Child awareness of and access to cigarettes: impacts of the point-of-sale display ban in England.

INTRODUCTION: England introduced a tobacco display ban for shops with >280 m2 floor area ('partial ban') in 2012, then a total ban in 2015. This study assessed whether these were linked to child awareness of and access to cigarettes. METHODS: Data come from the Smoking, Drinking and Drug Use survey, an annual survey of children aged 11-15 years for 2010-2014 and 2016. Multivariate logistic regression models assessed changes in having seen cigarettes on display, usual sources and ease of access to cigarettes in shops RESULTS: During the partial display ban in 2012, 89.9% of children reported seeing cigarettes on display in the last year, which was reduced to 86.0% in 2016 after the total ban (adjusted OR 0.58, 95% CI 0.50 to 0.66). Reductions were similar in small shops (84.1% to 79.3%)%) and supermarkets (62.6% to 57.3%)%). Although the ban was associated with a reduction in the proportion of regular child smokers reporting that they bought cigarettes in shops (57.0% in 2010 to 39.8% in 2016), we did not find evidence of changes in perceived difficulty or being refused sale among those who still did. DISCUSSION: Tobacco point-of-sale display bans in England reduced the exposure of children to cigarettes in shops and coincided with a decrease in buying cigarettes in shops. However, children do not report increased difficulty in obtaining cigarettes from shops, highlighting the need for additional measures to tackle tobacco advertising, stronger enforcement of existing laws and measures such as licencing for tobacco retailers.

Disparities in testing for renal function in UK primary care: cross-sectional study.

BACKGROUND: In the UK, explicit quality standards for chronic disease management, including for diabetes and chronic kidney disease (CKD), are set out National Service Frameworks and pay-for-performance indicators. These conditions are common with a prevalence of 4% and 5.4%, respectively. CKD is largely asymptomatic, detected following renal function testing and important because associated with increased mortality and morbidity, especially in people with diabetes and proteinuria. OBJECTIVES: To investigate who has their renal function tested and any association with age, sex, ethnicity and diabetes. METHOD: A cross-sectional survey in a primary care research network in south-west London (n = 220 721). The following data were extracted from routine data: age, gender, ethnicity, latest serum creatinine, diagnosis of diabetes and recording of proteinuria. We used logistic regression to explore any association in testing for CKD. RESULTS: People (82.1%) with diabetes had renal function and proteinuria tested; the proportion was much smaller (<0.5%) in those without. Women were more likely to have a creatinine test than men (28% versus 24%, P < 0.05), but this association was modified by age, ethnicity and presence of diabetes. People >75 years and with diabetes were most likely to have been tested. Black [adjusted odds ratio (AOR) 2.1, 95% confidence interval (CI) 2.0-2.2] and south Asian (AOR 1.65, 95% CI 1.56-1.75) patients were more likely to be tested than whites. Those where ethnicity was not stated were the only group not tested more than whites. CONCLUSIONS: Quality improvement initiatives and equity audits, which include CKD should take account of disparities in renal function testing.

Socio-demographic characteristics, health behaviour, co-morbidity and accidents in snorers: a population survey.

OBJECTIVE: We assessed the socio-demographic correlates of snoring and also the patterns of health behaviour and co-morbidity associated with different types of snoring in the Hungarian population. We wanted to study whether different types of snoring are associated with high-risk health behaviour, chronic illnesses, daytime consequences of poor sleep, and with frequent accidents compared with non-snoring individuals. METHOD: This is a cross-sectional study. Interviews were carried out in the homes of 12,643 people. This was the largest nationally representative study in Central Europe about health behaviour. In the Athens Insomnia Scale, questions about snoring and sleep behaviour, life-style factors and health behaviour, as well as questions on their history and current medical treatment were included in the questionnaire. RESULTS: Thirty-seven percent of males and 21% of females reported loud snoring with breathing pauses. We found a significant increasing trend for the consumption of alcohol and coffee as well as smoking among non-snorers, habitual snorers and loud snorers, respectively. In an ordinal regression model male gender, the presence of smoking, the presence of three or more co-morbid conditions and alcohol consumption were independent predictors of snoring (OR [95% CI], 1.99 [1.85-2.1], 1.76 [1.60-1.92], 1.45 [1.30-1.62] and 1.22 [1.04-1.43], respectively, P < 0.001) after controlling for multiple socio-demographic and clinical variables. The frequency of accidents was higher in the loud snoring group than among non-snoring individuals (24% vs 17%, P < 0.0001). CONCLUSIONS: Snoring is common in the Hungarian adult population. Snoring, especially loud snoring with breathing pauses, is strongly associated with high-risk health behaviour, higher co-morbidity and a higher frequency of accidents.

Symptoms of depression in kidney transplant recipients: a cross-sectional study.

BACKGROUND: Depression is associated with impaired quality of life and increased morbidity and mortality in patients with end-stage renal disease. Little is known about the prevalence and correlates of depression in kidney transplant recipients. In this study, we aimed to compare depressive symptoms between kidney transplant recipients and wait-listed dialysis patients and identify the correlates of depressive symptoms in the transplant recipient population. STUDY DESIGN: Observational cross-sectional study using the Center for Epidemiologic Studies Depression Scale (CES-D) to assess the severity of depressive symptoms. A cutoff score of 18 was used to identify the presence of depression. SETTING & PARTICIPANTS: 1,067 kidney transplant recipients and 214 wait-listed dialysis patients were asked to participate; the final analysis included 854 kidney transplant and 176 wait-listed dialysis patients, respectively. PREDICTORS: Sociodemographic and clinical variables. OUTCOME: Severity of depressive symptoms and presence of depression (CES-D score > or = 18). RESULTS: The prevalence of depression was 33% versus 22% in wait-listed versus transplant patients, respectively (P = 0.002). In multivariate regression, number of comorbid conditions, estimated glomerular filtration rate, perceived financial situation, and marital status were significant and independent predictors of depression in the transplant recipient group. Treatment modality was associated significantly with the presence of depression, even after adjustment for clinical and sociodemographic variables (OR, 2.01; 95% CI, 1.25-3.23; P = 0.004). LIMITATIONS: Self-reported measurement of depressive symptoms. CONCLUSIONS: The prevalence of depression is lower in transplant recipients than in wait-listed patients. However, one-fifth of transplant patients are still at high risk of clinically significant depression. Comorbid conditions, socioeconomic status, and treatment modality predicted depressive symptoms in patients with end-stage renal disease.

Depressive symptoms and mortality in patients after kidney transplantation: a prospective prevalent cohort study.

OBJECTIVE: To analyze in a prospective cohort study if depressive symptoms are an independent predictor of mortality in kidney transplant recipients. METHODS: Data from 840 transplanted patients followed at a single outpatient transplant center were analyzed. Sociodemographic parameters and clinical data were collected at enrollment (between August 2002 and February 2003). Participants completed the Center for Epidemiologic Studies-Depression (CES-D) scale. Depression was defined as CES-D score of > or = 18. Data on 5-year outcomes (death censored graft loss or mortality) were collected. RESULTS: The prevalence of depression was 22%. Mortality was higher (21% versus 13%; p = .004) in patients with versus without depression. In a multivariate Cox proportional hazard model, both the baseline CES-D score (hazard ratio(for each 1-point increase) = 1.02; 95% confidence interval, 1.00-1.04) and the presence of depression at baseline (hazard ratio(presence) = 1.66; 95% confidence interval, 1.12-2.47) were significantly associated with mortality. The baseline CES-D score also significantly predicted death censored graft loss (hazard ratio(for each 1-point increase) = 1.03; 95% confidence interval, 1.01-1.05). CONCLUSION: Depressive symptoms are an independent predictor of mortality in kidney transplanted patients.

Comorbid depression is associated with increased healthcare utilization and lost productivity in persons with diabetes: a large nationally representative Hungarian population survey.

OBJECTIVE: To estimate the prevalence of depression among people with diabetes and to examine the association of comorbid depression with lost productivity and health resource utilization in persons with and without diabetes. METHODS: Cross-sectional survey, enrolling 12,643 individuals aged >18 years. Clustered, stratified sampling procedure was utilized. This sample represented 0.16% of the Hungarian adult population according to age, gender, and geographic regions. The severity of depressive symptoms was measured by the abbreviated Beck Depression Inventory. RESULTS: The prevalence of diabetes in the sample was 6.2% (95% Confidence Interval (CI) = 5.7-6.6), and 13.4% (95% CI = 12.8-13.9) were classified as depressed. Adults with diabetes were two times more likely to have depression (adjusted odds ratio (OR) = 1.83, 95% CI = 1.53-2.19, p < .001) versus individuals without diabetes. Compared with nondepressed people with diabetes, those with diabetes and comorbid depression were older, less educated, more likely to be female and physically inactive, less likely to be employed, and married and had more comorbidities. In multivariate regression analyses, people with diabetes and depression had significantly greater odds of prolonged bed days due to illness (>or=20 days) (OR = 2.6, 95% CI = 1.69-3.88, p < .001), prolonged length of hospital stay (>or=18 days) (OR = 2.1, 95% CI = 1.27-3.45, p = .004), and multiple hospital admissions (>or=2) (OR = 1.8, 95% CI = 1.13-2.82, p = .01) compared with nondepressed diabetic patients. CONCLUSIONS: These findings further document the association between depression and health resource utilization and lost productivity in people with diabetes. Screening and treating depression are important for everyday clinical care and public health initiatives to improve health outcomes for people with diabetes.

Sociodemographic factors and patient perceptions are associated with attitudes to kidney transplantation among haemodialysis patients.

BACKGROUND: Treatment decisions made by patients with chronic kidney disease are crucial in the renal transplantation process. These decisions are influenced, amongst other factors, by attitudes towards different treatment options, which are modulated by knowledge and perceptions about the disease and its treatment and many other subjective factors. Here we study the attitude of dialysis patients to renal transplantation and the association of sociodemographic characteristics, patient perceptions and experiences with this attitude. METHODS: In a cross-sectional study, all patients from eight dialysis units in Budapest, Hungary, who were on haemodialysis for at least 3 months were approached to complete a self-administered questionnaire. Data collected from 459 patients younger than 70 years were analysed in this manuscript. RESULTS: Mean age of the study population was 53 +/- 12 years, 54% were male and the prevalence of diabetes was 22%. Patients with positive attitude to renal transplantation were younger (51 +/- 11 versus 58 +/- 11 years), better educated, more likely to be employed (11% versus 4%) and had prior transplantation (15% versus 7%)(P < 0.05 for all). In a multivariate model, negative patient perceptions about transplantation, negative expectations about health outcomes after transplantation and the presence of fears about the transplant surgery were associated, in addition to increasing age, with unwillingness to consider transplantation. CONCLUSIONS: Negative attitudes to renal transplantation are associated with potentially modifiable factors. Based on this we suggest that it would be necessary to develop standardized, comprehensible patient information systems and personalized decision support to facilitate modality selection and to enable patients to make fully informed treatment decisions.

Association of systolic and diastolic blood pressure and all cause mortality in people with newly diagnosed type 2 diabetes: retrospective cohort study.

OBJECTIVE: To examine the effect of systolic and diastolic blood pressure achieved in the first year of treatment on all cause mortality in patients newly diagnosed with type 2 diabetes, with and without established cardiovascular disease. DESIGN: Retrospective cohort study. SETTING: United Kingdom General Practice Research Database, between 1990 and 2005. PARTICIPANTS: 126,092 adult patients (age ≥ 18 years) with a new diagnosis of type 2 diabetes who had been registered with participating practices for at least 12 months. MAIN OUTCOME MEASURE: All cause mortality. RESULTS: Before diagnosis, 12,379 (9.8%) patients had established cardiovascular disease (myocardial infarction or stroke). During a median follow-up of 3.5 years, we recorded 25,495 (20.2%) deaths. In people with cardiovascular disease, tight control of systolic (<130 mm Hg) and diastolic (<80 mm Hg) blood pressure was not associated with improved survival, after adjustment for baseline characteristics (age at diagnosis, sex, practice level clustering, deprivation score, body mass index, smoking, HbA(1c) and cholesterol levels, and blood pressure). Low blood pressure was also associated with an increased risk of all cause mortality. Compared with patients who received usual control of systolic blood pressure (130-139 mm Hg), the hazard ratio of all cause mortality was 2.79 (95% confidence interval 1.74 to 4.48, P<0.001) for systolic blood pressure at 110 mm Hg. Compared with patients who received usual control of diastolic blood pressure (80-84 mm Hg), the hazard ratios were 1.32 (1.02 to 1.78, P=0.04) and 1.89 (1.40 to 2.56, P<0.001) for diastolic blood pressures at 70-74 mm Hg and lower than 70 mm Hg, respectively. Similar associations were found in people without cardiovascular disease. Subgroup analyses of people diagnosed with hypertension and who received treatment for hypertension confirmed initial findings. CONCLUSION: Blood pressure below 130/80 mm Hg was not associated with reduced risk of all cause mortality in patients with newly diagnosed diabetes, with or without known cardiovascular disease. Low blood pressure, particularly below 110/75 mm Hg, was associated with an increased risk for poor outcomes.

Association of pre-transplant dialysis duration with outcome in kidney transplant recipients: a prevalent cohort study.

INTRODUCTION: Dialysis treatment prior to transplantation may contribute to premature mortality and graft loss in kidney-transplanted patients. In this prevalent cohort study (TransQol-HU Study), we analyzed the association between pre-transplant dialysis duration versus mortality and death-censored graft loss in kidney-transplanted patients. METHODS: Data from 926 kidney-transplanted patients followed at a single outpatient transplant center were analyzed. Socio-demographic parameters, laboratory data, medical history, donor characteristics and information on co-morbidities were collected at baseline. Data on 5-year outcome (graft loss, mortality) were collected. RESULTS: In multivariate analyses, pre-transplant dialysis duration was an independent risk factor for mortality (HR(for each month increase) = 1.011; 95% CI: 1.005-1.016) and also for death-censored graft loss (HR(for each month increase) = 1.008; 95% CI: 1.001-1.015) after adjustment for several co-variables. In the multivariate model, patients with less than 1 year (HR = 0.498; 95% CI: 0.302-0.820; P = 0.006) and 1-3 years (HR = 0.577; 95% CI: 0.371-0.899; P = 0.015) of pre-transplant dialysis had significantly better survival after transplantation compared to those with more than 3 years on dialysis. CONCLUSIONS: These findings add further strength to existing evidence about the significant association between longer pre-transplant dialysis duration and poor outcome in kidney-transplanted patients.

Ethnic differences in diabetes management in patients with and without comorbid medical conditions: a cross-sectional study.

OBJECTIVE: To examine ethnic disparities in diabetes management among patients with and without comorbid medical conditions after a period of sustained investment in quality improvement in the U.K. RESEARCH DESIGN AND METHODS: This cross-sectional study examined associations between ethnicity, comorbidity, and intermediate outcomes for mean A1C, total cholesterol, and blood pressure levels in 6,690 diabetes patients in South West London. RESULTS: The presence of ≥ 2 cardiovascular comorbidities was associated with similar blood pressure control among white and South Asian patients when compared with whites without comorbidity but with worse blood pressure control among black patients, with a mean difference in systolic blood pressure of +1.5, +1.4, and +6.2 mmHg, respectively. CONCLUSIONS: Despite major reforms to improve quality, disparities in blood pressure management have persisted in the U.K., particularly among patients with cardiovascular comorbidities. Policy makers should consider the potential impacts of quality initiatives on high-risk groups.

Trends in lower extremity amputations in people with and without diabetes in England, 1996-2005.

AIMS: To examine trends in non-traumatic lower extremity amputations over a 10-year-period in people with and without diabetes (DM) in England. METHODS: All individuals admitted to NHS hospitals for non-traumatic amputations between 1996 and 2005 in England were identified using hospital activity data. Postoperative and 1-year mortality were examined between 2000 and 2004. RESULTS: There was a reduction in minor and major amputations during the study period. The number of type 1 DM- and non-DM-related minor amputations decreased by 11.4% and 32.4%, respectively, while the number of type 2 DM-related minor amputations almost doubled. The incidence of type 1- and non-DM-related minor amputations decreased from 1.5 to 1.2 and from 8.1 to 5.1/100,000 population, respectively, while type 2 DM-related amputations increased from 2.4 to 4.1/100,000 population. The number of type 1- and non-DM-related major amputations declined by 41% and 22%, respectively, whereas type 2 DM-related amputations increased by 43%. The incidence of type 2 DM-related amputations increased from 2.0 to 2.7/100,000 population. Overall perioperative and 1-year mortality did not significantly change between 2000 and 2004. CONCLUSIONS: While several factors may explain the increase in type 2 DM-related LEAs, these findings highlight the importance of diabetes prevention strategies and controlling risk factors for LEAs in people with diabetes.

Impact of a pay-for-performance incentive scheme on age, sex, and socioeconomic disparities in diabetes management in UK primary care.

We examined the impact of a major pay-for-performance initiative introduced into UK primary care in 2004 on disparities in diabetes management between age, sex, and socioeconomic groups in this retrospective cohort study. We used data from the General Practice Research Database enrolling 422 family practices. Existing disparities in risk factor management (HbA1c, blood pressure, cholesterol) narrowed between men and women. Younger patients (<45 years) with diabetes appear to have benefited less from Quality and Outcomes Framework than older patients, resulting in some widening of existing age group disparities. Patients living in affluent and deprived areas appeared to have derived a similar level of benefit from pay for performance.

Impaired renal function is associated with mortality in kidney-transplanted patients.

INTRODUCTION: To date, only a few, at times conflicting, reports suggested that renal function and mortality are associated in kidney-transplanted patients. In our prevalence cohort study, we tested the hypothesis that renal function is associated with mortality in transplanted patients. METHODS: Data from 985 transplanted patients were analyzed. Socio-demographic parameters, laboratory data, medical and transplant history, type of immunosuppression and estimated glomerular filtration rate were tabulated at baseline. Data on 5-year outcome were collected prospectively. RESULTS: In multivariate Cox proportional hazard models, the estimated glomerular filtration rate measured at baseline significantly predicted mortality [hazard ratio (HR)(for each 10 ml/min decrease) = 1.271; 95% confidence interval (CI): 1.121-1.440] after adjustment for several covariables. Additionally, in multivariate Cox proportional hazard models, chronic kidney disease stage 4-5 (HR = 2.678; 95% CI: 1.494-4.802) significantly increased the mortality hazard compared to chronic kidney disease stage 1-2. CONCLUSIONS: Renal function is significantly and independently associated with mortality over 5 years in kidney-transplanted patients among whom mycophenolate mofetil use was very prevalent.

Non-medical factors influencing access to renal transplantation.

Considering the scarcity of available donor kidneys and the increasing number of patients with end-stage renal disease (ESRD) who would potentially benefit from renal transplantation, objective and equitable patient selection and equitable access to renal transplantation bear substantial importance. Inequalities in access to renal transplantation have been extensively documented over the last 2 decades with regard to age, gender, ethnicity, socioeconomic and psycho-social factors. In this paper we review a wide spectrum of social, patient and system-related factors along the transplantation process that may be associated with disparities, and we aim to describe the complex interrelationship between these factors that might influence treatment decisions by patients and health-care professionals. Understanding potentially modifiable barriers to kidney transplantation may allow designing targeted interventions in order to guarantee fair recipient selection and equal access to renal transplantation.

Association between restless legs syndrome and depression in patients with chronic kidney disease.

Restless legs syndrome (RLS) is reportedly associated with depression. This association may be mediated by both sleep-dependent and sleep-independent mechanisms. Here we analyze the association between RLS and depressive symptoms in patients with chronic kidney disease (CKD). We also assessed whether the relationship is independent of insomnia. In a cross-sectional study, socio-demographic parameters, laboratory data, and medical history were collected from 788 kidney transplant patients and 161 dialyzed patients. Insomnia, depression, and the presence of RLS symptoms were assessed with standard questionnaires. Patients with probable RLS had a higher prevalence of depressive symptoms than those without RLS (56% vs. 22% with vs. without RLS, respectively; P<.001). Patients presenting RLS symptoms had higher Athens Insomnia Scale (AIS) scores than patients without RLS [median AIS score (interquartile range): 7 (6) vs. 3 (4) with vs. without RLS, respectively; P<.001]. The AIS score correlated with the CES-D score (Spearman's rho=0.54, P<.001). In multivariate analysis, the presence of RLS symptoms was independently associated with depressive symptoms (OR=3.96, 95% CI 2.21-7.1, P<.001). This relationship remained significant even after including insomnia in the model (OR=2.9, CI 1.55-5.43, P<.001). The presence of RLS symptoms is associated with depression in patients with CKD. This relationship remained significant even after accounting for insomnia. Sleep-independent mechanisms may also contribute to the association between RLS and depression in patients with CKD.