Venous thromboembolism risk in amyotrophic lateral sclerosis: a hospital record-linkage study.

BACKGROUND: Venous thromboembolism (VTE) can occur in amyotrophic lateral sclerosis (ALS) and pulmonary embolism causes death in a minority of cases. The benefits of preventing VTE must be weighed against the risks. An accurate estimate of the incidence of VTE in ALS is crucial to assessing this balance. METHODS: This retrospective record-linkage cohort study derived data from the Hospital Episode Statistics database, covering admissions to England's hospitals from 1 April 2003 to 31 December 2019 and included 21 163 patients with ALS and 17 425 337 controls. Follow-up began at index admission and ended at VTE admission, death or 2 years (whichever came sooner). Adjusted HRs (aHRs) for VTE were calculated, controlling for confounders. RESULTS: The incidence of VTE in the ALS cohort was 18.8/1000 person-years. The relative risk of VTE in ALS was significantly greater than in controls (aHR 2.7, 95% CI 2.4 to 3.0). The relative risk of VTE in patients with ALS under 65 years was five times higher than controls (aHR 5.34, 95% CI 4.6 to 6.2), and higher than that of patients over 65 years compared with controls (aHR 1.86, 95% CI 1.62 to 2.12). CONCLUSIONS: Patients with ALS are at a higher risk of developing VTE, but this is similar in magnitude to that reported in other chronic neurological conditions associated with immobility, such as multiple sclerosis, which do not routinely receive VTE prophylaxis. Those with ALS below the median age of symptom onset have a notably higher relative risk. A reappraisal of the case for routine antithrombotic therapy in those diagnosed with ALS now requires a randomised controlled trial.

Low risk of some common cancers in women with anorexia nervosa: Evidence from a national record-linkage study.

BACKGROUND: Some studies report that women with anorexia nervosa (AN) have lower risk than others of breast cancer, but increased risk of cancers of other sites. No work has been done to quantify the risk in the English population. METHODS: Retrospective cohort study using a national linked dataset of Hospital Episode Statistics for 1999-2021. We selected individuals with a hospital admission for AN, and compared their relative risk (RR) of developing site-specific cancers, with that in a reference cohort. RESULTS: We identified 75 cancers in 15,029 women hospitalised with AN. There was a low RR of all cancers combined at 0.75 (95%CI 0.59-0.94), and, notably, low RR for breast cancer 0.43 (0.20-0.81), cancers of secondary and ill-defined sites 0.52 (0.26-0.93). The RR for parotid gland cancer was 4.4 (1.4-10.6) within a year of first recorded diagnosis of AN. In men, we found 12 cancers in 1413 individuals hospitalised with AN, but no increased risks beyond the first year of diagnosis of AN. CONCLUSIONS: This is the first report on the association between AN and cancers in the all-England population. The study showed low rates of breast cancer, and of all cancers combined, in women hospitalised with AN. It is possible that some of the metabolic or hormonal changes observed in AN could work as a protective factor for breast cancer. More experimental work is needed to identify and explain these factors. The new finding on the higher risk of salivary gland tumours could inform clinicians caring for patients with AN.

Group B Streptococcal Disease in England (1998 - 2017): A Population-based Observational Study.

BACKGROUND AND OBJECTIVES: Group B Streptococcus (GBS) is the leading cause of sepsis and meningitis in infants <90 days. In this study, the burden of GBS disease and mortality in young infants in England was assessed. METHODS: Using linked hospitalization records from every National Health Service (NHS) hospital from April 1, 1998 to March 31, 2017, we calculated annual GBS incidence in infants aged <90 days and, using regression models, compared their perinatal factors, rates of hospital-recorded disease outcomes, and all-cause infant mortality rates with those of the general infant population. RESULTS: 15 429 infants aged <90 days had a hospital-recorded diagnosis of GBS, giving an average annual incidence of 1.28 per 1000 live births (95% CI 1.26-1.30) with no significant trend over time. GBS-attributable mortality declined significantly from 0.044 (95% CI .029-.065) per 1000 live births in 2001 to 0.014 (95% CI .010-.026) in 2017 (annual percentage change -6.6, 95% CI -9.1 to -4.0). Infants with GBS had higher relative rates of visual impairment (HR 7.0 95% CI 4.1-12.1), cerebral palsy (HR 9.3 95% CI 6.6-13.3), hydrocephalus (HR 17.3 95% CI 13.8-21.6), and necrotizing enterocolitis (HR 18.8 95% CI 16.7-21.2) compared with those without GBS. CONCLUSIONS: Annual rates of GBS disease in infants have not changed over 19 years. The reduction in mortality is likely multifactorial and due to widespread implementation of antibiotics in at-risk mothers and babies, as well as advances in managing acutely unwell infants. New methods for prevention, such as maternal vaccination, must be prioritized.

Junior doctors' early career choices do not predict career destination in neurology: 40 years of surveys of UK medical graduates.

BACKGROUND: The rapidly rising rates of brain diseases due to the growing ageing population and the explosion in treatment options for many neurological conditions increase the demand for neurologists. We report trends in doctors' career choices for neurology; investigate factors driving their choices; and compare doctors' original choices with their specialty destinations. METHODS: A multi-cohort, multi-purpose nation-wide study using both online and postal questionnaires collected data on career choice, influencing factors, and career destinations. UK-trained doctors completed questionnaires at one, three, five, and ten years after qualification. They were classified into three groups: graduates of 1974-1983, graduates of 1993-2002, and graduates of 2005-2015. RESULTS: Neurology was more popular among graduates of 2005-2015 than earlier graduates; however, its attraction for graduates of 2005-2015 doctors reduced over time from graduation. A higher percentage of men than women doctors chose neurology as their first career choice. For instance, among graduates of 2005-2015, 2.2% of men and 1.1% of women preferred neurology as first choice in year 1. The most influential factor on career choice was "enthusiasm for and commitment to the specialty" in all cohorts and all years after graduation. Only 39% who chose neurology in year 1 progressed to become neurologists later. Conversely, only 28% of practicing neurologists in our study had decided to become neurologists in their first year after qualification. By year 3 this figure had risen to 65%, and by year 5 to 76%. CONCLUSIONS: Career decision-making among UK medical graduates is complicated. Early choices for neurology were not highly predictive of career destinations. Some influential factors in this process were identified. Improving mentoring programmes to support medical graduates, provide career counselling, develop professionalism, and increase their interest in neurology were suggested.

Declining comorbidity-adjusted mortality rates in English patients receiving maintenance renal replacement therapy.

We aimed to compare long-term mortality trends in end-stage renal disease versus general population controls after accounting for differences in age, sex and comorbidity. Cohorts of 45,000 patients starting maintenance renal replacement therapy (RRT) and 5.3 million hospital controls were identified from two large electronic hospital inpatient data sets: the Oxford Record Linkage Study (1965-1999) and all-England Hospital Episode Statistics (2000-2011). All-cause and cause-specific three-year mortality rates for both populations were calculated using Poisson regression and standardized to the age, sex, and comorbidity structure of an average 1970-2008 RRT population. The median age at initiation of RRT in 1970-1990 was 49 years, increasing to 61 years by 2006-2008. Over that period, there were increases in the prevalence of vascular disease (from 10.0 to 25.2%) and diabetes (from 6.7 to 33.9%). After accounting for age, sex and comorbidity differences, standardized three-year all-cause mortality rates in treated patients with end-stage renal disease between 1970 and 2011 fell by about one-half (relative decline 51%, 95% confidence interval 41-60%) steeper than the one-third decline (34%, 31-36%) observed in the general population. Declines in three-year mortality rates were evident among those who received a kidney transplant and those who remained on dialysis, and among those with and without diabetes. These data suggest that the full extent of mortality rate declines among RRT patients since 1970 is only apparent when changes in comorbidity over time are taken into account, and that mortality rates in RRT patients appear to have declined faster than in the general population.

Psychiatric disorders in children with demyelinating diseases of the central nervous system.

INTRODUCTION: The profile of psychiatric disorders associated with multiple sclerosis (MS) may differ in children. We aimed to assess the risk of psychiatric disorders in children with MS and other demyelinating diseases, and vice versa. PATIENTS AND METHODS: We analyzed linked English Hospital Episode Statistics, and mortality data, 1999-2011. Cohorts were constructed of children admitted with MS and other central nervous system (CNS) demyelinating diseases. We searched for any subsequent episode of care with psychiatric disorders in these cohorts and compared to a reference cohort. RESULTS: Children with CNS demyelinating diseases had an increased rate of psychotic disorders (rate ratio (RR) = 5.77 (95% confidence interval (CI) = 2.48-11.41)); anxiety, stress-related, and somatoform disorders (RR = 2.38 (1.39-3.81)); intellectual disability (RR = 6.56 (3.66-10.84)); and other behavioral disorders (RR = 8.99 (5.13-14.62)). In analysis of the pediatric MS cohort as the exposure, there were elevated rates of psychotic disorders (RR = 10.76 (2.93-27.63)), mood disorders (RR = 2.57 (1.03-5.31)), and intellectual disability (RR = 6.08 (1.25-17.80)). In reverse analyses, there were elevated rates of a recorded hospital episode with CNS demyelinating disease after a previous recorded episode with anxiety, stress-related, and somatoform disorders; attention-deficit hyperactivity disorder (ADHD); autism; intellectual disability; and other behavioral disorders. CONCLUSION: This analysis of a national diagnostic database provides strong evidence for an association between pediatric CNS demyelinating diseases and psychiatric disorders, and highlights a need for early involvement of mental health professionals.

Views of UK doctors in training on the timing of choosing a clinical specialty: quantitative and qualitative analysis of surveys 3 years after graduation.

BACKGROUND: Workforce studies show a declining proportion of UK junior doctors proceeding directly to specialist training, with many taking career breaks. Doctors may be choosing to delay this important career decision. AIM: To assess doctors' views on the timing of choosing a clinical specialty. METHODS: Surveys of two cohorts of UK-trained doctors 3 years after qualification, in 2011 and 2015. RESULTS: Presented with the statement 'I had to choose my career specialty too soon after qualification', 61% agreed (27% strongly) and 22% disagreed (3% strongly disagreed). Doctors least certain about their choice of specialty were most likely to agree (81%), compared with those who were more confident (72%) or were definite regarding their choice of long-term specialty (54%). Doctors not in higher specialist training were more likely to agree with this statement than those who were (72% vs 59%). Graduate medical school entrants (ie, those who had completed prior degrees) were less likely to agree than non-graduates (56% vs 62%). Qualitative analysis of free text comments identified three themes as reasons why doctors felt rushed into choosing their future career: insufficient exposure to a wide range of specialties; a desire for a greater breadth of experience of medicine in general; and inadequate career advice. CONCLUSIONS: Most UK-trained doctors feel rushed into choosing their long-term career specialty. Doctors find this difficult because they lack sufficient medical experience and adequate career advice to make sound choices. Workforce trainers and planners should enable greater flexibility in training pathways and should further improve existing career guidance.

Career specialty choices of UK medical graduates of 2015 compared with earlier cohorts: questionnaire surveys.

OBJECTIVE: To report the career specialty choices of UK medical graduates of 2015 one year after graduation and to compare these with the choices made at the same postgraduate stage by previous cohorts. DESIGN: National survey using online and postal questionnaires. SETTING: UK. PARTICIPANTS: UK-trained medical graduates. MAIN OUTCOME MEASURES: Grouped and individual specialty choices. RESULTS: The response rate was 41.3% (3040/7095). Among the graduates of 2015, general practice (27.8% of first choices) and hospital medical specialties (26.5%) were the most frequent first choices of long-term career. First choices for general practice declined among women from 36.1% for the 2005-2009 cohorts to 33.3% for the 2015 cohort, and among men from 22.4% for the 2005-2009 cohorts to 19.3% for the 2015 cohort. First choices for surgery declined among men (from 29.5% for the 2005-2009 cohorts to 21.7% for the 2015 cohort), but not among women (12.3% for the 2005-2009 cohorts and 12.5% for the 2015 cohort). There was an increase in the percentage of first choices for anaesthesia, psychiatry, radiology and careers outside medicine. Anaesthesia, oncology, paediatrics and radiology increased in popularity over time among men, but not among women. CONCLUSIONS: Career choices for general practice remain low. Other current shortage specialties, apart from radiology and psychiatry, are not showing an increase in the number of doctors who choose them. Large gender differences remain in the choices for some specialties. Further work is needed into the determinants of junior doctors' choices for shortage specialties and those with large gender imbalances.

Trends in the Incidence and Recurrence of Inpatient-Treated Spontaneous Pneumothorax, 1968-2016.

Importance: Spontaneous pneumothorax is a common disease known to have an unusual epidemiological profile, but there are limited contemporary population-based data. Objective: To estimate the incidence of hospital admissions for spontaneous pneumothorax, its recurrence and trends over time using large, longstanding hospitalization data sets in England. Design, Setting, and Participants: A population-based epidemiological study was conducted using an English national data set and an English regional data set, each spanning 1968 to 2016, and including 170 929 hospital admission records of patients 15 years and older. Final date of the study period was December 31, 2016. Exposures: Calendar year (for incidence) and readmission to hospital for spontaneous pneumothorax (for recurrence). Main Outcomes and Measures: Primary outcomes were rates of hospital admissions for spontaneous pneumothorax and recurrence, defined as a subsequent hospital readmission with spontaneous pneumothorax. Record-linkage was used to identify multiple admissions per person and comorbidity. Risk factors for recurrence over 5 years of follow-up were assessed using cumulative time-to-failure analysis and Cox proportional hazards regression. Results: From 1968 to 2016, there were 170 929 hospital admissions for spontaneous pneumothorax (median age, 44 years [IQR, 26-88]; 73.0% male). In 2016, there were 14.1 spontaneous pneumothorax admissions per 100 000 population 15 years and older (95% CI, 13.7-14.4), a significant increase compared with earlier years, up from 9.1 (95% CI, 8.1-10.1) in 1968. The population-based rate per 100 000 population 15 years and older was higher for males (20.8 [95% CI, 20.2-21.4]) than for females (7.6 [95% CI, 7.2-7.9]). Of patients with spontaneous pneumothorax, 60.8% (95% CI, 59.5%-62.0%) had chronic lung disease. Record-linkage analysis demonstrated that the overall increase in admissions over time could be due in part to an increase in repeat admissions, but there were also significant increases in the annual rate of first-known spontaneous pneumothorax admissions in some population subgroups, for example in women 65 years and older (annual percentage change from 1968 to 2016, 4.08 [95% CI, 3.33-4.82], P < .001). The probability of recurrence within 5 years was similar by sex (25.5% [95% CI, 25.1%-25.9%] for males vs 26.0% [95% CI, 25.3%-26.7%] for females), but there was variation by age group and presence of chronic lung disease. For example, the probability of readmission within 5 years among males aged 15 to 34 years with chronic lung disease was 39.2% (95% CI, 37.7%-40.7%) compared with 19.6% (95% CI, 18.2%-21.1%) in men 65 years and older without chronic lung disease. Conclusions and Relevance: This study provides contemporary information regarding the trends in incidence and recurrence of inpatient-treated spontaneous pneumothorax.

Psychiatric disorders prior to amyotrophic lateral sclerosis.

It is recognized that neuropsychiatric conditions are overrepresented in amyotrophic lateral sclerosis (ALS) patient kindreds and psychiatric symptoms may precede the onset of motor symptoms. Using a hospital record linkage database, hospitalization with a diagnosis of schizophrenia, bipolar disorder, depression, or anxiety was significantly associated with a first diagnosis of ALS within the following year. This is likely to specifically reflect the clinicopathological overlap of ALS with frontotemporal dementia. A diagnosis of depression was significantly associated with a first record of ALS ≥5 years later, in keeping with growing evidence for major depressive disorder as an early marker of cerebral neurodegeneration. Ann Neurol 2016;80:935-938.

Aspirations to become an anaesthetist: longitudinal study of historical trends and trajectories of UK-qualified doctors' early career choices and of factors that have influenced their choices.

BACKGROUND: It is important to inform medical educators and workforce planners in Anaesthesia about early career choices for the specialty, factors that influence them and to elucidate how recent choices of men and women doctors relate to the overall historical trends in the specialty's popularity. METHODS: We analysed longitudinal data on career choice, based on self-completed questionnaires, from national year-of-qualification cohorts of UK-trained doctors from 1974 to 2012 surveyed one, three and 5 years post-qualification. Career destination data 10 years post-qualification were used for qualifiers between 1993 and 2002, to investigate the association between early choice and later destinations. RESULTS: In years 1, 3 and 5 post-qualification, respectively, 59.9% (37,385), 64.6% (31,473), and 67.2% (24,971) of contactable doctors responded. There was an overall increase, from the early to the later cohorts, in the percentage of medical graduates who wished to enter anaesthesia: for instance year 1 choices rose from 4.6 to 9.4%, comparing the 1974 and 2012 cohorts. Men were more likely than women to express an early preference for a career in anaesthesia: for example, at year 3 after qualification anaesthesia was the choice of 10.1% of men and 7.9% of women. There was a striking increase in the certainty with which women chose anaesthesia as their future career specialty in recent compared to earlier cohorts, not reflected in any trends observed in men choosing anaesthesia. Sixty percent of doctors who were anaesthetists, 10 years after qualifying, had specified anaesthesia as their preferred specialty when surveyed in year 1, 80% in year 3, and 92% in year 5. Doctors working as anaesthetists were less likely than those working in other hospital specialties to have specified, as strong influences on specialty choice, 'experience of the subject' as students, 'inclinations before medical school', and 'what I really want to do'. Men anaesthetists were more influenced in their specialty choice than men in other hospital specialties by 'wanting a career with acceptable hours'; the corresponding difference among women was not significant. CONCLUSIONS: We suggest a focus on inspirational teaching of anaesthesia in medical school and on greater exposure to the specialty in the foundation programme. Factors which may discourage women from entering anaesthesia should be explored and addressed.

Adequacy of postgraduate medical training: views of different generations of UK-trained doctors.

BACKGROUND: Over the last decade, many changes have taken place in the UK, which have affected the training that doctors receive. AIM: To assess doctors' views on quality and adequacy of postgraduate training. METHODS: Questionnaires about training sent to UK-trained doctors who graduated between 1974 and 2012. RESULTS: Among trainees towards the end of their first year of medical work and training, 36% agreed that in their first year "Training was of a high standard"; 21% disagreed; 43% neither agreed nor disagreed. Only 16% agreed "I had to perform clinical tasks for which I felt inadequately trained".Among doctors 12 years into their careers, 83% agreed "My training has been long enough, and good enough, to enable me to practise adequately when I first become/became a consultant or GP".Among senior hospital doctors aged in their 50s or 60s, 21% agreed that "These days, the training of specialist doctors in the NHS is sufficient to enable them to practise adequately when they first become consultants"; 38% disagreed, and the rest neither agreed nor disagreed. Of senior GPs, 41% agreed "These days, the training of GP trainees in the NHS is sufficient to enable them to practise adequately when they first become GPs"; 28% disagreed. CONCLUSIONS: Views on early career training were mixed, but few felt exposed to clinical situations beyond their ability. Most newly appointed consultants and GPs felt adequately trained for practice, though many senior doctors were unsure that this was the case.

Cerebrovascular injury as a risk factor for amyotrophic lateral sclerosis.

OBJECTIVE: To use an unbiased method to test a previously reported association between cerebral arteriovenous malformation (AVM) embolisation and the subsequent development of amyotrophic lateral sclerosis (ALS). METHODS: A hospital record linkage database was used to create cohorts of individuals coded as having cerebral and peripheral vessel AVMs, stroke (separately for haemorrhagic and ischaemic), transient ischaemic attack (TIA) and subarachnoid haemorrhage (SAH). The rate ratio for subsequent ALS was compared to a reference cohort. RESULTS: An increased rate ratio for ALS was found in relation to prior AVM (2.69; p=0.005), all strokes (1.38; p<0.001), and TIA (1.47; p<0.001). CONCLUSIONS: Cerebrovascular injury from a variety of causes, rather than the presence of AVM or the associated embolisation procedure per se, may be a risk factor for ALS within the context of a more complex multiple-hit model of pathogenesis.

Gender identity disorders and multiple sclerosis risk: A national record-linkage study.

BACKGROUND: An altered balance of gonadal hormones in males with gender identity disorders (GIDs) may increase multiple sclerosis (MS) risk both inherently and secondary to treatment in undergoing male-to-female conversion. OBJECTIVE: We investigated any association between GIDs and MS through analysis of record-linked hospital statistics. METHOD: Analysis of English Hospital Episode Statistics, 1999-2012. RESULTS: The adjusted rate ratio (RR) of MS following GIDs in males was 6.63 (95% confidence interval (95% CI) = 1.81-17.01, p = 0.0002). The RR of MS following GIDs in females was 1.44 (95% CI = 0.47-3.37, p = 0.58). CONCLUSION: We report a strong association between GIDs and MS in male-to-females, supporting a potential role for low testosterone and/or feminising hormones on MS risk in males.

Coexistence of eating disorders and autoimmune diseases: Record linkage cohort study, UK.

OBJECTIVE: Recent research indicates that eating disorders (ED) are associated with type 1 diabetes and Crohn's disease. The aim of this study was to determine whether, in a hospitalized population, a range of autoimmune diseases (AIDs) occurred more often than expected in people with anorexia nervosa (AN) or bulimia nervosa (BN), and whether AIDs elevated the risk of ED. METHOD: Retrospective, record-linkage cohort study using national administrative statistical data on hospital care and mortality in England, 1999-2011. In people admitted when aged 10-44, cohorts of 8,700 females and 651 males with AN, and 4,783 females and 330 males with BN were constructed, along with a control cohort with the same age range. Results were expressed as risk ratios comparing each ED cohort with the control cohort. RESULTS: The overall rate ratio for an AID after admission for AN was 2.04 (95% confidence interval 1.81-2.28) in females, and 1.14 (0.37-2.67) in males; and, for BN, 1.83 (1.56-2.14) in females, and 4.41 (2.11-8.10) in males. Rate ratios for AN after admission for an AID were 3.34 (2.94-3.79) in females, 3.76 (2.06-6.53) in males; and those for BN were 2.57 (2.22-2.97) in females, and 3.10 (1.50-5.90) in males. There were significant associations between ED and several specific individual AIDs. DISCUSSION: Strong associations between ED and specific AIDs exist, although it is not possible from this study to determine if these are causal. Clinicians should be aware of the co-occurrence of these conditions. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:663-672).

Factors associated with less-than-full-time working in medical practice: results of surveys of five cohorts of UK doctors, 10 years after graduation.

BACKGROUND: The greater participation of women in medicine in recent years, and recent trends showing that doctors of both sexes work fewer hours than in the past, present challenges for medical workforce planning. In this study, we provide a detailed analysis of the characteristics of doctors who choose to work less-than-full-time (LTFT). We aimed to determine the influence of these characteristics on the probability of working LTFT. METHODS: We used data on working patterns obtained from long-term surveys of 10,866 UK-trained doctors. We analysed working patterns at 10 years post-graduation for doctors of five graduating cohorts, 1993, 1996, 1999, 2000 and 2002 (i.e. in the years 2003, 2006, 2009, 2010 and 2012, respectively). We used multivariable binary logistic regression models to examine the influence of a number of personal and professional characteristics on the likelihood of working LTFT in male and female doctors. RESULTS: Across all cohorts, 42 % of women and 7 % of men worked LTFT. For female doctors, having children significantly increased the likelihood of working LTFT, with greater effects observed for greater numbers of children and for female doctors in non-primary care specialties (non-GPs). While >40 % of female GPs with children worked LTFT, only 10 % of female surgeons with children did so. Conversely, the presence of children had no effect on male working patterns. Living with a partner increased the odds of LTFT working in women doctors, but decreased the odds of LTFT working in men (independently of children). Women without children were no more likely to work LTFT than were men (with or without children). For both women and men, the highest rates of LTFT working were observed among GPs (~10 and 6 times greater than non-GPs, respectively), and among those not in training or senior positions. CONCLUSIONS: Family circumstances (children and partner status) affect the working patterns of women and men differently, but both sexes respond similarly to the constraints of their clinical specialty and seniority. Thus, although women doctors comprise the bulk of LTFT workers, gender is just one of several determinants of doctors' working patterns, and wanting to work LTFT is evidently not solely an issue for working mothers.

Self-reported preparedness for clinical work has increased among recent cohorts of UK-trained first-year doctors.

INTRODUCTION: UK medical schools have made considerable efforts to ensure that graduates are well prepared for their first year of clinical work. We report the views of two recent cohorts of UK-trained doctors 1 year after graduation about whether their medical school prepared them well, and compare responses with earlier cohorts. METHODS: We surveyed doctors who qualified in 2011 and 2012 from all UK medical schools. We obtained their responses to the statement 'My experience at medical school prepared me well for the jobs I have undertaken so far' on a 5-point scale from 'Strongly Agree' to 'Strongly Disagree'. Responses were compared with those of the UK graduates of 1999, 2000, 2002, 2005, 2008 and 2009, surveyed in the same way 1 year after graduation. RESULTS: The percentage of doctors who either 'Agreed' or 'Strongly Agreed' that they were well prepared doubled from 35% in 1999 to 70% in 2012, while the percentage who 'Strongly Agreed' with the statement increased fourfold. Perceptions of being well prepared have increased in graduates from almost every medical school. Variation between medical schools in self-reported preparedness of their graduates has decreased in recent cohorts. However, some large differences between medical schools remain. Significant differences in perceived preparedness remain between white and non-white doctors, but have diminished between men and women. CONCLUSIONS: Our work contributes to growing evidence suggesting that changes to medical education in the UK are producing doctors who feel well prepared for the challenges of being a doctor, though further improvements could be made.

Associations between perceived institutional support, job enjoyment, and intentions to work in the United Kingdom: national questionnaire survey of first year doctors.

BACKGROUND: Identifying factors that improve job satisfaction of new doctors and ease the difficult transition from student to doctor is of great interest to public health agencies. Studies to date have focused primarily on the value of changes to medical school curricula and induction processes in this regard, but have overlooked the extent to which institutional support can influence new doctors' enjoyment of and attitude to work. Here, we examine variation in the perceived level of support received by new medical graduates in the United Kingdom (UK) from their employer and whether this influences enjoyment of and attitudes to the first postgraduate year, and whether doctors who perceived a lower level of support were less inclined to intend a long term career in medicine in the UK. METHODS: All UK medical graduates of 2012 were surveyed in 2013 in a cross-sectional study, towards the end of their first post-graduate year (the 'F1' year of the 2-year Foundation Training Programme for new UK doctors). We used linear regression to assess whether the level of support doctors reported receiving from their employing Trust (Very Good, Good, Adequate, Poor, or Very Poor) was associated with the extent to which they enjoyed their F1 year. Similarly, we assessed the strength of associations between self-reported level of Trust support and doctors' responses to 12 statements about fundamental aspects of their working lives, each assessed on a 5-point scale of agreement. Using χ (2) tests we examined whether doctors' intentions to practise medicine in the UK varied with the level of support they reported receiving from their Trust. RESULTS: The response rate was 45 % (2324/5171). Of 2324 responding junior doctors, 63.8 % reported receiving 'Very Good' (23.6 %) or 'Good' (40.2 %) initial support from their Trust, while a further 27.4 % stated they received 'Adequate' support. 'Poor' support was reported by 5.8 % and 'Very Poor' support by 2.2 %. We found very strong positive associations between the institutional support doctors reported receiving and their enjoyment of the F1 year and their self-expressed attitudes to aspects of their first year of work. Crucially, doctors who reported receiving lower levels of support ('Poor' or 'Very Poor') were significantly less likely to express intentions to continue practising medicine in the UK. CONCLUSIONS: The provision of effective institutional support for graduate doctors may promote workplace satisfaction and could help safeguard the long-term retention of junior doctors.

Risk of dementia in patients hospitalised with type 1 and type 2 diabetes in England, 1998-2011: a retrospective national record linkage cohort study.

AIMS/HYPOTHESIS: Type 2 diabetes increases the risk of subsequent dementia. Our objective was to determine whether a similar risk of subsequent dementia is associated with type 1 diabetes in a large defined population. METHODS: This retrospective cohort study examined national administrative record-linked statistical data on hospital care and mortality in England, 1998-2011. Cohorts of people admitted to hospital when aged 30 or over were constructed: 343,062 people with type 1 diabetes; 1,855,141 people with type 2 diabetes; and a reference cohort. Results were expressed as rate ratios (RR) comparing each diabetes cohort with the control cohort. RESULTS: The overall RR for dementia in people admitted to hospital with type 1 diabetes was 1.65 (95% CI 1.61, 1.68), and for people admitted to hospital with type 2 diabetes was 1.37 (1.35, 1.38). Young age at admission for diabetes appeared to confer a greater rate of subsequent dementia; the RR for dementia in people admitted to hospital with type 1 diabetes aged 30-39 years was 7.10 (4.65, 10.6), which reduced to 4.40 (3.55, 5.40) in those aged 40-49 at admission, and further reduced with increasing age to 1.16 (1.11, 1.20) in those aged 80 or over at admission. A similar pattern was seen with type 2 diabetes. CONCLUSIONS/INTERPRETATION: Type 1 diabetes, as well as type 2 diabetes, may be associated with an elevated risk of subsequent dementia. The risk of dementia varies with age at admission to hospital with diabetes, and appears to be much greater in the young.

Testicular hypofunction and multiple sclerosis risk: a record-linkage study.

The influence of gonadal hormones on multiple sclerosis (MS) is not well characterized and has thus far been investigated primarily in animal models or as a proposed therapeutic approach. We investigated a potential association between testicular hypofunction, as a proxy for low testosterone levels, and MS risk through analysis of linked English national Hospital Episode Statistics from 1999 to 2011. We report a strong positive association between testicular hypofunction and subsequent MS (rate ratio = 4.62, 95% confidence interval = 2.3-8.24, p < 0.0001). Future work should aim more directly to elucidate the relationship between testosterone levels and MS in both males and females.