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1.
Eur J Pain ; 2021 Feb 08.
Artículo en Inglés | MEDLINE | ID: mdl-33559289

RESUMEN

BACKGROUND: Domestic abuse is a global public health issue. The association between the development of central sensitivity syndromes (CSS) and previous exposure to domestic abuse has been poorly understood particularly within European populations. METHODS: A retrospective cohort study using the 'The Health Improvement Network,' (UK primary care medical records) between 1st January 1995- 31st December 2018. 22,604 adult women exposed to domestic abuse were age matched to 44,671 unexposed women. Average age at cohort entry was 36 years and median follow up was 2.5 years. The outcomes of interest were the development of a variety of syndromes which demonstrate central nervous system sensitisation. Fibromyalgia, chronic fatigue syndrome and temporomandibular joint disorder outcomes have been reported previously. Outcomes were adjusted for the presence of mental ill health. RESULTS: During the study period, women exposed to domestic abuse experienced an increased risk of developing chronic lower back pain (adjusted incidence rate ratio (aIRR) 2.28; 95% CI 1.85-2.80), chronic headaches (aIRR 3.15; 95% CI 1.07-9.23), irritable bowel syndrome (aIRR 1.41; 95% CI 1.25-1.60) and restless legs syndrome (aIRR 1.89; 95% CI 1.44-2.48). However, no positive association was seen with the development of interstitial cystitis (aIRR 0.52; 95% CI 0.14-1.93), vulvodynia (aIRR 0.42; 95% CI 0.14-1.25) and myofascial pain syndrome (aIRR 1.01; 95% CI 0.28-3.61). CONCLUSION: This study demonstrates the need to consider a past history of domestic abuse in patients presenting with CSS; and also consider preventative approaches in mitigating the risk of developing CSS following exposure to domestic abuse.

2.
Artículo en Inglés | MEDLINE | ID: mdl-33560344

RESUMEN

OBJECTIVE: Diabetes has emerged as an important risk factor for mortality from COVID-19. Metformin, the most commonly prescribed glucose-lowering agent, has been proposed to influence susceptibility to and outcomes of COVID-19 via multiple mechanisms. We investigated whether, in patients with diabetes, metformin is associated with susceptibility to COVID-19 and its outcomes. RESEARCH DESIGN AND METHODS: We performed a propensity score-matched cohort study with active comparators using a large UK primary care dataset. Adults with type 2 diabetes patients and a current prescription for metformin and other glucose lowering agents (MF+) were compared to those with a current prescription for glucose-lowering agents that did not include metformin (MF-). Outcomes were confirmed COVID-19, suspected/confirmed COVID-19, and associated mortality. A negative control outcome analysis (back pain) was also performed. RESULTS: There were 29,558 and 10,271 patients in the MF+ and MF- groups respectively who met the inclusion criteria. In the propensity score-matched analysis, the adjusted hazard ratio for suspected/confirmed COVID-19, confirmed COVID-19, and COVID-19 related mortality were 0.85 (95%CI 0.67, 1.08), 0.80 (95%CI 0.49, 1.30), and 0.87 (95%CI 0.34, 2.20) respectively. The negative outcome control analysis did not suggest unobserved confounding. CONCLUSION: Current prescription of metformin was not associated with the risk of COVID-19 or COVID-19 related mortality. It is safe to continue prescribing metformin to improve glycaemic control in patients with diabetes, despite concerns about an impending second wave of COVID-19.

3.
Artículo en Inglés | MEDLINE | ID: mdl-33590842

RESUMEN

OBJECTIVE: To compare the incident risk of rheumatoid arthritis (RA) in patients with type 2 diabetes mellitus (T2DM), and to explore the role of glycaemic control and associated therapeutic use on the onset of RA. METHODS: This study was a retrospective cohort study using patients derived from the IQVIA medical research database (IMRD-UK) between 1995 and 2019. 224 551 newly diagnosed patients with T2DM were matched to 449 101 patients without T2DM and followed up to assess their risk of RA. Further analyses investigated the effect of glycaemic control, statin use, and anti-diabetic drugs on the relationship between T2DM and RA using time-dependent Cox regression model. RESULTS: During the study period, the incidence rate for RA was 8.1 and 10.6 per 10 000 person-years in the exposed and unexposed groups respectively. Following adjustment, the hazard ratio (aHR) was 0.73 (95% CI 0.67-0.79). In patients who had not used statins in their lifetime, the aHR was 0.89 (95% CI 0.69-1.14). When quantifying the effects of glycaemic control, anti-diabetic drugs and statins using time-varying analyses, there was no association with glycaemic control (aHR 1.00 (95% CI 0.99-1.00)), use of metformin (aHR 1.00 (95% CI 0.82-1.22)), dipeptidyl peptidase-4 inhibitors (DPP4i) (aHR 0.94 (95% CI 0.71-1.24)), and the development of RA. However, statins demonstrated a protective effect for progression of RA in those with T2DM (aHR 0.76 (95% CI 0.66-0.88), with evidence of duration-response relationship. CONCLUSION: There is a reduced risk of RA in patients with T2DM, that may be attributable to the use of statins.

4.
Diabetes Care ; 44(1): 116-124, 2021 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-33444160

RESUMEN

OBJECTIVE: To assess the impact of bariatric surgery (BS) on incident microvascular complications of diabetes-related foot disease (DFD), sight-threatening diabetic retinopathy (STDR), and chronic kidney disease (CKD) in patients with type 2 diabetes and obesity. RESEARCH DESIGN AND METHODS: A retrospective matched, controlled population-based cohort study was conducted of adults with type 2 diabetes between 1 January 1990 and 31 January 2018 using IQVIA Medical Research Data (IMRD), a database of primary care electronic records. Each patient with type 2 diabetes who subsequently had BS (surgical group) was matched on the index date with up to two patients with type 2 diabetes who did not have BS (nonsurgical group) within the same general practice by age, sex, preindex BMI, and diabetes duration. RESULTS: Included were 1,126 surgical and 2,219 nonsurgical participants. In the study population 2,261 (68%) were women. Mean (SD) age was 49.87 (9.3) years vs. 50.12 (9.3) years and BMI was 46.76 (7.96) kg/m2 vs. 46.14 (7.49) kg/m2 in the surgical versus nonsurgical group, respectively. In the surgical group, 22.1%, 22.7%, 52.2%, and 1.1% of patients had gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB), and duodenal switch, respectively. Over a median follow-up of 3.9 years (interquartile range 1.8-6.4), BS was associated with reduction in incident combined microvascular complications (adjusted hazard ratio 0.53, 95% CI 0.43-0.66, P < 0.001), DFD (0.61, 0.50-0.75, P < 0.001), STDR (0.66, 0.44-1.00, P = 0.048), and CKD (0.63, 0.51-0.78, P < 0.001). Analysis based on the type of surgery showed that all types of surgery were associated with a favorable impact on the incidence of composite microvascular complications, with the greatest reduction for RYGB. CONCLUSIONS: BS was associated with a significant reduction in incident diabetes-related microvascular complications.

5.
Diabetes Care ; 44(3): 731-739, 2021 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-33483358

RESUMEN

OBJECTIVE: To investigate the relationship between social deprivation and incident diabetes-related foot disease (DFD) in newly diagnosed patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: A population-based open retrospective cohort study using The Health Improvement Network (1 January 2005 to 31 December 2019) was conducted. Patients with type 2 diabetes free of DFD at baseline were stratified by Townsend deprivation index, and risk of developing DFD was calculated. DFD was defined as a composite of foot ulcer (FU), Charcot arthropathy, lower-limb amputation (LLA), peripheral neuropathy (PN), peripheral vascular disease (PVD), and gangrene. RESULTS: A total of 176,359 patients were eligible (56% men; mean age 62.9 [SD 13.1] years). After excluding 26,094 patients with DFD before/within 15 months of type 2 diabetes diagnosis, DFD incidentally developed in 12.1% of the study population over 3.27 years (interquartile range 1.41-5.96). Patients in the most deprived Townsend quintile had increased risk of DFD compared with those in the least deprived (adjusted hazard ratio [aHR] 1.22; 95% CI 1.16-1.29) after adjusting for sex, age at type 2 diabetes diagnosis, ethnicity, smoking, BMI, HbA1c, cardiovascular disease, hypertension, retinopathy, estimated glomerular filtration rate, insulin, glucose/lipid-lowering medication, and baseline foot risk. Patients in the most deprived Townsend quintile had higher risk of PN (aHR 1.18; 95% CI 1.11-1.25), FU (aHR 1.44; 95% CI 1.17-1.77), PVD (aHR 1.40; 95% CI 1.28-1.53), LLA (aHR 1.75; 95% CI 1.08-2.83), and gangrene (aHR 8.49; 95% CI 1.01-71.58) compared with those in the least. CONCLUSIONS: Social deprivation is an independent risk factor for the development of DFD, PN, FU, PVD, LLA, and gangrene in newly diagnosed patients with type 2 diabetes. Considering the high individual and economic burdens of DFD, strategies targeting patients in socially deprived areas are needed to reduce health inequalities.

6.
Eur J Endocrinol ; 2020 Dec 01.
Artículo en Inglés | MEDLINE | ID: mdl-33306038

RESUMEN

Since the introduction of sensitive assays for serum thyroid stimulating hormone (TSH) clinicians have advised hypothyroid patients to adjust the dose of levothyroxine (L-T4) in order to achieve a normal serum TSH. A minority of patients are dissatisfied with this treatment strategy and experience symptoms. Some indirect evidence suggests that a normal serum TSH may not necessarily reflect euthyroidism at tissue level in patients treated with L-T4. Increasingly hypothyroid patients demand higher doses of L-T4 or liothyronine (L-T3) or animal thyroid extract, often purchased online, and titrate the dose against symptoms, although ample evidence suggests that combination treatment (L-T4 with L-T3) is no more effective than L-T4 alone. Community surveys show that up to 53% of treated hypothyroid patients at any time have a serum TSH outside the normal range. The recommendation by guidelines that the upper limit of the normal range for serum TSH should not be exceeded is supported by robust evidence and is generally accepted by clinicians and patients. However, until recently the lower limit of serum TSH for optimal L-T4 replacement has been controversial. New evidence obtained by two independent large population studies over the past two years has shown that mortality of hypothyroid patients treated with levothyroxine is increased when the serum TSH exceeds or is reduced outside the normal reference range. It is estimated that implementation of a policy of normalising serum TSH in hypothyroid patients will reduce the risk of death of 28.3 million people in the USA and Europe alone.

7.
N Z Med J ; 133(1527): 39-50, 2020 12 18.
Artículo en Inglés | MEDLINE | ID: mdl-33332327

RESUMEN

AIMS: Evaluate trends in foot examinations for people with diabetes by primary healthcare nurses between 2006-2008 and 2016 in Auckland, New Zealand. METHODS: All primary care nurses in 2006-2008 and 2016 were identified and 26% and 24% were randomly sampled and surveyed, respectively. Nurse participants completed a self-administered questionnaire and telephone interview about the care provided for people with diabetes. RESULTS: Significantly more patients consulted by practice nurses received foot examinations in 2016 (58%) compared with 2006-2008 (36%), and foot-care education (66% versus 26%). Of the 43% of patients who had no foot examination in 2016, 23% had no previous examination documented. Significantly more nurses in 2016 than in 2006-2008 self-reported routinely examining patients' feet (45% versus 31%) and giving foot-care education (28% versus 13%). These practices were associated with nurses undertaking >5 hours of diabetes education within the past five years. CONCLUSIONS: Practice nurses have significantly expanded their role in managing people with diabetes over the last decade by increasing the number of foot examinations and providing recommended foot-care education. Improved management was associated with nurses attending diabetes education in the past five years. Gaps were identified in conducting the recommended number of foot examinations, categorising patients' risk of foot disease and recording previous examinations.


Asunto(s)
Pie Diabético/prevención & control , Rol de la Enfermera , Enfermeras y Enfermeros/tendencias , Examen Físico/tendencias , Atención Primaria de Salud/tendencias , Estudios Transversales , Diabetes Mellitus/enfermería , Pie Diabético/diagnóstico , Educación en Enfermería , Femenino , Pie , Humanos , Masculino , Persona de Mediana Edad , Nueva Zelanda , Enfermeras y Enfermeros/estadística & datos numéricos , Educación del Paciente como Asunto/estadística & datos numéricos , Educación del Paciente como Asunto/tendencias , Examen Físico/estadística & datos numéricos , Atención Primaria de Salud/métodos , Autoinforme
8.
Arthritis Rheumatol ; 2020 Nov 13.
Artículo en Inglés | MEDLINE | ID: mdl-33185016

RESUMEN

OBJECTIVES: To identify whether active use of non-steroidal anti-inflammatory drugs (NSAIDs) increases susceptibility to developing suspected or confirmed COVID-19 compared to the use of other common analgesics. METHODS: We performed a propensity score-matched cohort study with active comparators using a large UK primary care dataset. The cohort consisted of adult patients aged ≥18 years with a diagnosis of osteoarthritis and followed up from 30th January to 31st July 2020. Patients prescribed an NSAID (excluding topical preparations) were compared to those prescribed either co-codamol (paracetamol and codeine) or co-dydramol (paracetamol and dihydrocodeine). We identified 13,202 patients prescribed NSAIDs compared to 12,457 prescribed the comparator drugs. The primary outcome was documentation of suspected or confirmed COVID-19 and secondary outcome measure was all-cause mortality. RESULTS: During follow up, the incidence rates of suspected/confirmed COVID-19 were 15.4 and 19.9 per 1000 person-years in the NSAID-exposed and comparator groups, respectively. Adjusted hazard ratios in the unmatched and propensity score matched analyses for primary care consultations with suspected/confirmed COVID-19 were 0.82 (95% CI 0.62-1.10) and 0.79 (95% CI 0.57-1.11) respectively, and for subsequent mortality were 0.97 (95% CI 0.75-1.27) and 0.85 (95% CI 0.61-1.20). There was no effect modification by age or sex. CONCLUSION: We did not observe an increased risk of suspected or confirmed COVID-19 or mortality among patients in primary care with osteoarthritis who were prescribed NSAIDs compared to comparator drugs. These results are reassuring and suggest that in the absence of acute illness, NSAIDs can be safely prescribed during the ongoing pandemic.

9.
JMIR Diabetes ; 5(4): e19650, 2020 Nov 18.
Artículo en Inglés | MEDLINE | ID: mdl-33206055

RESUMEN

BACKGROUND: Attempts to utilize eHealth in diabetes mellitus (DM) management have shown promising outcomes, mostly targeted at patients; however, few solutions have been designed for health care providers. OBJECTIVE: The purpose of this study was to conduct a feasibility project developing and evaluating a mobile clinical decision support system (CDSS) tool exclusively for health care providers to manage chronic kidney disease (CKD) in patients with DM. METHODS: The design process was based on the 3 key stages of the user-centered design framework. First, an exploratory qualitative study collected the experiences and views of DM specialist nurses regarding the use of mobile apps in clinical practice. Second, a CDSS tool was developed for the management of patients with DM and CKD. Finally, a randomized controlled trial examined the acceptability and impact of the tool. RESULTS: We interviewed 15 DM specialist nurses. DM specialist nurses were not currently using eHealth solutions in their clinical practice, while most nurses were not even aware of existing medical apps. However, they appreciated the potential benefits that apps may bring to their clinical practice. Taking into consideration the needs and preferences of end users, a new mobile CDSS app, "Diabetes & CKD," was developed based on guidelines. We recruited 39 junior foundation year 1 doctors (44% male) to evaluate the app. Of them, 44% (17/39) were allocated to the intervention group, and 56% (22/39) were allocated to the control group. There was no significant difference in scores (maximum score=13) assessing the management decisions between the app and paper-based version of the app's algorithm (intervention group: mean 7.24 points, SD 2.46 points; control group: mean 7.39, SD 2.56; t37=-0.19, P=.85). However, 82% (14/17) of the participants were satisfied with using the app. CONCLUSIONS: The findings will guide the design of future CDSS apps for the management of DM, aiming to help health care providers with a personalized approach depending on patients' comorbidities, specifically CKD, in accordance with guidelines.

10.
Drug Saf ; 2020 Oct 26.
Artículo en Inglés | MEDLINE | ID: mdl-33104975

RESUMEN

INTRODUCTION: There are concerns that hydrochlorothiazide may increase the risk of incident nonmelanoma (cutaneous squamous cell carcinoma [cSCC], basal cell carcinoma [BCC]) and melanoma skin cancer, with regulatory agencies and societies calling for additional studies. METHODS: We conducted a propensity score-matched population-based cohort study using the United Kingdom Clinical Practice Research Datalink. A total of 20,513 new users of hydrochlorothiazide were propensity score matched, in a 1:1 ratio, to new users of other thiazide diuretics between January 1, 1988 and March 31, 2018, with follow-up until March 31, 2019. Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) for cSCC, BCC, and melanoma, comparing use of hydrochlorothiazide with use of other thiazide diuretics overall, by cumulative duration of use, and cumulative dose. RESULTS: After an 8.6-year median follow-up, hydrochlorothiazide was associated with an increased risk of cSCC (HR 1.50, 95% CI 1.06-2.11). HRs increased with cumulative duration of use, with evidence of an association after 5-10 years (HR 2.10, 95% CI 1.20-3.67) and highest after > 10 years (HR 3.70, 95% CI 1.77-7.73). Similarly, HRs increased with cumulative dose, with higher estimates for ≥ 100,000 mg (HR 4.96, 95% CI 2.51-9.81). In contrast, hydrochlorothiazide was not associated with an increased risk of BCC (HR 1.01, 95% CI 0.91-1.13) or melanoma (HR 0.82, 95% CI 0.63-1.08), with no evidence of duration- or dose-response relationships. CONCLUSIONS: Use of hydrochlorothiazide was associated with an increased risk of cSCC and with evidence of a duration- and dose-response relationship. In contrast, no association was observed for BCC or melanoma.

11.
Am J Gastroenterol ; 2020 Oct 22.
Artículo en Inglés | MEDLINE | ID: mdl-33105192

RESUMEN

INTRODUCTION: Case reports describe individuals with achalasia features subsequently diagnosed with eosinophilic esophagitis (an atopic disorder). We have examined associations between achalasia and atopic and autoimmune conditions. METHODS: This is a UK cohort study of 2,593 subjects with achalasia matched to 10,402 controls. RESULTS: At diagnosis, achalasia was associated with autoimmune conditions (odds ratio 1.39; 95% confidence interval 1.02-1.90) and atopic conditions (1.40; 1.00-1.95) in those aged younger than 40 years. DISSCUSSION: Our findings support an autoimmune etiology in achalasia but also suggest a possible atopic etiology in younger subjects.

12.
BMJ Open Ophthalmol ; 5(1): e000579, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33083555

RESUMEN

Objectives: Risk stratification is needed for patients referred to hospital eye services by Diabetic Eye Screening Programme UK. This requires a set of candidate predictors. The literature contains a large number of predictors. The objective of this research was to arrive at a small set of clinically important predictors for the outcome of the progression of diabetic retinopathy (DR). They need to be evidence based and readily available during the clinical consultation. Methods and analysis: Initial list of predictors was obtained from a systematic review of prediction models. We sought the clinical expert opinion using a formal qualitative study design. A series of nominal group technique meetings to shorten the list and to rank the predictors for importance by voting were held with National Health Service hospital-based clinicians involved in caring for patients with DR in the UK. We then evaluated the evidence base for the selected predictors by critically appraising the evidence. Results: The source list was presented at nominal group meetings (n=4), attended by 44 clinicians. Twenty-five predictors from the original list were ranked as important predictors and eight new predictors were proposed. Two additional predictors were retained after evidence check. Of these 35, 21 had robust supporting evidence in the literature condensed into a set of 19 predictors by categorising DR. Conclusion: We identified a set of 19 clinically meaningful predictors of DR progression that can help stratify higher-risk patients referred to hospital eye services and should be considered in the development of an individual risk stratification model. Study design: A qualitative study and evidence review. Setting: Secondary eye care centres in North East, Midlands and South of England.

13.
Eur J Endocrinol ; 2020 Oct 01.
Artículo en Inglés | MEDLINE | ID: mdl-33112263

RESUMEN

CONTEXT: The incidence of gestational diabetes mellitus (GDM) has been on the rise, driven by maternal obesity. In parallel, pubertal tempo has increased in the general population, driven by childhood obesity. OBJECTIVE: To evaluate the available evidence on pubertal timing of boys and girls born to mothers with GDM. DATA SOURCES: We searched MEDLINE, EMBASE, CINAHL Plus, Cochrane library and grey literature for observational studies up to October 2019. Study selection and extraction: Two reviewers independently selected studies, collected data and appraised the studies for risk of bias. Results were tabulated and narratively described. RESULTS: Seven studies (six for girls and four for boys) were included. Study quality score was mostly moderate (ranging from 4 to 10 out of 11). In girls born to mothers with GDM, estimates suggest earlier timing of pubarche, thelarche and menarche although for each of these outcomes only one study each showed a statistically significant association. In boys, there was some association between maternal GDM and earlier pubarche, but inconsistency in the direction of shift of age at onset of genital and testicular development and first ejaculation. Only a single study analysed growth patterns in children of mothers with GDM, describing a 3-month advancement in the age of attainment of peak height velocity and a slight increase in pubertal tempo. CONCLUSIONS: Pubertal timing may be influenced by the presence of maternal GDM, though current evidence is sparse and of limited quality. Prospective cohort studies should be conducted, ideally coupled with objective biochemical tests.

14.
BMJ ; 371: m3502, 2020 10 07.
Artículo en Inglés | MEDLINE | ID: mdl-33028606

RESUMEN

OBJECTIVE: To consolidate evidence from systematic reviews and meta-analyses investigating the association between reproductive factors in women of reproductive age and their subsequent risk of cardiovascular disease. DESIGN: Umbrella review. DATA SOURCES: Medline, Embase, and Cochrane databases for systematic reviews and meta-analyses from inception until 31 August 2019. REVIEW METHODS: Two independent reviewers undertook screening, data extraction, and quality appraisal. The population was women of reproductive age. Exposures were fertility related factors and adverse pregnancy outcomes. Outcome was cardiovascular diseases in women, including ischaemic heart disease, heart failure, peripheral arterial disease, and stroke. RESULTS: 32 reviews were included, evaluating multiple risk factors over an average follow-up period of 7-10 years. All except three reviews were of moderate quality. A narrative evidence synthesis with forest plots and tabular presentations was performed. Associations for composite cardiovascular disease were: twofold for pre-eclampsia, stillbirth, and preterm birth; 1.5-1.9-fold for gestational hypertension, placental abruption, gestational diabetes, and premature ovarian insufficiency; and less than 1.5-fold for early menarche, polycystic ovary syndrome, ever parity, and early menopause. A longer length of breastfeeding was associated with a reduced risk of cardiovascular disease. The associations for ischaemic heart disease were twofold or greater for pre-eclampsia, recurrent pre-eclampsia, gestational diabetes, and preterm birth; 1.5-1.9-fold for current use of combined oral contraceptives (oestrogen and progesterone), recurrent miscarriage, premature ovarian insufficiency, and early menopause; and less than 1.5-fold for miscarriage, polycystic ovary syndrome, and menopausal symptoms. For stroke outcomes, the associations were twofold or more for current use of any oral contraceptive (combined oral contraceptives or progesterone only pill), pre-eclampsia, and recurrent pre-eclampsia; 1.5-1.9-fold for current use of combined oral contraceptives, gestational diabetes, and preterm birth; and less than 1.5-fold for polycystic ovary syndrome. The association for heart failure was fourfold for pre-eclampsia. No association was found between cardiovascular disease outcomes and current use of progesterone only contraceptives, use of non-oral hormonal contraceptive agents, or fertility treatment. CONCLUSIONS: From menarche to menopause, reproductive factors were associated with cardiovascular disease in women. In this review, presenting absolute numbers on the scale of the problem was not feasible; however, if these associations are causal, they could account for a large proportion of unexplained risk of cardiovascular disease in women, and the risk might be modifiable. Identifying reproductive risk factors at an early stage in the life of women might facilitate the initiation of strategies to modify potential risks. Policy makers should consider incorporating reproductive risk factors as part of the assessment of cardiovascular risk in clinical guidelines. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019120076.


Asunto(s)
Enfermedades Cardiovasculares/epidemiología , Fertilidad , Complicaciones del Embarazo/epidemiología , Salud Reproductiva/estadística & datos numéricos , Medición de Riesgo , Correlación de Datos , Femenino , Humanos , Metaanálisis como Asunto , Embarazo , Factores de Riesgo , Revisiones Sistemáticas como Asunto
15.
JAMA Neurol ; 2020 Oct 05.
Artículo en Inglés | MEDLINE | ID: mdl-33017023

RESUMEN

Importance: Epidemiologic data on optic neuritis (ON) incidence and associations with immune-mediated inflammatory diseases (IMIDs) are sparse. Objective: To estimate 22-year trends in ON prevalence and incidence and association with IMIDs in the United Kingdom. Design, Setting, and Participants: This cohort study analyzed data from The Health Improvement Network from January 1, 1995, to September 1, 2019. The study included 10 937 511 patients 1 year or older with 75.2 million person-years' follow-up. Annual ON incidence rates were estimated yearly (January 1, 1997, to December 31, 2018), and annual ON prevalence was estimated by performing sequential cross-sectional studies on data collected on January 1 each year for the same period. Data for 1995, 1996, and 2019 were excluded as incomplete. Risk factors for ON were explored in a cohort analysis from January 1, 1997, to December 31, 2018. Matched case-control and retrospective cohort studies were performed using data from January 1, 1995, to September 1, 2019, to explore the odds of antecedent diagnosis and hazard of incident diagnosis of 66 IMIDs in patients compared with controls. Exposures: Optic neuritis. Main Outcomes and Measures: Annual point prevalence and incidence rates of ON, adjusted incident rate ratios (IRRs) for risk factors, and adjusted odds ratios (ORs) and adjusted hazard ratios (HRs) for 66 IMIDs. Results: A total of 10 937 511 patients (median [IQR] age at cohort entry, 32.6 [18.0-50.4] years; 5 571 282 [50.9%] female) were studied. A total of 1962 of 2826 patients (69.4%) with incident ON were female and 1192 of 1290 92.4%) were White, with a mean (SD) age of 35.6 (15.6) years. Overall incidence across 22 years was stable at 3.7 (95% CI, 3.6-3.9) per 100 000 person-years. Annual point prevalence (per 100 000 population) increased with database maturity, from 69.3 (95% CI, 57.2-81.3) in 1997 to 114.8 (95% CI, 111.0-118.6) in 2018. The highest risk of incident ON was associated with female sex, obesity, reproductive age, smoking, and residence at higher latitude, with significantly lower risk in South Asian or mixed race/ethnicity compared with White people. Patients with ON had significantly higher odds of prior multiple sclerosis (MS) (OR, 98.22; 95% CI, 65.40-147.52), syphilis (OR, 5.76; 95% CI, 1.39-23.96), Mycoplasma (OR, 3.90; 95% CI, 1.09-13.93), vasculitis (OR, 3.70; 95% CI, 1.68-8.15), sarcoidosis (OR, 2.50; 95% CI, 1.21-5.18), Epstein-Barr virus (OR, 2.29; 95% CI, 1.80-2.92), Crohn disease (OR, 1.97; 95% CI, 1.13-3.43), and psoriasis (OR, 1.28; 95% CI, 1.03-1.58). Patients with ON had a significantly higher hazard of incident MS (HR, 284.97; 95% CI, 167.85-483.81), Behçet disease (HR, 17.39; 95% CI, 1.55-195.53), sarcoidosis (HR, 14.80; 95% CI, 4.86-45.08), vasculitis (HR, 4.89; 95% CI, 1.82-13.10), Sjögren syndrome (HR, 3.48; 95% CI, 1.38-8.76), and herpetic infection (HR, 1.68; 95% CI, 1.24-2.28). Conclusions and Relevance: The UK incidence of ON is stable. Even though predominantly associated with MS, ON has numerous other associations with IMIDs. Although individually rare, together these associations outnumber MS-associated ON and typically require urgent management to preserve sight.

16.
BMJ Open Respir Res ; 7(1)2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32873607

RESUMEN

BACKGROUND: Studies suggest that certain black and Asian minority ethnic groups experience poorer outcomes from COVID-19, but these studies have not provided insight into potential reasons for this. We hypothesised that outcomes would be poorer for those of South Asian ethnicity hospitalised from a confirmed SARS-CoV-2 infection, once confounding factors, health-seeking behaviours and community demographics were considered, and that this might reflect a more aggressive disease course in these patients. METHODS: Patients with confirmed SARS-CoV-2 infection requiring admission to University Hospitals Birmingham NHS Foundation Trust (UHB) in Birmingham, UK between 10 March 2020 and 17 April 2020 were included. Standardised admission ratio (SAR) and standardised mortality ratio (SMR) were calculated using observed COVID-19 admissions/deaths and 2011 census data. Adjusted HR for mortality was estimated using Cox proportional hazard model adjusting and propensity score matching. RESULTS: All patients admitted to UHB with COVID-19 during the study period were included (2217 in total). 58% were male, 69.5% were white and the majority (80.2%) had comorbidities. 18.5% were of South Asian ethnicity, and these patients were more likely to be younger and have no comorbidities, but twice the prevalence of diabetes than white patients. SAR and SMR suggested more admissions and deaths in South Asian patients than would be predicted and they were more likely to present with severe disease despite no delay in presentation since symptom onset. South Asian ethnicity was associated with an increased risk of death, both by Cox regression (HR 1.4, 95% CI 1.2 to 1.8), after adjusting for age, sex, deprivation and comorbidities, and by propensity score matching, matching for the same factors but categorising ethnicity into South Asian or not (HR 1.3, 95% CI 1.0 to 1.6). CONCLUSIONS: Those of South Asian ethnicity appear at risk of worse COVID-19 outcomes. Further studies need to establish the underlying mechanistic pathways.


Asunto(s)
Grupo de Ascendencia Continental Asiática/estadística & datos numéricos , Betacoronavirus/aislamiento & purificación , Infecciones por Coronavirus , Hospitalización/estadística & datos numéricos , Mortalidad/etnología , Pandemias , Neumonía Viral , Estudios de Cohortes , Comorbilidad , Infecciones por Coronavirus/etnología , Infecciones por Coronavirus/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Neumonía Viral/etnología , Neumonía Viral/terapia , Modelos de Riesgos Proporcionales , Factores de Riesgo , Índice de Severidad de la Enfermedad , Reino Unido/epidemiología
17.
J Clin Endocrinol Metab ; 105(12)2020 12 01.
Artículo en Inglés | MEDLINE | ID: mdl-32880390

RESUMEN

BACKGROUND: Systemic corticosteroids are now recommended in many treatment guidelines, although supporting evidence is limited to 1 randomized controlled clinical trial (RECOVERY). OBJECTIVE: To identify whether corticosteroids were beneficial to COVID-19 patients. METHODS: A total of 1514 severe and 249 critical hospitalized COVID-19 patients from 2 medical centers in Wuhan, China. Multivariable Cox models, Cox model with time-varying exposure and propensity score analysis (inverse-probability-of-treatment-weighting [IPTW] and propensity score matching [PSM]) were used to estimate the association of corticosteroid use with risk of in-hospital mortality in severe and critical cases. RESULTS: Corticosteroids were administered in 531 (35.1%) severe and 159 (63.9%) critical patients. Compared to the non-corticosteroid group, systemic corticosteroid use was not associated with beneficial effect in reducing in-hospital mortality in either severe cases (HR = 1.77; 95% CI, 1.08-2.89; P = 0.023), or critical cases (HR = 2.07; 95% CI, 1.08-3.98; P = 0.028). Findings were similar in time-varying Cox analysis. For patients with severe COVID-19 at admission, corticosteroid use was not associated with improved or harmful outcome in either PSM or IPTW analysis. For critical COVID-19 patients at admission, results were consistent with multivariable Cox model analysis. CONCLUSION: Corticosteroid use was not associated with beneficial effect in reducing in-hospital mortality for severe or critical cases in Wuhan. Absence of the beneficial effect in our study in contrast to that observed in the RECOVERY clinical trial may be due to biases in observational data, in particular prescription by indication bias, differences in clinical characteristics of patients, choice of corticosteroid used, timing of initiation of treatment, and duration of treatment.


Asunto(s)
Betacoronavirus/aislamiento & purificación , Infecciones por Coronavirus/tratamiento farmacológico , Infecciones por Coronavirus/mortalidad , Mortalidad Hospitalaria/tendencias , Hospitalización/estadística & datos numéricos , Neumonía Viral/tratamiento farmacológico , Neumonía Viral/mortalidad , Corticoesteroides/uso terapéutico , Anciano , Infecciones por Coronavirus/virología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Neumonía Viral/virología , Pronóstico , Estudios Retrospectivos , Tasa de Supervivencia
18.
Arthritis Rheumatol ; 2020 Sep 23.
Artículo en Inglés | MEDLINE | ID: mdl-32969145

RESUMEN

Cardiovascular disease (CVD) is a major complication and cause of mortality in Takayasu arteritis (TA). The frequency of cardiovascular, cerebrovascular and renal morbidity or risk of death in TA is unknown in the UK. Population-based controlled studies are lacking in this area. METHODS: Yearly cohort and cross-sectional studies were performed from 2000 to 2017 to estimate annual incidence rates and prevalence of TA respectively. An open retrospective matched cohort study was conducted to estimate risk of hypertension, diabetes, cardiovascular morbidity, chronic kidney disease (CKD) and all-cause mortality in TA, using a UK primary care database (IQVIA Medical Research Data). Risk (adjusted hazard ratio, aHR) of studied co-morbidities in TA compared to age and sex-matched controls was estimated. Changes in medication prescription were examined over time in both groups. RESULTS: Overall, 142 patients with TA (median (IQR) age 53.4 (33.8-70.7) years) and 1371 matched controls were included. The annual incidence and prevalence of TA was 0.8/million and 7.5/million respectively. All-cause mortality was increased in TA (aHR 1.88, 95% CI 1.29-2.76). Patients with TA had higher risk of developing ischaemic heart disease, stroke/TIA, combined CVD and peripheral vascular disease than controls, but not hypertension, CKD, heart failure or diabetes during follow up. Only 50% of patients with TA requiring secondary CVD prevention were prescribed statins or anti-platelets within one year after study entry. CONCLUSION: Cardiovascular morbidity was increased in patients with TA attending primary care services in the UK. Treatment with statins and anti-platelets in these patients was suboptimal.

19.
Diabetes Obes Metab ; 2020 Sep 29.
Artículo en Inglés | MEDLINE | ID: mdl-32991065

RESUMEN

Sodium-glucose co-transporter-2 (SGLT2) inhibitors are widely prescribed in people with type 2 diabetes. We aimed to investigate whether SGLT2 inhibitor prescription is associated with COVID-19, when compared with an active comparator. We performed a propensity-score-matched cohort study with active comparators and a negative control outcome in a large UK-based primary care dataset. Participants prescribed SGLT2 inhibitors (n = 9948) and a comparator group prescribed dipeptidyl peptidase-4 (DPP-4) inhibitors (n = 14 917) were followed up from January 30 to July 27, 2020. The primary outcome was confirmed or clinically suspected COVID-19. The incidence rate of COVID-19 was 19.7/1000 person-years among users of SGLT2 inhibitors and 24.7/1000 person-years among propensity-score-matched users of DPP-4 inhibitors. The adjusted hazard ratio was 0.92 (95% confidence interval 0.66 to 1.29), and there was no evidence of residual confounding in the negative control analysis. We did not observe an increased risk of COVID-19 in primary care amongst those prescribed SGLT2 inhibitors compared to DPP-4 inhibitors, suggesting that clinicians may safely use these agents in the everyday care of people with type 2 diabetes during the COVID-19 pandemic.

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