of less than two days (rate ratio = 1.1 (0.71 to 1.57)), two or more days (rate ratio = 1.0 (0.68 to 1.45)), or seven or more days (rate ratio = 1.3 (0.64 to 2.34)). CONCLUSIONS: The method used, record linkage, ensures that patients' recollection of injury, or any tendency to attribute MS to injury, cannot have influenced the results. Injuries to the head were not associated with either the aetiological initiation or the clinical precipitation of onset of multiple sclerosis.