Associations between neighbourhood deprivation, ethnicity and maternal health outcomes in England: a nationwide cohort study using routinely collected healthcare data.

BACKGROUND: In the United Kingdom, pregnant women who live in the most deprived areas have two times the risk of dying than those who live in the least deprived areas. There are even greater disparities between women from different ethnic groups. The aim of this study was to investigate the role of area-based deprivation and ethnicity in the increased risk of severe maternal morbidity (SMM), in primiparous women in England. METHODS: A retrospective nationwide population study was conducted using English National Hospital Episode Statistics Admitted Patient Care database. All primiparous women were included if they gave birth in an National Healthcare Service (NHS) hospital in England between 1 January 2016 and 31 December 2021. Logistic regression was used to examine the relative odds of SMM by Index of Multiple Deprivation and ethnicity, adjusting for age and health behaviours, medical and psychological factors. RESULTS: The study population comprised 1 178 756 primiparous women. Neighbourhood deprivation increased the risk of SMM at the time of childbirth. In the fully adjusted model, there was a linear trend (p=0.001) between deprivation quintile and the odds of SMM. Being from a minoritised ethnic group also independently increased the risk of SMM, with black or black British African women having the highest risk, adjusted OR 1.84 (95% CI 1.70 to 2.00) compared with white women. There was no interaction between deprivation and ethnicity (p=0.49). CONCLUSION: This study has highlighted that neighbourhood deprivation and ethnicity are important, independently associated risk factors for SMM.

UK neonatal stoma practice: a population study.

OBJECTIVE: The optimal time for neonatal stoma closure is unclear and there have been calls for a trial to compare early and late surgery. The feasibility of such a trial will depend on the population of eligible infants and acceptability to families and health professionals. In this study, we aimed to determine current UK practice and characteristics of those undergoing stoma surgery. DESIGN: A retrospective cohort study of neonates who had undergone stoma surgery (excluding anorectal malformations and Hirschsprung's disease) using three national databases: the National Neonatal Research Database (NNRD, 2012-2019), British Association of Paediatric Surgeons Congenital Anomalies Surveillance System (BAPS-CASS, 2013-2014) and Hospital Episode Statistics-Admitted Patient Care (HES-APC, 2011-2018). RESULTS: 1830 eligible neonates were identified from NNRD, 163 from BAPS-CASS, 2477 from HES-APC. Median (IQR) duration of stoma in days was 57 (36-80) in NNRD, 63 (41-130) in BAPS-CASS and 78 (55-122) for neonates identified from HES-APC. At the time of closure, there were low rates of invasive ventilation (13%), inotrope use (5%) and recent steroids use (4%). Infants who underwent earlier closure (<9 weeks) were less preterm (median 28 weeks vs 25 weeks), have higher birth weight (median 986 g vs 764 g) and more likely to have stoma complications (29% vs 5%). CONCLUSION: There are sufficient UK neonates undergoing stoma formation for a trial. Stoma closure is performed at around 2 months, with clinical stability, gestation, weight and stoma complications appearing to influence timing. The variation in practice we document indicates there is opportunity to optimise practice through a trial.

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.

Effects of the COVID-19 pandemic on secondary care for cardiovascular disease in the UK: an electronic health record analysis across three countries.

BACKGROUND: Although morbidity and mortality from COVID-19 have been widely reported, the indirect effects of the pandemic beyond 2020 on other major diseases and health service activity have not been well described. METHODS AND RESULTS: Analyses used national administrative electronic hospital records in England, Scotland, and Wales for 2016-21. Admissions and procedures during the pandemic (2020-21) related to six major cardiovascular conditions [acute coronary syndrome (ACS), heart failure (HF), stroke/transient ischaemic attack (TIA), peripheral arterial disease (PAD), aortic aneurysm (AA), and venous thromboembolism(VTE)] were compared with the annual average in the pre-pandemic period (2016-19). Differences were assessed by time period and urgency of care.In 2020, there were 31 064 (-6%) fewer hospital admissions [14 506 (-4%) fewer emergencies, 16 560 (-23%) fewer elective admissions] compared with 2016-19 for the six major cardiovascular diseases (CVDs) combined. The proportional reduction in admissions was similar in all three countries. Overall, hospital admissions returned to pre-pandemic levels in 2021. Elective admissions remained substantially below expected levels for almost all conditions in all three countries [-10 996 (-15%) fewer admissions]. However, these reductions were offset by higher than expected total emergency admissions [+25 878 (+6%) higher admissions], notably for HF and stroke in England, and for VTE in all three countries. Analyses for procedures showed similar temporal variations to admissions. CONCLUSION: The present study highlights increasing emergency cardiovascular admissions during the pandemic, in the context of a substantial and sustained reduction in elective admissions and procedures. This is likely to increase further the demands on cardiovascular services over the coming years.

Esophageal achalasia diagnosed in people previously diagnosed with an eating disorder: Epidemiological study using record-linkage.

OBJECTIVE: Occasionally, patients with eating disorders have been subsequently diagnosed with esophageal achalasia. We sought to establish whether eating disorders and achalasia coexisted more often than expected by chance alone. METHOD: National record-linkage study of hospital inpatients in England, between 2001 and 2017. Use of Cox proportional hazards to compare the occurrence of achalasia in cohorts of people with or without anorexia nervosa (AN), and with or without bulimia nervosa (BN), with adjustment of the comparisons for such confounders as age, sex, and year of admission. RESULTS: There were 18,500 people in the AN cohort, 11,300 in the BN cohort, and 8.7 million in the comparison cohort. The Cox regression hazard ratio, comparing the AN cohort with the reference cohort, was 3.4 (95% confidence interval 1.8-6.3) and that in the BN cohort was 4.2 (2.2-8.2). DISCUSSION: AN and achalasia, and BN and achalasia, were diagnosed in the same individuals, more often than expected by chance. Clinicians should be aware of the possible associations with achalasia because the treatment of eating disorders and achalasia is different.

Risk of Schizophrenia and Bipolar Disorder in Patients With Multiple Sclerosis: Record-Linkage Studies.

BACKGROUND: The epidemiology of psychiatric comorbidity in multiple sclerosis (MS) remains poorly understood. OBJECTIVE: We aimed to determine the risk of schizophrenia and bipolar disorder in MS patients. MATERIAL AND METHODS: Retrospective cohort analyses were performed using an all-England national linked Hospital Episode Statistics (HES) dataset (1999-2016) and to determine whether schizophrenia or bipolar disorder are more commonly diagnosed subsequently in people with MS (n=128,194), and whether MS is more commonly diagnosed subsequently in people with schizophrenia (n=384,188) or bipolar disorder (n=203,592), than would be expected when compared with a reference cohort (~15 million people) after adjusting for age and other factors. Adjusted hazard ratios (aHRs) were calculated using Cox proportional hazards models. RESULTS: Findings were dependent on whether the index and subsequent diagnoses were selected as the primary reason for hospital admission or were taken from anywhere on the hospital record. When searching for diagnoses anywhere on the hospital record, there was a significantly elevated risk of subsequent schizophrenia (aHR 1.51, 95% confidence interval (CI) 1.40 to 1.60) and of bipolar disorder (aHR 1.14, 95% CI 1.04 to 1.24) in people with prior-recorded MS and of subsequent MS in people with prior-recorded schizophrenia (aHR 1.26, 1.15-1.37) or bipolar disorder (aHR 1.73, 1.57-1.91), but most of these associations were reduced to null when analyses were confined to diagnoses recorded as the primary reason for admission. CONCLUSION: Further research is needed to investigate the potential association between MS and schizophrenia and/or bipolar disorder as it may shed light on underlying pathophysiology and help identify potential shared risk factors.

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.

Association between diabetes and subsequent Parkinson disease: A record-linkage cohort study.

OBJECTIVE: To investigate the association between type 2 diabetes mellitus (T2DM) and subsequent Parkinson disease (PD). METHODS: Linked English national Hospital Episode Statistics and mortality data (1999-2011) were used to conduct a retrospective cohort study. A cohort of individuals admitted for hospital care with a coded diagnosis of T2DM was constructed, and compared to a reference cohort. Subsequent PD risk was estimated using Cox regression models. Individuals with a coded diagnosis of cerebrovascular disease, vascular parkinsonism, drug-induced parkinsonism, and normal pressure hydrocephalus were excluded from the analysis. RESULTS: A total of 2,017,115 individuals entered the T2DM cohort and 6,173,208 entered the reference cohort. There were significantly elevated rates of PD following T2DM (hazard ratio [HR] 1.32, 95% confidence interval [CI] 1.29-1.35; p < 0.001). The relative increase was greater in those with complicated T2DM (HR 1.49, 95% CI 1.42-1.56) and when comparing younger individuals (HR 3.81, 95% CI 2.84-5.11 in age group 25-44 years). CONCLUSIONS: We report an increased rate of subsequent PD following T2DM in this large cohort study. These findings may reflect shared genetic predisposition and/or disrupted shared pathogenic pathways with potential clinical and therapeutic implications.

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.

Associations between clinically diagnosed testicular hypofunction and systemic lupus erythematosus: a record linkage study.

Systemic lupus erythematosus (SLE) has a high female predominance with a 9:1 female-to-male sex ratio, but males have poorer clinical outcomes than females. Gonadal hormones may mediate gender differences in SLE, but their role in SLE remains largely uncharacterised. We aimed to investigate a potential association between testicular hypofunction (TH), as a proxy for low testosterone levels, and SLE in males. A retrospective cohort study was conducted by analysing linked English national Hospital Episode Statistics (HES) and mortality data from 1999 to 2011. We calculated rates for SLE following TH, and TH following SLE, stratified and standardised by age, calendar year of first recorded admission, region of residence, and quintile of patients' Index of Deprivation score. The adjusted rate ratio (RR) of SLE following TH was 7.7 (95% confidence interval (95% CI) 2.5-18.1, p < 0.0001). The adjusted RR for TH following SLE was 6.5 (95% CI 2.1-15.1, p < 0.0001). The positive association between TH and SLE supports a hypothesis that low testosterone levels may influence the development of male SLE. Of clinical importance, it suggests that males with SLE are at increased risk of co-morbid TH (regardless of which precedes which) and this may warrant consideration in the management of patients.

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.

Biliary Tract and Liver Complications in Polycystic Kidney Disease.

Polycystic liver disease is a well described manifestation of autosomal dominant polycystic kidney disease (ADPKD). Biliary tract complications are less well recognized. We report a 50-year single-center experience of 1007 patients, which raised a hypothesis that ADPKD is associated with biliary tract disease. We tested this hypothesis using all England Hospital Episode Statistics data (1998-2012), within which we identified 23,454 people with ADPKD and 6,412,754 hospital controls. Hospitalization rates for biliary tract disease, serious liver complications, and a range of other known ADPKD manifestations were adjusted for potential confounders. Compared with non-ADPKD hospital controls, those with ADPKD had higher rates of admission for biliary tract disease (rate ratio [RR], 2.24; 95% confidence interval [95% CI], 2.16 to 2.33) and serious liver complications (RR, 4.67; 95% CI, 4.35 to 5.02). In analyses restricted to those on maintenance dialysis or with a kidney transplant, RRs attenuated substantially, but ADPKD remained associated with biliary tract disease (RR, 1.19; 95% CI, 1.08 to 1.31) and perhaps with serious liver complications (RR, 1.15; 95% CI, 0.98 to 1.33). The ADPKD versus non-ADPKD RRs for biliary tract disease were larger for men than women (heterogeneity P<0.001), but RRs for serious liver complications appeared higher in women (heterogeneity P<0.001). Absolute excess risk of biliary tract disease associated with ADPKD was larger than that for serious liver disease, cerebral aneurysms, and inguinal hernias but less than that for urinary tract infections. Overall, biliary tract disease seems to be a distinct and important extrarenal complication of ADPKD.

Viral hepatitis and Parkinson disease: A national record-linkage study.

OBJECTIVE: To study associations between viral hepatitis and Parkinson disease (PD). METHODS: A retrospective cohort study was done by analyzing linked English National Hospital Episode Statistics and mortality data (1999-2011). Cohorts of individuals with hepatitis B, hepatitis C, autoimmune hepatitis, chronic active hepatitis, and HIV were constructed, and compared to a reference cohort for subsequent rates of PD. RESULTS: The standardized rate ratio (RR) of PD following hepatitis B was 1.76 (95% confidence interval [CI] 1.28-2.37) (p < 0.001), based on 44 observed compared with 25 expected cases. The RR of PD following hepatitis C was 1.51 (95% CI, 1.18-1.9) (p < 0.001), based on 48.5 expected and 73 observed cases. There was no significant association between autoimmune hepatitis, chronic active hepatitis or HIV, and subsequent PD. When including only those episodes of care for PD that occurred first at least 1 year following each exposure condition, the RR for hepatitis B and hepatitis C were 1.82 (1.29-2.5) and 1.43 (1.09-1.84), respectively. CONCLUSIONS: We report strong evidence in favor of an elevation of rates of subsequent PD in patients with hepatitis B and hepatitis C. These findings may be explained by factors peculiar to viral hepatitis, but whether it reflects consequences of infection, shared disease mechanisms, or the result of antiviral treatment remains to be elucidated. Further work is needed to confirm this association and to investigate pathophysiologic pathways, potentially advancing etiologic understanding of PD more broadly.

Associations between obstructive sleep apnoea, primary open angle glaucoma and age-related macular degeneration: record linkage study.

BACKGROUND: Primary open angle glaucoma (POAG) is thought to be associated with obstructive sleep apnoea (OSA) but previous studies are conflicting and have methodological limitations. This potential relationship has implications for investigation and treatment strategies, and may provide insights into disease pathogenesis. The relationship between OSA and age-related macular degeneration (AMD) is unknown. METHODS: A sleep apnoea cohort of 67 786 people was constructed from linked English hospital episode statistics (1999-2011). We compared this cohort with a reference cohort (2 684 131 people) for rates of subsequent POAG and AMD. A POAG cohort (comprising 87 435 people) and an AMD cohort (248 408 people) were also constructed and compared with the reference cohort for rates of subsequent sleep apnoea. All analyses were restricted to people aged 55 and over and, within this age range, were age standardised using 5-year age groups. RESULTS: Risk of POAG following sleep apnoea was not elevated: the rate ratio for POAG was 1.01 (95% CI 0.85 to 1.19). Similarly, the risk of sleep apnoea following POAG was not elevated: the rate ratio was 1.00 (0.86 to 1.17). These findings held true across subgroup analysis according to sex and age group. By contrast, the risk of AMD following sleep apnoea was significantly elevated, with rate ratio 1.44 (1.32 to 1.57). CONCLUSIONS: Although plausible mechanisms exist to consider a link between OSA and POAG, the two conditions are not positively associated. This holds true in either temporal direction. By contrast, OSA is positively associated with AMD. While potential confounding factors may contribute, obesity does not appear sufficient to explain this association.

Trends over time in the incidence of congenital anophthalmia, microphthalmia and orbital malformation in England: database study.

AIMS: To study trends over time in the incidence of congenital anophthalmia, microphthalmia and orbital malformations in England, along with changes in hospital admission rates for these conditions. METHODS: Using English National Hospital Episode Statistics (1999-2011), the annual rate of hospital admissions related to anophthalmia, microphthalmia and congenital malformations of orbit/lacrimal apparatus was calculated per 100 000 infants. The records were person-linked, which enabled patients' 'first record' rates to be calculated as proxies for incidence. Similar analyses on pre-1999 datasets were also undertaken for microphthalmia. RESULTS: There was no systematic increase or decrease over time in the incidence of these conditions, but there was some fluctuation from year to year. The incidence of congenital anophthalmia ranged from 2.4 (95% CI 1.3 to 4.0) per 100 000 infants in 1999 to 0.4 (0 to 1.3) in 2011. The annual incidence of congenital microphthalmia was 10.8 (8.2 to 13.5) in 1999 and 10.0 (7.6 to 12.4) in 2011. The annual incidence of congenital orbital/lacrimal malformations was 0.5 (0 to 1.1) in 1999 and 0.7 (0 to 1.4) in 2011. Including multiple admissions per person, admission rates for microphthalmia showed a linear increase over time from 1999. The earlier data for microphthalmia indicated an increase in admission rates, but no change in incidence, from 1971 to 2011. CONCLUSIONS: The incidence of these conditions has remained stable in England in recent years. Although the incidence of microphthalmia was stable, hospital admission rates for it increased over time reflecting an increase in multiple admissions per affected person. These data may be useful for planning service provision.

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.

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.

ASSOCIATIONS BETWEEN AGE-RELATED MACULAR DEGENERATION, OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS: RECORD LINKAGE STUDY.

PURPOSE: The epidemiologic relationship between age-related macular degeneration (AMD) and arthritis is unknown and has implications for understanding disease pathogenesis and treatment strategies. METHODS: An AMD cohort of 245,912 people was constructed from English linked hospital episode statistics (1999-2011), principally comprising neovascular AMD patients undergoing anti-vascular endothelial growth factor therapy. We compared the AMD cohort with a reference cohort (2,134,771 people) for rates of subsequent osteoarthritis (OA) and rheumatoid arthritis. Osteoarthritis (2,032,472 people) and rheumatoid arthritis (261,232 people) cohorts were also constructed and compared with the reference cohort for rates of subsequent AMD. RESULTS: Risk of arthritis after AMD was not elevated. The rate ratio for OA was 0.96 (95% confidence interval 0.95-0.97) and for rheumatoid arthritis was 0.98 (0.94-1.02). However, risk of AMD after arthritis was modestly raised. For OA, the rate ratio was 1.06 (1.04-1.08), but risk increased with longer OA duration, for example, 1.15 (1.08-1.23) for >10 years. For rheumatoid arthritis, the rate ratio was also modestly elevated at 1.15 (1.12-1.19). CONCLUSION: Age-related macular degeneration and arthritis are degenerative aging conditions that share some disease mechanisms and extracellular matrix involvement. However, considering arthritis after AMD, they are not positively associated. By contrast, people with OA experience modestly increased AMD risk, perhaps owing to medical treatments for OA.