C-reactive protein is associated with cognitive performance in a large cohort of euthymic patients with bipolar disorder.

Data support the notion that 40-60% of patients with bipolar disorder (BD) have neurocognitive deficits. It is increasingly accepted that functioning in BD is negatively impacted by these deficits, yet they have not been a successful target for treatment. The biomarkers that predict cognitive deficits in BD are largely unknown, however recent evidence suggests that inflammation may be associated with poorer cognitive outcomes in BD. We measured C-reactive protein (CRP), a marker of systemic inflammation and risk of inflammatory disease, in 222 euthymic BD patients and 52 healthy controls. Within the patient sample, using multivariate analyses of covariance (MANCOVA) we compared cognitive performance of those with high CRP (≥5 mg/L) versus the remaining subjects (<5 mg/L) on a battery of cognitive tests. We evaluated relationships with several other relevant clinical features. We also examined the role of CRP in cognitive decline using a proxy cognitive decline metric, defined as the difference between premorbid and current IQ estimates, in a logistic regression analysis. Approximately 80% of our sample were BD-I, and the remainder were BD-II and 42.6% of our sample had a history of psychosis. We found a statistically significant effect of CRP on cognitive performance on a broad range of tests; participants with CRP ≥ 5 mg/L had worse performance on several measures of executive functioning, MATRICS processing speed and MATRICS reasoning and problem solving relative to those with lower CRP. We also identified CRP as a significant positive predictor of proxy cognitive decline. Our results indicate that elevated CRP is associated with a broad cognitive dysfunction in affectively remitted BD patients. These results may point to a subgroup of patients who might benefit from treatments to reduce inflammation.

TNF-α and its soluble receptors mediate the relationship between prior severe mood episodes and cognitive dysfunction in euthymic bipolar disorder.

BACKGROUND: Bipolar disorder (BD) is one of the most disabling mental health conditions in the world. Symptoms of cognitive impairment in BD contribute directly to occupational and social deficiencies and are very difficult to treat. Converging evidence suggests that BD patients have increased peripheral markers of inflammation. The hypothesis of neuroprogression in BD postulates that cognitive deficits develop over the course of the illness and are influenced by prior severe mood episodes, leading to wear-and-tear on the brain- however, there exists a paucity of data statistically testing a mediating role of immune molecules in cognitive dysfunction in BD. METHODS: This is a cross-sectional study. We measured serum levels of tumor necrosis factor alpha (TNF-α), and soluble (s) TNF receptors one and two (sTNF-R1 and sTNF-R2) in 219 euthymic BD patients and 52 Healthy Controls (HCs). Structural equation modeling (SEM) was used for the primary purpose of assessing whether TNF markers (measured by the multiple indicators TNF-α, sTNF-R1 and sTNF-R2) mediate the effect or number of prior severe mood episodes (number of prior psychiatric hospitalizations) on cognitive performance. RESULTS: BD and HC groups did not differ on circulating levels of TNF molecules in the present study. However, we found higher sTNF-R1 concentration in 'late-stage' BD illness (>1 prior psychiatric hospitalization) compared to those in early stage illness. In the subsequent SEM, we found that the model fits the data acceptably (Chi-square = 49.2, p = 0.3), and had a 'close fit' (RMSEA = 0.02, PCLOSE = 0.9). Holding covariates constant (age, sex, premorbid IQ, education, and race), we found that the standardized indirect effect was significant, p = 0.015, 90%CI [-0.07, -0.01], indicating that the estimated model was consistent with peripheral TNF markers partially mediating a causal effect of severe mood episodes on executive function. CONCLUSIONS: Our results indicate that circulating levels of TNF molecules partially mediate the relationship between prior severe mood episodes and executive function in BD. These results may implicate TNF variables in the neuroprogressive course of BD and could point to novel interventions for cognition.

Emotional processing subtypes in bipolar disorder: A cluster analysis.

BACKGROUND: Evidence regarding the performance of Bipolar Disorder patients (BD) on Emotional Processing (EP) is conflicting, suggesting that heterogeneity within this population may exist. It is not completely understood if this impacts on clinical presentation and functional outcomes. METHODS: A total of 212 BD patients were recruited. Patients underwent MATRICS Consensus Cognitive Battery as well as a clinical evaluation to detect premorbid traits, comorbidities and clinical features. Performance on each basic emotion on the Emotional Recognition Task (ERT) and Reading the Mind in the Eyes Test were entered into hierarchical cluster analyses in order to determine the number of clusters and to assign subjects to specific clusters. We then compared subgroups on clinical factors and real-world community functioning. RESULTS: No differences between BD patients as a group and controls were found in EP performance. Two clusters of BD patients were found, one with "intact" performance (71.2%) that performed as healthy controls (HC) and other with "impaired" performance (28.8%) performing worse than HC and schizophrenic patients on basic emotion recognition. Patients in the "impaired group" presented higher rates of childhood trauma, schizotypal traits, lower premorbid IQ and education, poor psychosocial functioning and cognitive performance. LIMITATIONS: Cross-sectional data which limits our ability to infer directionality of our findings. CONCLUSION: These results suggest the presence of two subgroups regarding EP performance with unique clinical and neurodevelopmental profiles associated. Next steps will include using these data to identify a homogeneous group of patients to target these disabling symptoms with treatment.

Physical activity accrued as part of public transport use in England.

BACKGROUND: Walking and cycling for transport (active travel) is an important source of physical activity with established health benefits. However, levels of physical activity accrued during public transport journeys in England are unknown. METHODS: Using the English National Travel Survey 2010-14 we quantified active travel as part of public transport journeys. Linear regression models compared levels of physical activity across public transport modes, and logistic regression models compared the odds of undertaking 30 min a day of physical activity. RESULTS: Public transport users accumulated 20.5 min (95% confidence interval=19.8, 21.2) a day of physical activity as part of public transport journeys. Train users accumulated 28.1 min (26.3, 30.0) with bus users 16.0 min (15.3, 16.8). Overall, 34% (32%, 36%) of public transport users achieved 30 min a day of physical activity in the course of their journeys; 21% (19%, 24%) of bus users and 52% (47%, 56%) of train users. CONCLUSION: Public transport use is an effective way to incorporate physical activity into daily life. One in three public transport users meet physical activity guidelines suggesting that shifts from sedentary travel modes to public transport could dramatically raise the proportion of populations achieving recommended levels of physical activity.

Sweetened beverage intake in association to energy and sugar consumption and cardiometabolic markers in children.

BACKGROUND: Artificially sweetened beverages (ASBs) are promoted as healthy alternatives to sugar-sweetened beverages (SSBs) in order to reduce sugar intake, but their effects on weight control and glycaemia have been debated. This study examines associations of SSBs and ASBs with energy and sugar intake and cardiometabolic measures. METHODS: One thousand six hundred eighty-seven children aged 4-18 participated in the National Diet and Nutrition Survey Rolling Programme (2008/9-2011/12) in the UK. Linear regression was used to examine associations between SSBs and ASBs and energy and sugar, overall and from solid foods and beverages, and body mass index, waist-to-hip ratio and blood analytes. Fixed effects linear regression examined within-person associations with energy and sugar. RESULTS: Compared with non-consumption, SSB consumption was associated with higher sugar intake overall (6.1%; 4.2, 8.1) and ASB consumption with higher sugar intake from solid foods (1.7%; 0.5, 2.9) but not overall, mainly among boys. On SSB consumption days, energy and sugar intakes were higher (216 kcal; 163, 269 and 7.0%; 6.2, 7.8), and on ASB consumption days, sugar intake was lower (-1.0%; -1.8, -0.1) compared with those on non-consumption days. SSB and ASB intakes were associated with higher levels of blood glucose (SSB: 0.30 mmol L-1 ; 0.11, 0.49 and ASB: 0.24 mmol L-1 ; 0.06, 0.43) and SSB intake with higher triglycerides (0.29 mmol L-1 ; 0.13, 0.46). No associations were found with other outcomes. CONCLUSION: Sugar-sweetened beverage intake was associated with higher sugar intake and both SSBs and ASBs with a less healthy cardiometabolic profile. These findings add to evidence that health policy should discourage all sweetened beverage consumption.

Community-based pilot intervention to tackle childhood obesity: a whole-system approach.

OBJECTIVES: Go-Golborne is a pilot intervention to prevent childhood obesity in the Royal Borough of Kensington and Chelsea between 2014 and 2018. It is a multistrategy approach targeting children aged 0-16 years and their families in all settings where children live, learn and play. This paper describes the methodology and the practical steps in the development of Go-Golborne. STUDY DESIGN: The programme uses a quasi-experimental design for the evaluation of changes in weight status using data from the extended National Child Measurement Programme across local schools. For specific behavioural change objectives, baseline self-reported lifestyle measures will be compared against annual follow-up data over the 3-year study period. Qualitative methods will be used to explore the perceptions of stakeholders and participants and organizational change. METHODS: Go-Golborne aims to mobilize everyone in the community who has a role or interest in shaping the local environment, norms and behaviours across a range of sectors. A community network of local organizations has been established to codesign all programme activities. The Steering Group of Council officers support programme implementation and environmental changes. The programme has identified six specific behaviour change objectives representing the key areas of need in Golborne and all activities in the council and the community target these objectives during specific programme phases. Key components include community capacity building, community-wide social marketing, environment and policy change and evaluation. RESULTS (PROGRESS): The programme is currently at the beginning of its implementation phase with activities in the community and council targeting the first behaviour change objective. CONCLUSIONS: The pilot aims to test the effectiveness of this approach to support behaviour change and prevent unhealthy weight gain in children using multiple strategies. This programme will inform the development of an intervention model that defines essential programme components, accountability of partner organizations delivering obesity prevention programmes and the effective use of existing assets.

Use of hospital admissions data to quantify the burden of emergency admissions in people with diabetes mellitus.

AIMS: Accurate measurement of emergency diabetes admissions is essential for healthcare delivery and research. This study examines whether current approaches to identifying diabetes-related admissions may underestimate the true burden on hospital care. METHODS: Data spanning the period 1 January 2006 to 31 December 2010 inclusive were extracted from Hospital Episode Statistics data for England. Emergency admissions citing diabetes (E10, E11, E13 or E14) in any diagnosis position in adults (≥ 17 years) were included. E10 and E11 were considered analogous to type 1 and type 2 diabetes mellitus respectively; E13 and E14 were grouped as 'other or unspecified' diabetes mellitus. For admissions citing diabetes multiple times, those with concordant citations were classified as appropriate; discordant citations were assigned to the 'other or unspecified' group. Frequencies of diabetes classifications and complications for each diagnosis position and frequencies of all International Classification of Diseases 10th revision codes for the primary diagnosis field were calculated. RESULTS: In total, 2 443 046 admissions were identified. Diabetes was cited as the primary diagnosis in 6.2% and most commonly cited as the third diagnosis (23.1%). Type 2 diabetes mellitus was the most common (85.0%). The majority of diabetes citations were 'without complication' (2 188 965, 89.6%). The most common primary diagnosis was 'chest pain, unspecified' (R07.4, 99 678, 4.1%). CONCLUSIONS: Reliance on the primary diagnosis field to identify emergency admissions in people with diabetes grossly underestimates the true burden placed on hospital care and leads to underestimates of effect sizes in studies utilizing admission rates as outcome measures. An alternative strategy to identify such admissions is required.

Effect of financial incentives on delivery of alcohol screening and brief intervention (ASBI) in primary care: longitudinal study.

INTRODUCTION: Alcohol screening and brief intervention (ASBI) is effective but underprovided in primary care. Financial incentives may help address this. This study assesses the impact of a local pay-for-performance programme on delivery of ASBI in UK primary care. METHODS: Longitudinal study using data from 30 general practices in north-west London from 2008 to 2011 with logistic regression to examine disparities in ASBI delivery. RESULTS: Of 211 834 registered patients, 45 040 were targeted by the incentive (cardiovascular conditions or high risk; mental health conditions), of whom 65.7% were screened (up from a baseline of 4.8%, P < 0.001), compared with 14.7% of non-targeted patients (P < 0.001). Screening rates were lower after adjustment in younger patients, White patients, less deprived areas and in patients with mental health conditions (P < 0.05). Of those screened, 11.5% were positive and 88.6% received BI. Men and White patients were significantly more likely to screen positive. Women and younger patients were less likely to receive BI. 30.1% of patients re-screened were now negative. However, patients with mental health conditions were less likely to re-screen negative than those with cardiovascular conditions. CONCLUSION: Financial incentives appear to be effective in increasing delivery of ASBI in primary care and may reduce hazardous and harmful drinking in some patients. The findings support universal rather than targeted screening.

Obesity paradox in people newly diagnosed with type 2 diabetes with and without prior cardiovascular disease.

AIM: To address the debate on 'obesity paradox' in patients with type 2 diabetes mellitus (T2DM) by evaluating the cardiovascular and mortality risks associated with normal and overweight patients compared to obese at diagnosis of diabetes, separately for patients with and without cardiovascular disease (CVD) before diagnosis. METHODS: A retrospective study with two study cohorts with/without prior CVD (n = 10237/37272) with complete measures of body mass index (BMI) at diagnosis of T2DM from UK General Practice Research Database. Primary outcomes were long-term risks of cardiovascular events (CVEs) and all-cause mortality in patients with normal weight, overweight and obesity at diagnosis. RESULTS: The mortality rates per 1000 person-years in normal weight, overweight and obese patients among patients without prior CVD were 13.1, 8.6 and 6.0, respectively, during 5 years of median follow-up. For patients with prior CVD, these estimates were 30.1, 21.1 and 15.5, respectively. Among patients without and with prior CVD, normal weight patients had 47% (hazard ratio, HR CI: 1.29, 1.69) and 30% (HR CI: 1.11, 1.53) increased mortality risk respectively compared to obese patients. In the cohort without prior CVD, compared to obese patients, those with normal body weight did not have increased CVE risk. Interactions between age, HbA1c and BMI at diagnosis were observed in both cohorts. CONCLUSIONS: Adults with normal weight at the diagnosis of T2DM have significantly higher mortality risk compared to those who are obese, with significant interactions between age, BMI and HbA1c. Elevated cardiovascular risk was not observed in normal weight patients without prior CVD.

Primary care and population factors associated with NHS Health Check coverage: a national cross-sectional study.

INTRODUCTION: High and equitable coverage of systematic cardiovascular disease (CVD) prevention programmes, such as the NHS Health Check programme in England, is essential if they are to effectively reduce the population CVD burden. METHODS: We conducted a cross-sectional study using data from 151 English primary care trusts (PCTs) on NHS Health Check coverage during 2011-12. We examined the associations between programme coverage and primary care and population factors, including patient demographics, primary care workforce and cardiovascular health need. RESULTS: Median coverage of NHS Health Checks was 8.2%, with wide PCT-level variation (range = 0-29.8%). Coverage was significantly higher in PCTs in the most deprived areas compared with the least deprived (P = 0.035), adjusting for covariates. Significant negative associations between coverage and a higher proportion of PCT population aged 40-74 years-the eligible Health Check age group, a larger total population size and higher practice staffing levels were found in the unadjusted analyses. CONCLUSIONS: NHS Health Check coverage during 2011-12 was lower than the government projection of 18% coverage. Coverage must be increased through concerted multi-disciplinary strategies, for the programme to improve cardiovascular health in England. Considerable variation in participation between PCTs warrants attention, with enhanced support for poor performers.

Socio-economic patterning of tobacco use in Indian states.

BACKGROUND: Studies in India have identified marked variations in overall tobacco use between socio-economic groups. We examined whether associations between socio-economic status (SES) and tobacco use varied across individual Indian states by tobacco type. METHODS: Cross-sectional survey of 100,855 households in 24 Indian states and Union Territories conducted in 2009-2010. Outcome measures were household tobacco consumption by type. Logistic and linear regression models were used to examine associations at the household level between education, income and use and volume of tobacco consumed. RESULTS: Overall, 52% of households used any form of tobacco product; the predominant form was smokeless tobacco (22%), followed by bidi (17%) and cigarettes (4%). Increasing household income and higher education level were associated with a higher likelihood of cigarette use but a lower likelihood of bidi and smokeless tobacco use in some Indian states. Increasing household income was associated with higher volumes of cigarette and bidi use among consuming households; however, association between educational level and volume of tobacco consumption was inconsistent. CONCLUSION: SES has a varying impact on different types of tobacco use in Indian states. Policy makers should consider socio-economic patterning of tobacco use when designing, implementing and evaluating tobacco control interventions in different states of India.

Effect of financial incentives on ethnic disparities in smoking cessation interventions in primary care: cross-sectional study.

BACKGROUND: Smoking cessation interventions are underprovided in primary care. Financial incentives may help address this. However, few studies in the UK have examined their impact on disparities in the delivery of smoking cessation interventions. METHODS: Cross-sectional study using 2007 data from 29 general practices in Wandsworth, London, UK. We used logistic regression to examine associations between disease group [cardiovascular disease (CVD), respiratory disease, depression or none of these diseases], ethnicity and smoking outcomes following the introduction of the Quality and Outcomes Framework in 2004. RESULTS: Significantly, more CVD patients had smoking status ascertained compared with those with respiratory disease (89 versus 72%), but both groups received similar levels of cessation advice (93 and 89%). Patients with depression or none of the diseases were less likely to have smoking status ascertained (60% for both groups) or to receive advice (80 and 75%). Smoking prevalence was high, especially for patients with depression (44%). White British patients had higher rates of smoking than most ethnic groups, but black Caribbean men with depression had the highest smoking prevalence (62%). CONCLUSIONS: Smoking rates remain high, particularly for white British and black Caribbean patients. Extending financial incentives to include recording of ethnicity and rewarding quit rates may further improve smoking cessation outcomes in primary care.

Waterpipe smoking: prevalence and attitudes among medical students in London.

Although waterpipe smoking is growing in popularity worldwide, its epidemiology remains poorly understood. The purpose of this study was to determine the prevalence and attitudes of waterpipe smoking among 489 medical students (54.6% female; mean age 20.4 ± 2.0 years) in the United Kingdom by conducting a cross-sectional survey. Waterpipe smoking was more common than cigarette smoking (current 11.0% vs. 6.3%, ever 51.7% vs. 16.8%). Mean age at waterpipe smoking initiation was 16.1 ± 2.6 years. Sex, ethnicity and sociodemographic factors did not predict current/ever waterpipe smoking. Tobacco control efforts need to consider waterpipe smoking in the light of this high prevalence.

Effectiveness of providing financial incentives to healthcare professionals for smoking cessation activities: systematic review.

OBJECTIVE: Financial incentives are seen as one approach to encourage more systematic use of smoking cessation interventions by healthcare professionals. A systematic review was conducted to examine the evidence for this. METHODS: Medline, Embase, PsychINFO, Cochrane Library, ISI Web of Science and sources of grey literature were used as data sources. Studies were included if they reported the effects of any financial incentive provided to healthcare professionals to undertake smoking cessation-related activities. Data extraction and quality assessment for each study were conducted by one reviewer and checked by a second. A total of 18 studies were identified, consisting of 3 randomised controlled trials and 15 observational studies. All scored in the mid range for quality. In all, 8 studies examined smoking cessation activities alone and 10 studied the UK's Quality and Outcomes Framework targeting quality measures for chronic disease management including smoking recording or cessation activities. Five non-Quality and Outcomes Framework studies examined the effects of financial incentives on individual doctors and three examined effects on groups of healthcare professionals based in clinics and general practices. Most studies showed improvements in recording smoking status and smoking cessation advice. Five studies examined the impact of financial incentives on quit rates and longer-term abstinence and these showed mixed results. CONCLUSIONS: Financial incentives appear to improve recording of smoking status, and increase the provision of cessation advice and referrals to stop smoking services. Currently there is not sufficient evidence to show that financial incentives lead to reductions in smoking rates.

Trends and transient change in end-digit preference in blood pressure recording: studies of sequential and longitudinal collected primary care data.

BACKGROUND: End-digit preference (EDP) is a known cause of inaccurate BP recording. Distortion has been reported around pay-for-performance (P4P) indicators. METHODS: We studied sequential datasets (n = 148,000 to n = 900,000) and performed a longitudinal analysis of CONDUIT data (n = 250,000) over a 10-year period. We examined general trends in EDP and investigated the impact of diabetes and chronic kidney disease (CKD) P4P targets. RESULTS: EDP reduces over time in both datasets; the percentage of patients with a zero EDP declined from 70% to 27% and 68% to 26% for SBP and DBP respectively. There is more zero EDP at the extremes of BP, but in people with chronic disease, the use of zero EDP was mainly seen at higher BP levels. P4P targets are associated with increased preference for the even end-digit just below target: in diabetes odds ratio (OR) is 1.47 (p = 0.003) for SBP, 1.19 (p = 0.09) for DBP and in CKD OR 1.65 (p < 0.001) for SBP and 1.48 (p = 0.0001) for DBP. Trends observed in pilot data were validated with a longitudinal set. CONCLUSIONS: The decline in EDP is levelling off and P4P targets are associated with sub-target-EDP. Primary care should automate BP measurement and recording.

Exclusion of patients from quality measurement of diabetes care in the UK pay-for-performance programme.

BACKGROUND: We examined associations between patient and practice characteristics and exclusions from quality indicators for diabetes during the first 3 years of the Quality and Outcomes Framework, a major pay-for-performance scheme in the UK. METHODS: Three cross-sectional analyses, conducted using data from the electronic medical records of all patients with diabetes registered in 23 general practices in Brent, North West London between 2004/2005 and 2006/2007. Patterns of exclusions were examined for three intermediate outcome indicators. RESULTS: Excluded patients were less likely to achieve treatment targets for HbA(1c) (2004/2005, 2006/2007), blood pressure (2005/2006, 2006/2007) and cholesterol (2005/2006). Black and South Asian patients were more likely to be excluded from the HbA(1c) indicator than White patients [adjusted odds ratio = 1.64 (1.17-2.29) in 2005/2006]. Patients diagnosed with diabetes duration of > 10 years [adjusted odds ratio = 2.01 (1.65-2.45) for HbA(1c) in 2006-2007] and those with co-morbidities (adjusted odds ratio, ≥ 3 co-morbidities compared with no co-morbidity for HbA(1c) adjusted odds ratio = 1.90 (1.24-2.90) in 2004/2005] were more likely to be excluded. Larger practices excluded more patients from the HbA(1c) indicator [adjusted odds ratio, practice ≥ 7000 compared with < 3000, 3.52 (2.35-5.27) in 2005-2006]. More deprived practices consistently excluded more patients from all indicators, whilst in 2007 older patients were excluded to a larger degree [adjusted odds ratio = 2.52 (1.21-5.28) ≥ 75 compared with 18-44 for blood pressure control]. CONCLUSIONS: Patients excluded from pay-for-performance programmes may be less likely to achieve treatment goals and disproportionately come from disadvantaged groups. Permitting physicians to exclude patients from pay-for-performance programmes may worsen health disparities.

A method of identifying and correcting miscoding, misclassification and misdiagnosis in diabetes: a pilot and validation study of routinely collected data.

AIMS: Incorrect classification, diagnosis and coding of the type of diabetes may have implications for patient management and limit our ability to measure quality. The aim of the study was to measure the accuracy of diabetes diagnostic data and explore the scope for identifying errors. METHOD: We used two sets of anonymized routinely collected computer data: the pilot used Cutting out Needless Deaths Using Information Technology (CONDUIT) study data (n = 221 958), which we then validated using 100 practices from the Quality Improvement in Chronic Kidney Disease (QICKD) study (n = 760,588). We searched for contradictory diagnostic codes and also compatibility with prescription, demographic and laboratory test data. We classified errors as: misclassified-incorrect type of diabetes; misdiagnosed-where there was no evidence of diabetes; or miscoded-cases where it was difficult to infer the type of diabetes. RESULTS: The standardized prevalence of diabetes was 5.0 and 4.0% in the CONDUIT and the QICKD data, respectively: 13.1% (n = 930) of CONDUIT and 14.8% (n = 4363) QICKD are incorrectly coded; 10.3% (n = 96) in CONDUIT and 26.2% (n = 1143) in QICKD are misclassified; nearly all of these cases are people classified with Type 1 diabetes who should be classified as Type 2. Approximately 5% of T2DM in both samples have no objective evidence to support a diagnosis of diabetes. Miscoding was present in approximately 7.8% of the CONDUIT and 6.1% of QICKD diabetes records. CONCLUSIONS: The prevalence of miscoding, misclassification and misdiagnosis of diabetes is high and there is substantial scope for further improvement in diagnosis and data quality. Algorithms which identify likely misdiagnosis, misclassification and miscoding could be used to flag cases for review.

Trends in cardiovascular admissions and procedures for people with and without diabetes in England, 1996-2005.

AIMS/HYPOTHESIS: The aim of this study was to compare 10-year trends in admissions, with and without diabetes recorded, for myocardial infarction, angina, stroke, percutaneous coronary interventions (PCI) and coronary artery bypass graft (CABG). METHODS: We used national hospital-activity data in England collected between 1996 and 2005 and compared trends in admissions, after adjusting for age, sex and area-level deprivation. RESULTS: Overall, there was a modest fall in the number of admissions for angina and little change in the numbers of admissions for myocardial infarction (MI) and stroke. From 1996/1997 to 2005/2006, the numbers of admissions with diabetes recorded rose for each of MI, angina and stroke; the proportion of admissions with type 2 diabetes recorded rose from 7.2% to 13.9% for MI, from 6.7% to 15.3% for angina and from 6.2% to 11.3% for stroke. Over the 10-year period, after adjusting for age, sex and deprivation, the number of admissions for CABG rose about threefold; for PCI, the number of admissions with diabetes recorded rose 15-fold, compared with a fourfold increase in the number of admissions with diabetes not recorded. CONCLUSIONS/INTERPRETATION: We found significant increases in the numbers of admissions with type 2 diabetes recorded for major cardiovascular events and procedures, which has important financial and public-health implications. Better prevention of type 2 diabetes in at-risk patients and aggressive cardiovascular risk-factor management in current patients with diabetes is needed.