Presentation of B-cell lymphoma in childhood and adolescence: a systematic review and meta-analysis.

BACKGROUND: The diagnosis of B-cell lymphoma, one of the commonest cancers seen in childhood and adolescence, is challenging. There is a crucial need to identify and delineate the prevalence of associated symptoms in order to improve early diagnosis. AIMS: To identify clinical presentations associated with childhood and adolescent B-cell lymphomas and estimate symptom prevalence. METHODS: A systematic review of observational studies and meta-analysis of proportions was carried out. Medline and EMBASE were systematically searched, with no language restrictions, from inception to 1st August 2022. Observational studies with at least 10 participants, exploring clinical presentations of any childhood and adolescent lymphoma, were selected. Proportions from each study were inputted to determine the weighted average (pooled) proportion, through random-effects meta-analysis. RESULTS: Studies reported on symptoms, signs and presentation sites at diagnosis of 12,207 children and adolescents up to the age of 20. Hodgkin's lymphoma most frequently presented with adenopathy in the head-and-neck region (79% [95% CI 58%-91%]), whilst non-Hodgkin's lymphoma presented abdominally (55% [95% CI 43%-68%]). Symptoms associated with lymphoma included cervical lymphadenopathy (48% [95% CI 20%-77%]), peripheral lymphadenopathy (51% [95% CI 37%-66%]), B-symptoms (40% [95% CI 34%-44%]), fever (43% [95% CI 34%-54%]), abdominal mass (46% [95% CI 29%-64%]), weight loss (53% [95% CI 39%-66%]), head-and-neck mass (21% [95% CI 6%-47%]), organomegaly (29% [95% CI 23%-37%]), night sweats (19% [95% CI 10%-32%]), abdominal pain (28% [95% CI 15%-47%]), bone pain (17% [95% CI 10%-28%]) and abnormal neurology (11% [95% CI 3%-28%]). CONCLUSION: This systematic review and meta-analysis of proportions provides insight into the heterogeneous clinical presentations of B-cell lymphoma in childhood and adolescence and provides estimates of symptom prevalence. This information is likely to increase public and clinical awareness of lymphoma presentations and aid earlier diagnosis. This review further highlights the lack of studies exploring childhood and adolescent lymphoma presentations in primary care, where patients are likely to present at the earliest stages of their disease.

Incidence, prevalence and mortality of bullous pemphigoid in England 1998-2017: a population-based cohort study.

BACKGROUND: A rising incidence and high mortality were found for bullous pemphigoid (BP) over a decade ago in the UK. Updated estimates of its epidemiology are required to understand the healthcare needs of an ageing population. OBJECTIVES: To determine the incidence, prevalence and mortality rates of BP in England from 1998 to 2017. METHODS: We conducted a cohort study of longitudinal electronic health records using the Clinical Practice Research Datalink and linked Hospital Episode Statistics. Incidence was calculated per 100 000 person-years and annual point prevalence per 100 000 people. Multivariate analysis was used to determine incidence rate ratios by sociodemographic factors. Mortality was examined in an age-, sex- and practice-matched cohort, using linked Office of National Statistics death records. Hazard ratios (HRs) were stratified by matched set. RESULTS: The incidence was 7·63 [95% confidence interval (CI) 7·35-7·93] per 100 000 person-years and rose with increasing age, particularly for elderly men. The annual increase in incidence was 0·9% (95% CI 0·2-1·7). The prevalence almost doubled over the observation period, reaching 47·99 (95% CI 43·09-53·46) per 100 000 people and 141·24 (95% CI 125·55-158·87) per 100 000 people over the age of 60 years. The risk of all-cause mortality was highest in the 2 years after diagnosis (HR 2·96; 95% CI 2·68-3·26) and remained raised thereafter (HR 1·54; 95% CI 1·36-1·74). CONCLUSIONS: We report a modest increase in the incidence rate of BP, but show that the burden of disease in the elderly population is considerable. Mortality is high, particularly in the first 2 years after diagnosis.

Using electronic health records to inform trial feasibility in a rare autoimmune blistering skin disease in England.

BACKGROUND: Trials of novel agents are required to improve the care of patients with rare diseases, but trial feasibility may be uncertain due to concerns over insufficient patient numbers. We aimed to determine the size of the pool of potential participants in England 2015-2017 for trials in the autoimmune blistering skin disease bullous pemphigoid. METHODS: The size of the pool of potential participants was estimated using routinely collected healthcare data from linked primary care (Clinical Practice Research Datalink; CPRD) and secondary care (Hospital Episode Statistics; HES) databases. Thirteen consultant dermatologists were surveyed to determine the likelihood that a patient would be eligible for a trial based on the presence of cautions or contra-indications to prednisolone use. These criteria were applied to determine how they influenced the potential pool of participants. RESULTS: Extrapolated to the population of England, we would expect approximately 10,800 (point estimate 10,747; 95% CI 7191 to 17,239) new cases of bullous pemphigoid to be identified in a three-year period. For a future trial involving oral prednisolone (standard care), the application of cautions to its use as exclusion criteria would result in approximately 365 potential participants unlikely to be recruited, a further 5332 could be recruited with caution, and 5104 in whom recruitment is still possible. 11-17% of potential participants may have pre-existing dementia and require an alternative consent process. CONCLUSIONS: Routinely collected electronic health records can be used to inform the feasibility of clinical trials in rare diseases, such as whether recruitment is feasible nationally and how long recruitment might take to meet recruitment targets. Future trials of bullous pemphigoid in England may use the data presented to inform trial design, including eligibility criteria and consent processes for enrolling people with dementia.

Exposure to bisphosphonates and risk of common non-gastrointestinal cancers: series of nested case-control studies using two primary-care databases.

BACKGROUND: Bisphosphonates are the most commonly prescribed osteoporosis drugs but long-term effects are unclear, although antitumour properties are known from preclinical studies. METHODS: Nested case-control studies were conducted to investigate bisphosphonate use and risks of common non-gastrointestinal cancers (breast, prostate, lung, bladder, melanoma, ovarian, pancreas, uterus and cervical). Patients 50 years and older, diagnosed with primary cancers between 1997 and 2011, were matched to five controls using the UK practice-based QResearch and Clinical Practice Research Datalink (CPRD) databases. The databases were analysed separately and the results combined. RESULTS: A total of 91 556 and 88 845 cases were identified from QResearch and CPRD, respectively. Bisphosphonate use was associated with reduced risks of breast (odds ratio (OR): 0.92, 95% confidence interval (CI): 0.87-0.97), prostate (OR: 0.87, 95% CI: 0.79-0.96) and pancreatic (OR: 0.79, 95% CI: 0.68-0.93) cancers in the combined analyses, but no significant trends with duration. For alendronate, reduced risk associations were found for prostate cancer in the QResearch (OR: 0.81, 95% CI: 0.70-0.93) and combined (OR: 0.84, 95% CI: 0.75-0.93) analyses (trend with duration P-values 0.009 and 0.001). There were no significant associations from any of the other analyses. CONCLUSION: In this series of large population-based case-control studies, bisphosphonate use was not associated with increased risks for any common non-gastrointestinal cancers.

Use of a large general practice syndromic surveillance system to monitor the progress of the influenza A(H1N1) pandemic 2009 in the UK.

The Health Protection Agency/QSurveillance national surveillance system utilizes QSurveillance®, a recently developed general practitioner database covering over 23 million people in the UK. We describe the spread of the first wave of the influenza A(H1N1) pandemic 2009 using data on consultations for influenza-like illness (ILI), respiratory illness and prescribing for influenza from 3400 contributing general practices. Daily data, provided from 27 April 2009 to 28 January 2010, were used to give a timely overview for those managing the pandemic nationally and locally. The first wave particularly affected London and the West Midlands with a peak in ILI in week 30. Children aged between 1 and 15 years had consistently high consultation rates for ILI. Daily ILI rates were used for modelling national weekly case estimates. The system enabled the 'real-time' monitoring of the pandemic to a small geographical area, linking morbidity and prescribing for influenza and other respiratory illnesses.

Exposure to cyclooxygenase-2 inhibitors and risk of cancer: nested case-control studies.

BACKGROUND: Selective cyclooxygenase-2 (COX2) inhibitors are widely used as analgesics and it is unclear whether its long-term use affects cancer risk. METHODS: A series of nested case-control studies using the QResearch primary care database. Associations of COX2 inhibitor use with risk of all cancers and 10 common site-specific cancers were estimated using conditional logistic regression adjusted for comorbidities, smoking status, socioeconomic status, and use of non-steroidal anti-inflammatory drugs, aspirin and statins. RESULTS: A total of 88,125 cancers, diagnosed between 1998 and 2008, matched with up to five controls, were analysed. Use of COX2 inhibitors for more than a year was associated with a significantly increased risk of breast cancer (odds ratio (OR) 1.24, 95% confidence interval (CI) 1.08-1.42) and haematological malignancies (OR 1.38, 95% CI 1.12-1.69) and a decreased risk of colorectal cancer (OR 0.76, 95% CI 0.63-0.92). There were no other significant associations. CONCLUSION: Prolonged use of COX2 inhibitors was associated with an increased risk of breast and haematological cancers and decreased risk of colorectal cancer. These findings need to be confirmed using other data sources.

Early spread of the 2009 influenza A(H1N1) pandemic in the United Kingdom--use of local syndromic data, May-August 2009.

Following the confirmation of the first two cases of pandemic influenza on 27 April 2009 in the United Kingdom (UK), syndromic surveillance data from the Health Protection Agency (HPA)/QSurveillance and HPA/NHS Direct systems were used to monitor the possible spread of pandemic influenza at local level during the first phase of the outbreak. During the early weeks, syndromic indicators sensitive to influenza activity monitored through the two schemes remained low and the majority of cases were travel-related. The first evidence of community spread was seen in the West Midlands region following a school-based outbreak in central Birmingham. During the first phase several Primary Care Trusts had periods of exceptional influenza activity two to three weeks ahead of the rest of the region. Community transmission in London began slightly later than in the West Midlands but the rates of influenza-like illness recorded by general practitioners (GPs) were ultimately higher. Influenza activity in the West Midlands and London regions peaked a week before the remainder of the UK. Data from the HPA/NHS Direct and HPA/QSurveillance systems were mapped at local level and used alongside laboratory data and local intelligence to assist in the identification of hotspots, to direct limited public health resources and to monitor the progression of the outbreak. This work has demonstrated the utility of local syndromic surveillance data in the detection of increased transmission and in the epidemiological investigation of the pandemic and has prompted future spatio-temporal work.

Value of syndromic surveillance in monitoring a focal waterborne outbreak due to an unusual Cryptosporidium genotype in Northamptonshire, United Kingdom, June - July 2008.

The United Kingdom (UK) has several national syndromic surveillance systems. The Health Protection Agency (HPA)/NHS Direct syndromic surveillance system uses pre-diagnostic syndromic data from a national telephone helpline, while the HPA/QSurveillance national surveillance system uses clinical diagnosis data extracted from general practitioner (GP)-based clinical information systems. Data from both of these systems were used to monitor a local outbreak of cryptosporidiosis that occurred following Cryptosporidium oocyst contamination of drinking water supplied from the Pitsford Reservoir in Northamptonshire, United Kingdom, in June 2008. There was a peak in the number of calls to NHS Direct concerning diarrhoea that coincided with the incident. QSurveillance data for the local areas affected by the outbreak showed a significant increase in GP consultations for diarrhoea and gastroenteritis in the week of the incident but there was no increase in consultations for vomiting. A total of 33 clinical cases of cryptosporidiosis were identified in the outbreak investigation, of which 23 were confirmed as infected with the outbreak strain. However, QSurveillance data suggest that there were an estimated 422 excess diarrhoea cases during the outbreak, an increase of about 25% over baseline weekly levels. To our knowledge, this is the first time that data from a syndromic surveillance system, the HPA/QSurveillance national surveillance system, have been able to show the extent of such a small outbreak at a local level. QSurveillance, which covers about 38% of the UK population, is currently the only GP database that is able to provide data at local health district (primary care trust) level. The Cryptosporidium contamination incident described demonstrates the potential usefulness of this information, as it is unusual for syndromic surveillance systems to be able to help monitor such a small-scale outbreak.

NHS Health Checks for people with mental ill-health 2013-2017: an observational study.

AIMS: People living with serious mental ill-health experience adverse cardiovascular outcomes causing some of the greatest health inequality gaps in England, UK. We describe uptake of the NHS Health Check programme in people with mental ill-health, and rates of new diagnoses and management of cardiovascular risk factors in those who attend NHS Health Checks in comparison to those people without mental ill-health. METHODS: We used a large nationally representative database of people registered with general practitioners in England (QResearch). Between 2013 and 2017, we analysed attendance at NHS Health Checks and outcomes in the succeeding 12 months, in people with serious mental illness (SMI) including psychoses and in people prescribed long-term antidepressant medications (LTAD), with comparison to attendees who did not have these conditions. Hazard ratios (HR) were used to describe the association between outcomes and SMI and LTAD adjusting for sociodemographic variables. RESULTS: In those eligible for the NHS Health Check programme, we found a higher percentage of people with SMI attended an NHS Health Check (65 490, 19.8%) than those without SMI (524 728, 16.6%); adjusted HR 1.05 [95% confidence interval 1.02-1.08]. We also observed a higher percentage of attendance in people on LTAD (46 437, 20.1%) compared to people who were not prescribed LTAD (543 781, 16.7%); adjusted HR 1.10 (1.08-1.13). People with SMI were more likely to be identified with chronic kidney disease (CKD, HR 1.23, 1.12-1.34) and type 2 diabetes (HR 1.14, 1.03-1.25) within the 12 months following their NHS Health Check compared with those without SMI. People on LTAD were more likely to be identified with CKD (HR 1.55, 1.42-1.70) and type 2 diabetes (HR 1.45, 1.31-1.60) and also hypertension, cardiovascular disease, non-diabetic hyperglycaemia, familial hypercholesterolemia and dementia within the 12 months following their NHS Health Check. Statins were more likely to be prescribed to NHS Health Check attendees with SMI and those on LTAD than those without these conditions; HR 1.31 (1.25-1.38) and 1.91 (1.82-2.01), respectively. Antihypertensives were more likely to be prescribed to those on LTAD; HR 1.21 (1.14-1.29). CONCLUSIONS: We found evidence that people with SMI or on LTAD treatment were 5-10% more likely to access NHS Health Checks than people without these conditions. People with SMI or on LTAD treatment who attended NHS Health Checks had higher rates of diagnosis of CKD, type 2 diabetes and some other relevant co-morbidities and increased treatment with statins and also anti-hypertensive medication in people on LTAD. This is likely to contribute to equitable reduction in adverse cardiovascular events for people with mental ill-health.

Prevalence, care, and outcomes for patients with diet-controlled diabetes in general practice: cross sectional survey.

BACKGROUND: Tight glycaemic control reduces microvascular complications in patients with type 1 and type 2 diabetes. We aimed to establish the proportion with type 2 diabetes treated through diet only and to determine levels of complications and quality of care received compared with patients on hypoglycaemic medication. METHODS: We undertook a cross-sectional study of 7870 patients with type 2 diabetes from a population of 253,618 patients from 42 general practices in the UK. Our primary outcome was process of care measures and diabetes-related complications. FINDINGS: 31.3% of all patients with type 2 diabetes are being managed with diet only (1% of the total population). More than four-fold variation between practices exists (range 15.6-73.2%). Patients treated with diet only are much less likely to have HbA1c (glycosylated haemoglobin) measurements, blood pressure, cholesterol, smoking, microalbuminuria testing, or screening for foot pulses recorded. 38.4% of patients with type 2 diabetes on medication have a HbA(1c) above 7.5% compared with 17.3% of those treated with diet only. Compared with those on medication, patients treated by diet only are more likely to have raised blood pressure and less likely to be on anti-hypertensive medication; they are 45% more likely to have raised cholesterol and less likely to be prescribed lipid-lowering medication. Although fewer of those treated by diet (68%) have diabetes-related complications compared with those on medication (80%), the rate is much higher than for the population without diabetes. INTERPRETATION: Diabetics treated by diet only have significant rates of complications and are less likely than those on medication to be adequately monitored. There is great scope for improved management within general practice.

Smoking cessation treatment in primary care: prospective cohort study.

OBJECTIVE: To compare the characteristics of smokers who do and do not receive smoking cessation treatment in primary care. DESIGN: Prospective cohort study using practices registered with the pilot QRESEARCH database. SETTING: 156,550 patients aged 18 years and over from 39 general practices located within four strategic health authorities, representing the former Trent Region, UK. SUBJECTS: Patients registered with practices between 1 April 2001 and 31 March 2003 aged 18 years and over who were identified as smokers before the two year study period. OUTCOME: Prescription for smoking cessation treatment (nicotine replacement therapy (NRT) or bupropion) in the two year study period. VARIABLES: Age, sex, deprivation score, co-morbidity. RESULTS: Of the 29,492 patients recorded as current smokers at the start of the study period 1892 (6.4%) were given prescriptions for smoking cessation treatment during the subsequent two years. Of these, 1378 (72.8%) were given NRT alone, 406 (21.5%) bupropion alone, and 108 (5.7%) both treatments. Smokers were more likely to receive smoking cessation treatment if they lived in the most deprived areas (odds ratio (OR) for the most relative to the least deprived fifth, adjusted for sex, age, and co-morbidity, 1.50, 95% confidence interval (CI) 1.26 to 1.78), and if they were aged 25-74 years compared to 18-24 years or 75 and over. Smokers with co-morbidity were also more likely to receive smoking cessation treatment. Smokers were less likely to receive smoking cessation treatment if they were male (adjusted OR 0.68, 95% CI 0.62 to 0.75). CONCLUSION: The low proportion of smokers being prescribed these products strongly suggests that a major public health opportunity to prevent smoking related illness is being missed.

Association of panic disorder and panic attacks with hypertension.

PURPOSE: Previous studies of the association between hypertension and panic disorder were uncontrolled or involved small numbers of patients. PATIENTS AND METHODS: We compared the prevalence of panic disorder and panic attacks in 351 patients with documented hypertension who were randomly selected from all hypertensive patients registered in one primary care practice with age- and gender-matched normotensive patients from the same practice and with hypertensive patients attending a hospital clinic. All three groups completed questionnaires for panic disorder based on standard criteria, as well as the Hospital Anxiety and Depression scale. RESULTS: The prevalence of current (previous 6 months) panic attacks was significantly greater in primary care patients with hypertension (17%, P <0.05) and hospital-based hypertensive patients (19%, P <0.01) than in normotensive patients (11%). Similar results were seen for lifetime panic attacks (35% versus 39% versus 22%; both P for comparisons with normotensive patients <0.001). The prevalence of panic disorder was significantly greater in primary care patients with hypertension (13%) than normotensive patients (8%, P <0.05). Anxiety scores were significantly higher in both hypertensive groups than in normotensive patients. Depression scores were significantly higher in hospital-based hypertensive patients than in the other two groups. The reported diagnosis of hypertension antedated the onset of panic attacks in a large majority of patients (P <0.01). CONCLUSIONS: Physicians caring for patients with hypertension should be aware of the significantly greater prevalence of panic attacks in these patients.

Panic disorder, anxiety and depression in resistant hypertension--a case-control study.

BACKGROUND: It has been suggested that panic disorder can cause or contribute to hypertension or resistance to antihypertensive drugs. OBJECTIVE: To compare the prevalences of panic disorder, panic attacks, anxiety and depression between patients with resistant hypertension and age- and sex-matched patients with non-resistant hypertension. DESIGN: A case-control study of patients attending the Sheffield Hypertension Clinic, using self-completed postal questionnaires to assess panic disorder, anxiety and depression. PATIENTS CASES: With resistant hypertension were defined as patients who presently or previously had systolic blood pressure above 160 mmHg or diastolic blood pressure above 90 mmHg despite the use of three or more antihypertensive agents at full dose. For each of 136 cases, one control with non-resistant hypertension, defined as controlled to < or = 160/90 mmHg by one or two antihypertensive agents, was identified by a bias-free method. Cases and controls were matched for age and sex. MAIN OUTCOME MEASURES: Lifetime and current prevalence of panic attacks, the prevalences of panic disorder, anxiety and depression by Hospital Anxiety and Depression Scale scores, and the severity and frequency of panic attacks. RESULTS: Of the resistant hypertensive patients, 33% had experienced a panic attack compared with 39% of the control non-resistant hypertensives (resistant-non-resistant -6%, 95% confidence interval -19 to +7%). Twelve per cent of the resistant patients and 14% of controls fulfilled the criteria for a current or previous diagnosis of panic disorder (resistant-non-resistant -2%, 95% confidence interval -11% to +7%). There were also no significant differences between the groups in the prevalences of current panic attacks, panic attacks rated as moderate or worse, spontaneous panic attacks and in the frequency of panic attacks. There remained no significant difference between the groups for panic attacks and panic disorder when the analysis was limited to those patients who had idiopathic hypertension. The two groups did not differ significantly in scores for anxiety and depression measured by the Hospital Anxiety and Depression Scale. CONCLUSION: We observed no differences in the prevalences of panic, anxiety and depression between patients with resistant hypertension and non-resistant controls. These factors are probably not implicated in resistance to drug treatment. However, the prevalences of panic disorder and panic attacks were remarkably high in both groups of patients attending a hospital hypertension clinic. The relationship between panic disorder and hypertension deserves further study in a general hypertensive population.

Inequalities in access to coronary angiography and revascularisation: the association of deprivation and location of primary care services.

BACKGROUND: Coronary artery surgery reduces re-infarction rates and mortality in patients with ischaemic heart disease. This study examines inequality in relation to primary care services. AIM: To determine the effect of primary care services on access to coronary angiography and revascularisation. METHOD: A cross-sectional survey of all 180 Nottinghamshire practices in the Trent region that were in existence between 1993 and 1997. The numbers of coronary bypass grafts, angioplasties, and angiographies were determined from the regional National Health Service database and linked to a database of general practice characteristics. Poisson regression analysis was used to determine the relationship between the angiography and revascularisation rates and the following practice characteristics: deprivation score, distance from nearest secondary or tertiary referral centre, medical cardiology admission rate for ischaemic heart disease, fundholding status, and partnership size. Multiple linear regression analysis was used to determine the relationship between practice characteristics and the waiting times for revascularisation and angiography. RESULTS: Practices with high deprivation scores had significantly lower rates of utilisation of angiography and revascularisation procedures. Their patients also waited longer for angiography. Practices that were 20 km or further from a revascularisation centre had significantly lower angiography and revascularisation rates. On average, their patients had to wait more than twice as long for an angiography compared with patients from nearer practices. Fundholding practices had higher angiography rates but similar revascularisation rates compared with non-fundholding practices. CONCLUSION: The results suggest that there may be some under-investigation and/or treatment of patients with ischaemic heart disease from 'deprived' practices and for those from practices far from a secondary or tertiary referral centre.

The cost-effectiveness of lipid lowering in patients with ischaemic heart disease: an intervention and evaluation in primary care.

BACKGROUND: There has been a major revolution in the recommended treatment of hyperlipidaemia in patients with ischaemic heart disease following the publication of the Scandinavian Simvastatin Survival Study. This was the first major study to demonstrate that lipid-lowering drugs reduced mortality and morbidity in patients with ischaemic heart disease. AIM: To evaluate the feasibility and cost-effectiveness of screening and treating hyperlipidaemia in patients with ischaemic heart disease in primary care. METHOD: A study conducted in a rural dispensing training practice on the border of Nottinghamshire and Lincolnshire involving 327 patients with ischaemic heart disease who were registered with the practice on 1 January 1996. RESULTS: Eighty per cent of patients with ischaemic heart disease were considered eligible for screening and 80% of those attended for screening. The majority of patients who were screened had hyperlipidaemia that persisted after dietary advice. Despite lipid-lowering drugs, few patients had serum lipid concentrations in the target range at the end of six months. The costs of identifying and treating 83 patients with lipid-lowering drugs over five years is estimated at 105,318 Pounds at 1996 prices, or 94,257 Pounds assuming a 6% discount rate per annum. Two-thirds of this is owing to the cost of lipid-lowering drugs. The discounted cost per coronary event prevented would be 17,138 Pounds (95% CI = 12,568 Pounds-26,183 Pounds). The discounted cost per coronary death prevented would be 32,502 Pounds (95% CI = 23,564 Pounds-55,445 Pounds). There were no important adverse effects of lipid-lowering drugs on quality of life or mood. CONCLUSION: Such a programme is feasible and acceptable within primary care, although the ongoing cost implications need to be considered against the costs and benefits of other interventions.

A pilot study of a randomized controlled trial of pragmatic eradication of Helicobactor pylori in primary care.

We report on a pilot study for a randomized control trial of pragmatic eradication of Helicobacter Pylori in primary care. Although the sample size is small, pragmatic eradication is likely to be cost-effective for patients with documented or suspected peptic ulcer disease on maintenance acid suppression therapy in primary care.

Are spouses of patients with hypertension at increased risk of having hypertension? A population-based case-control study.

BACKGROUND: Studies of couples, who tend to share an environment but are genetically dissimilar, can shed light on the contribution of environmental factors to hypertension. There has been renewed interest in these environmental factors following the re-analysis of the INTERSALT study. AIM: To determine whether patients whose spouses have hypertension are at increased risk of hypertension, using a population-based case-control study. METHOD: The total study population consisted of all 3923 patients over 30 years old registered with one general practice. Male cases with hypertension were matched to male controls without hypertension. Female cases with hypertension were matched to female controls without hypertension. The variables were: diagnosed hypertension; having a spouse with diagnosed hypertension; age; sex; weight; height; body-mass index; couple status; diabetes; and systolic and diastolic blood pressure readings. RESULTS: On multivariate analysis, when age, body-mass index, diabetes, couple status, and having a blood pressure reading were included, men whose spouses had hypertension had a two-fold increased risk of hypertension (adjusted odds ratio (OR) 2.24; 95% CI 1.77-2.72; P = 0.001). Similarly, on multivariate analysis, women whose spouses had hypertension had a two-fold increased risk of hypertension (adjusted OR = 2.23; 95% CI 1.75-2.72; P = 0.001). The risk for both male and female subjects persisted after adjustment for other variables. There was a significant correlation between systolic (r = 0.41; P < 0.0001) and diastolic (r = 0.25; P < 0.0001) blood pressures between spouse pairs. CONCLUSION: The independent association between having a spouse with hypertension and increased risk of hypertension supports the view that there are significant environmental factors in the aetiology of hypertension. The finding has implications for the screening and treatment of hypertension in primary care.

Are patients who present late with cancer registered with low referring practices?

This study examines whether a clinical outcome (stage of breast or bowel cancer at referral) was related to variations in GP referral rates. A multivariate analysis of breast and bowel cancer patients referred from 183 Nottinghamshire practices during 1993 showed no adverse outcome associated with low GP referral rates. Variables included in the analysis were total and surgical referral rates, fundholding status, UPA(8) score of the practice, partnership size, and age and sex of the referred patient.

No evidence that panic attacks are associated with the white coat effect in hypertension.

The authors aimed to determine whether hypertensive patients with panic attacks or panic disorder have a larger white coat effect (difference between clinic blood pressure measured under standard conditions and mean daytime ambulatory blood pressure) than hypertensive patients without panic attacks. White coat effect was compared in a hospital hypertension clinic between 24 patients with panic attacks in the previous 6 months (12 with panic disorder) and 23 hypertensive controls. There were no significant differences between cases and controls in clinic blood pressure, mean daytime ambulatory blood pressure, or white coat effect (18/3 vs. 19/6 mm Hg; difference for systolic, -1.9 mm Hg; 95% confidence interval, -15.8 to +12.0; difference for diastolic, -3.0 mm Hg; 95% confidence interval, -10.2 to +4.3). Comparing only patients with panic disorder with controls, there were again no significant differences in clinic blood pressure, mean daytime ambulatory blood pressure, or white coat effect. This study provides no evidence for an exaggerated white coat effect in hypertensive patients who have experienced panic attacks or panic disorder. However, only larger studies could exclude differences in white coat effect <12/4 mm Hg, or an exaggerated white coat effect in a minority of patients with panic attacks.

Depression as a risk factor for ischaemic heart disease in men: population based case-control study.

OBJECTIVE: To determine the relation between depression, anxiety, and use of antidepressants and the onset of ischaemic heart disease. DESIGN: Population based case-control study. SETTING: All 5623 patients registered with one general practice. SUBJECTS: 188 male cases with ischaemic heart disease matched by age to 485 male controls without ischaemic heart disease; 139 female cases with ischaemic heart disease matched by age to 412 female controls. MAIN OUTCOME MEASURE: Adjusted odds ratios calculated by conditional logistic regression. RESULTS: The risk of ischaemic heart disease was three times higher among men with a recorded diagnosis of depression than among controls of the same age (odds ratio 3.09; 95% confidence interval 1.33 to 7.21; P=0.009). This association persisted when smoking status, diabetes, hypertension, and underprivileged area (UPA(8)) score were included in a multivariate model (adjusted 2.75; 1.13 to 6.69; P=0.03). Men with depression within the preceding 10 years were three times more likely to develop ischaemic heart disease than were the controls (3.13; 1.27 to 7.70; P=0.01). Men with ischaemic heart disease had a higher risk of subsequent depression [corrected] than men without ischaemic heart disease (adjusted 2.34; 1.34 to 4.10; P=0.003). Depression was not a risk factor for ischaemic heart disease in women on multivariate analysis (adjusted 1.34; 0.70 to 2.56; P=0.38). Anxiety and subsequent ischaemic heart disease were not significantly associated in men or women. CONCLUSION: Depression may be an independent risk factor for ischaemic heart disease in men, but not in women.