Cardiovascular risk management among individuals with type 2 diabetes and severe mental illness: a cohort study.

AIMS/HYPOTHESIS: The aim of this study was to compare cardiovascular risk management among people with type 2 diabetes according to severe mental illness (SMI) status. METHODS: We used linked electronic data to perform a retrospective cohort study of adults diagnosed with type 2 diabetes in Scotland between 2004 and 2020, ascertaining their history of SMI from hospital admission records. We compared total cholesterol, systolic BP and HbA1c target level achievement 1 year after diabetes diagnosis, and receipt of a statin prescription at diagnosis and 1 year thereafter, by SMI status using logistic regression, adjusting for sociodemographic factors and clinical history. RESULTS: We included 291,644 individuals with type 2 diabetes, of whom 1.0% had schizophrenia, 0.5% had bipolar disorder and 3.3% had major depression. People with SMI were less likely to achieve cholesterol targets, although this difference did not reach statistical significance for all disorders. However, people with SMI were more likely to achieve systolic BP targets compared to those without SMI, with effect estimates being largest for schizophrenia (men: adjusted OR 1.72; 95% CI 1.49, 1.98; women: OR 1.64; 95% CI 1.38, 1.96). HbA1c target achievement differed by SMI disorder and sex. Among people without previous CVD, statin prescribing was similar or better in those with vs those without SMI at diabetes diagnosis and 1 year later. In people with prior CVD, SMI was associated with lower odds of statin prescribing at diabetes diagnosis (schizophrenia: OR 0.54; 95% CI 0.43, 0.68, bipolar disorder: OR 0.75; 95% CI 0.56, 1.01, major depression: OR 0.92; 95% CI 0.83, 1.01), with this difference generally persisting 1 year later. CONCLUSIONS/INTERPRETATION: We found disparities in cholesterol target achievement and statin prescribing by SMI status. This reinforces the importance of clinical review of statin prescribing for secondary prevention of CVD, particularly among people with SMI.

Ethnic disparities in quality of diabetes care in Scotland: A national cohort study.

AIMS: The aim of this study is to compare quality of diabetes care in people with type 2 diabetes by ethnicity, in Scotland. METHODS: Using a linked national diabetes registry, we included 162,122 people newly diagnosed with type 2 diabetes between 2009 and 2018. We compared receipt of nine guideline indicated processes of care in the first-year post-diabetes diagnosis using logistic regression, comparing eight ethnicity groups to the White group. We compared annual receipt of HbA1c and eye screening during the entire follow-up using generalised linear mixed effects. All analyses adjusted for confounders. RESULTS: Receipt of diabetes care was lower in other ethnic groups compared to White people in the first-year post-diagnosis. Differences were most pronounced for people in the: African, Caribbean or Black; Indian; and other ethnicity groups for almost all processes of care. For example, compared to White people, odds of HbA1c monitoring were: 44% lower in African, Caribbean or Black people (OR 0.56 [95% CI 0.48, 0.66]); 47% lower in Indian people (OR 0.53 [95% CI 0.47, 0.61]); and 50% lower in people in the other ethnicity group (OR 0.50 [95% CI 0.46, 0.58]). Odds of receipt of eye screening were 30%-40% lower in most ethnic groups compared to the White group. During median 5 year follow-up, differences in HbA1c monitoring and eye screening largely persisted, but attenuated slightly for the former. CONCLUSIONS: There are marked ethnic disparities in routine diabetes care in Scotland in the short- and medium-term following diabetes diagnosis. Further investigation is needed to establish and effectively address the underlying reasons.

Antidepressant and antipsychotic prescribing in patients with type 2 diabetes in Scotland: A time-trend analysis from 2004 to 2021.

AIMS: Prescribing of antidepressant and antipsychotic drugs in general populations has increased in the United Kingdom, but prescribing trends in people with type 2 diabetes (T2D) have not previously been investigated. The aim of this study was to describe time trends in annual prevalence of antidepressant and antipsychotic drug prescribing in adult patients with T2D. METHODS: We conducted repeated annual cross-sectional analysesof a population-based diabetes registry with 99% coverage, derived from primary and secondary care data in Scotland, from 2004 to 2021. For each cross-sectional calendar year time period, we calculated the prevalence of antidepressant and antipsychotic drug prescribing, overall and by sociodemographic characteristics and drug subtype. RESULTS: The number of patients with a T2D diagnosis in Scotland increased from 161 915 in 2004 to 309 288 in 2021. Prevalence of antidepressant and antipsychotic prescribing in patients with T2D increased markedly between 2004 and 2021 (from 20.0 per 100 person-years to 33.3 per 100 person-years and from 2.8 per 100 person-years to 4.7 per 100 person-years, respectively). We observed this pattern for all drug subtypes except for first-generation antipsychotics, prescribing of which remained largely stable. The degree of increase, as well as the overall prevalence of prescribing, differed by age, sex, socioeconomic status and subtype of drug class. CONCLUSIONS: There has been a marked increase in the prevalence of antidepressant and antipsychotic prescribing in patients with T2D in Scotland. Further research should identify the reasons for this increase, including indication for use and the extent to which this reflects increases in incident prescribing rather than increased duration.

The association of depression and patient and resuscitation characteristics with survival after out-of-hospital cardiac arrest: a cohort study.

AIMS: Out-of-hospital cardiac arrest (OHCA) is a leading cause of death worldwide, with cardiovascular disease (CVD) being a key risk factor. This study aims to investigate disparities in patient/OHCA characteristics and survival after OHCA among patients with vs. without depression. METHODS AND RESULTS: This is a retrospective cohort study using data from the AmsteRdam REsuscitation Studies (ARREST) registry from 2008 to 2018. History of comorbidities, including depression, was obtained from the patient's general practitioner. Out-of-hospital cardiac arrest survival was defined as survival at 30 days post-OHCA or hospital discharge. Logistic regression models were used to obtain crude and adjusted odds ratios (ORs) for the association between depression and OHCA survival and possible effect modification by age, sex, and comorbidities. The potential mediating effects of initial heart rhythm and provision of bystander cardiopulmonary resuscitation were explored. Among 5594 OHCA cases, 582 individuals had pre-existing depression. Patients with depression had less favourable patient and OHCA characteristics and lower odds of survival after adjustment for age, sex, and comorbidities [OR 0.65, 95% confidence interval (CI) 0.51-0.82], with similar findings by sex and age groups. The association remained significant among the Utstein comparator group (OR 0.63, 95% CI 0.45-0.89) and patients with return of spontaneous circulation (OR 0.60, 95% CI 0.42-0.85). Initial rhythm and bystander cardiopulmonary resuscitation partially mediated the observed association (by 27 and 7%, respectively). CONCLUSION: Out-of-hospital cardiac arrest patients with depression presented more frequently with unfavourable patient and OHCA characteristics and had reduced chances of survival. Further investigation into potential pathways is warranted.

Continuous renal replacement therapy and therapeutic plasma exchange in pediatric liver failure.

Patients with acute liver failure (ALF) and acute on chronic liver failure (ACLF) have significant morbidity and mortality. They require extracorporeal blood purification modalities like continuous renal replacement therapy (CRRT) and therapeutic plasma exchange (TPE) as a bridge to recovery or liver transplantation. Limited data are available on the outcomes of patients treated with these therapies. This is a retrospective single-center study of 23 patients from 2015 to 2022 with ALF/ACLF who underwent CRRT and TPE. We aimed to describe the clinical characteristics and outcomes of these patients. Median (IQR) age was 0.93 years (0.57, 9.88), range 16 days to 20 years. Ten (43%) had ALF and 13 (57%) ACLF. Most (n = 19, 82%) started CRRT for hyperammonemia and/or hepatic encephalopathy and all received TPE for refractory coagulopathy. CRRT was started at a median of 2 days from ICU admission, and TPE started on the same day in most. The liver transplant was done in 17 (74%), and 2 recovered native liver function. Four patients, all with ACLF, died prior to ICU discharge without a liver transplant. The median peak ammonia pre-CRRT was 131 µmol/L for the whole cohort. The mean (SD) drop in ammonia after 48 h of CRRT was 95.45 (43.72) µmol/L in those who survived and 69.50 (21.70) µmol/L in those who did not (p 0.26). Those who survived had 0 median co-morbidities compared to 2.5 in non-survivors (aOR (95% CI) for mortality risk of 2.5 (1.1-5.7), p 0.028). Conclusion: In this cohort of 23 pediatric patients with ALF or ACLF who received CRRT and TPE, 83% survived with a liver transplant or recovered with their native liver. Survival was worse in those who had ACLF and those with co-morbid conditions. What is Known: •  Pediatric acute liver failure is associated with high mortality. •  Patients may require extracorporeal liver assist therapies (like CRRT, TPE, MARS, SPAD) to bridge them over to a transplant or recovery of native liver function. What is New: • Standard volume plasma exhange has not been evaluated against high volume plasma exchange for ALF. • The role, dose, and duration of therapeutic plasma exchange in patients with acute on chronic liver failure is not well described.

The UK prosthetic and orthotic workforce: current status and implications for the future.

BACKGROUND: Prosthetists and orthotists (POs) are the smallest of the 14 allied health profession (AHP) workforces within NHS England. Obtaining data on the workforce has always been challenging due to this information being held across different organisations. An understanding of the prosthetic and orthotic (P&O) workforce is essential to ensure that it is adequately equipped to meet the evolving needs of users of P&O services. The study aims to estimate the size and composition, for the first time, of the UK P&O workforce and P&O service provision. METHODS: To gather the required information, two surveys (one for the UK P&O workforce and one for UK P&O private company) and two freedom of information (FOI) requests [one for all NHS Trusts and Health Boards (HB) in the UK and one for the higher education institutes in the UK offering programmes leading to registration as a PO were developed and distributed from September to December 2022. RESULTS: The P&O workforce survey received a 74% response rate (863 POs) and 25 private companies reported employing one or more P&O staffing groups. From the FOI requests, 181 of a potential 194 Trusts/Health Boards and all four higher education institutions responded. The study indicated a total of 1766 people in the UK P&O workforce, with orthotists and orthotic technicians representing the largest percentage of the workforce at 32% and 30%, respectively. A greater percentage of prosthetists (65%) and orthotists (57%) were employed by private companies compared to the NHS. Only 34% of POs stated that they "definitely" planned to remain in the workforce for the next 5 years. The current UK PO employment levels are 142 to 477 short of the World Health Organisation's (WHO) recommendation. CONCLUSIONS: The low job satisfaction amongst many POs and the projected increase in the number of people who will require prosthetic and/or orthotic care in the UK are challenges for future UK P&O services. Strategies are required to create a sustainable and resilient workforce that can meet the needs of a changing healthcare landscape.

Just a story? Leadership, lived experience and integrated care.

BACKGROUND: Integrated care is based around values of involvement and shared decision-making, but these are not often reflected within planning and implementation. Barriers include continued emphasis on professional and managerial perspectives, skills gaps on how best to engage people and communities and insufficient investment in involvement infrastructure. Despite such challenges, people with lived experience have still led changes in policy and services. DESIGN: Qualitative study involving 25 participants with lived experience from 12 countries. Participants shared their background stories and engaged in semistructured interviews relating to leadership identity, experience of influencing and personal learning. Transcripts were analysed through a framework approach informed by narrative principles. RESULTS: Participants were motivated by their own experiences and a wish to improve care for future individuals and communities. Sharing their story was often the entry point for such influencing. Participants gained skills and confidence in story telling despite a lack of support and development. Many felt comfortable being described as a leader while others rejected this identity and preferred a different title. No common alternative term to leader was identified. Influencing services required considerable personal cost but also led to new networks, skills development and satisfaction when change was achieved. DISCUSSION: Leadership within integrated care is often awarded to those with structural power related to management or clinical seniority. People with lived experience are though uniquely placed to identify what needs to change and can develop inspiring visions based around their personal stories. Claiming identity as leader can be challenging due to traditional notions of who is eligible to lead and unwillingness by professionals and managers to grant such identity. CONCLUSIONS: People with lived experience should be recognised as leaders of integrated care and have access to developmental opportunities and practical support to strengthen their skills, including that of storytelling. PATIENT AND PUBLIC CONTRIBUTION: The research was instigated on the request of a community advisory board of people with lived experience who shaped its design, contributed to the analysis and informed the conclusions and implications.

Depression, diabetes, comorbid depression and diabetes and risk of all-cause and cause-specific mortality: a prospective cohort study.

AIMS/HYPOTHESIS: The aim of this study was to investigate the risks of all-cause and cause-specific mortality among participants with neither, one or both of diabetes and depression in a large prospective cohort study in the UK. METHODS: Our study population included 499,830 UK Biobank participants without schizophrenia and bipolar disorder at baseline. Type 1 and type 2 diabetes and depression were identified using self-reported diagnoses, prescribed medication and hospital records. Mortality was identified from death records using the primary cause of death to define cause-specific mortality. We performed Cox proportional hazards models to estimate the risk of all-cause mortality and mortality from cancer, circulatory disease and causes of death other than circulatory disease or cancer among participants with either depression (n=41,791) or diabetes (n=22,677) alone and with comorbid diabetes and depression (n=3597) compared with the group with neither condition (n=431,765), adjusting for sociodemographic and lifestyle factors, comorbidities and history of CVD or cancer. We also investigated the interaction between diabetes and depression. RESULTS: During a median of 6.8 (IQR 6.1-7.5) years of follow-up, there were 13,724 deaths (cancer, n=7976; circulatory disease, n=2827; other causes, n=2921). Adjusted HRs of all-cause mortality and mortality from cancer, circulatory disease and other causes were highest among people with comorbid depression and diabetes (HRs 2.16 [95% CI 1.94, 2.42]; 1.62 [95% CI 1.35, 1.93]; 2.22 [95% CI 1.80, 2.73]; and 3.60 [95% CI 2.93, 4.42], respectively). The risks of all-cause, cancer and other mortality among those with comorbid depression and diabetes exceeded the sum of the risks due to diabetes and depression alone. CONCLUSIONS/INTERPRETATION: We confirmed that depression and diabetes individually are associated with an increased mortality risk and also identified that comorbid depression and diabetes have synergistic effects on the risk of all-cause mortality that are largely driven by deaths from cancer and causes other than circulatory disease and cancer.

Association of severe mental illness with stroke outcomes and process-of-care quality indicators: nationwide cohort study.

BACKGROUND: Severe mental illness (SMI) is associated with increased stroke risk, but little is known about how SMI relates to stroke prognosis and receipt of acute care. AIMS: To determine the association between SMI and stroke outcomes and receipt of process-of-care quality indicators (such as timely admission to stroke unit). METHOD: We conducted a cohort study using routinely collected linked data-sets, including adults with a first hospital admission for stroke in Scotland during 1991-2014, with process-of-care quality indicator data available from 2010. We identified pre-existing schizophrenia, bipolar disorder and major depression from hospital records. We used logistic regression to evaluate 30-day, 1-year and 5-year mortality and receipt of process-of-care quality indicators by pre-existing SMI, adjusting for sociodemographic and clinical factors. We used Cox regression to evaluate further stroke and vascular events (stroke and myocardial infarction). RESULTS: Among 228 699 patients who had had a stroke, 1186 (0.5%), 859 (0.4%), 7308 (3.2%) had schizophrenia, bipolar disorder and major depression, respectively. Overall, median follow-up was 2.6 years. Compared with adults without a record of mental illness, 30-day mortality was higher for schizophrenia (adjusted odds ratio (aOR) = 1.33, 95% CI 1.16-1.52), bipolar disorder (aOR = 1.37, 95% CI 1.18-1.60) and major depression (aOR = 1.11, 95% CI 1.05-1.18). Each disorder was also associated with marked increased risk of 1-year and 5-year mortality and further stroke and vascular events. There were no clear differences in receipt of process-of-care quality indicators. CONCLUSIONS: Pre-existing SMI was associated with higher risks of mortality and further vascular events. Urgent action is needed to better understand and address the reasons for these disparities.

Severe mental illness and mortality and coronary revascularisation following a myocardial infarction: a retrospective cohort study.

BACKGROUND: Severe mental illness (SMI), comprising schizophrenia, bipolar disorder and major depression, is associated with higher myocardial infarction (MI) mortality but lower coronary revascularisation rates. Previous studies have largely focused on schizophrenia, with limited information on bipolar disorder and major depression, long-term mortality or the effects of either sociodemographic factors or year of MI. We investigated the associations between SMI and MI prognosis and how these differed by age at MI, sex and year of MI. METHODS: We conducted a national retrospective cohort study, including adults with a hospitalised MI in Scotland between 1991 and 2014. We ascertained previous history of schizophrenia, bipolar disorder and major depression from psychiatric and general hospital admission records. We used logistic regression to obtain odds ratios adjusted for sociodemographic factors for 30-day, 1-year and 5-year mortality, comparing people with each SMI to a comparison group without a prior hospital record for any mental health condition. We used Cox regression to analyse coronary revascularisation within 30 days, risk of further MI and further vascular events (MI or stroke). We investigated associations for interaction with age at MI, sex and year of MI. RESULTS: Among 235,310 people with MI, 923 (0.4%) had schizophrenia, 642 (0.3%) had bipolar disorder and 6239 (2.7%) had major depression. SMI was associated with higher 30-day, 1-year and 5-year mortality and risk of further MI and stroke. Thirty-day mortality was higher for schizophrenia (OR 1.95, 95% CI 1.64-2.30), bipolar disorder (OR 1.53, 95% CI 1.26-1.86) and major depression (OR 1.31, 95% CI 1.23-1.40). Odds ratios for 1-year and 5-year mortality were larger for all three conditions. Revascularisation rates were lower in schizophrenia (HR 0.57, 95% CI 0.48-0.67), bipolar disorder (HR 0.69, 95% CI 0.56-0.85) and major depression (HR 0.78, 95% CI 0.73-0.83). Mortality and revascularisation disparities persisted from 1991 to 2014, with absolute mortality disparities more apparent for MIs that occurred around 70 years of age, the overall mean age of MI. Women with major depression had a greater reduction in revascularisation than men with major depression. CONCLUSIONS: There are sustained SMI disparities in MI intervention and prognosis. There is an urgent need to understand and tackle the reasons for these disparities.

Incidence of ischaemic heart disease and stroke among people with psychiatric disorders: retrospective cohort study.

BACKGROUND: Psychiatric disorders are associated with increased risk of ischaemic heart disease (IHD) and stroke, but it is not known whether the associations or the role of sociodemographic factors have changed over time. AIMS: To investigate the association between psychiatric disorders and IHD and stroke, by time period and sociodemographic factors. METHOD: We used Scottish population-based records from 1991 to 2015 to create retrospective cohorts with a hospital record for psychiatric disorders of interest (schizophrenia, bipolar disorder or depression) or no record of hospital admission for mental illness. We estimated incidence and relative risks of IHD and stroke in people with versus without psychiatric disorders by calendar year, age, gender and area-based deprivation level. RESULTS: In all cohorts, incidence of IHD (645 393 events) and stroke (276 073 events) decreased over time, but relative risks decreased for depression only. In 2015, at the mean age at event onset, relative risks were 2- to 2.5-fold higher in people with versus without a psychiatric disorder. Age at incidence of outcome differed by cohort, gender and socioeconomic status. Relative but not absolute risks were generally higher in women than men. Increasing deprivation conveys a greater absolute risk of IHD for people with bipolar disorder or depression. CONCLUSIONS: Despite declines in absolute rates of IHD and stroke, relative risks remain high in those with versus without psychiatric disorders. Cardiovascular disease monitoring and prevention approaches may need to be tailored by psychiatric disorder and cardiovascular outcome, and be targeted, for example, by age and deprivation level.

Long-term all-cause mortality and cardiovascular outcomes in Scottish children after initiation of renal replacement therapy: a national cohort study.

BACKGROUND: Data on long-term outcomes in children who have received renal replacement therapy (RRT) for end-stage renal disease are limited. METHODS: We studied long-term survival and incidence of fatal and nonfatal cardiovascular disease (CVD) events and determinants of these outcomes in children who initiated RRT between 1961 and 2013 using data from the Scottish Renal Registry (SRR). Linkage to morbidity records was available from 1981. RESULTS: A total of 477 children of whom 55% were boys, almost 50% had congenital urinary tract disease (CAKUT), 10% received a transplant as the first mode of RRT and almost 60% were over 11 years of age at start of RRT were followed for a median of 17.8 years (interquartile range (IQR) 8.7-26.6 years). Survival was 87.3% (95% confidence interval (CI) 84.0-90.1) at 10 years and 77.6% (95% CI 73.3-81.7) at 20 years. During a median follow-up of 14.96 years (IQR 7.1-22.9), 20.9% of the 381 patients with morbidity data available had an incident of CVD event. Age < 2 years at start of RRT, receiving dialysis rather than a kidney transplant and primary renal disease (PRD) other than CAKUT or glomerulonephritis (GN), were associated with a higher risk of all-cause mortality. Male sex, receiving dialysis rather than a kidney transplant and PRD other than CAKUT or GN, was associated with a higher risk of CVD incidence. CONCLUSIONS: Mortality and CVD incidence among children receiving RRT are high. PRD and RRT modality were associated with increased risk of both all-cause mortality and CVD incidence.

Sex differences in the association between socioeconomic status and diabetes prevalence and incidence in China: cross-sectional and prospective studies of 0.5 million adults.

AIMS/HYPOTHESIS: China has undergone rapid socioeconomic transition accompanied by lifestyle changes that are expected to have a profound impact on the health of its population. However, there is limited evidence from large nationwide studies about the relevance of socioeconomic status (SES) to risk of diabetes. We describe the associations of two key measures of SES with prevalent and incident diabetes in Chinese men and women. METHODS: The China Kadoorie Biobank study included 0.5 million adults aged 30-79 years recruited from ten diverse areas in China during 2004-2008. SES was assessed using the highest educational level attained and annual household income. Prevalent diabetes was identified from self-report and plasma glucose measurements. Incident diabetes was identified from linkage to disease and death registries and national health insurance claim databases. We estimated adjusted ORs and HRs for prevalent and incident diabetes associated with SES using logistic and Cox regression models, respectively. RESULTS: At baseline, 30,066 (5.9%) participants had previously diagnosed (3.1%) or screen-detected (2.8%) diabetes among 510,219 participants included for cross-sectional analyses. There were 480,153 people without prevalent diabetes at baseline, of whom 9544 (2.0%) had new-onset diabetes during follow-up (median 7 years). Adjusted ORs (95% CIs) for prevalent diabetes, comparing highest vs lowest educational level, were 1.21 (1.09, 1.35) in men and 0.69 (0.63, 0.76) in women; for incident diabetes, the corresponding HRs were 1.27 (1.07, 1.51) and 0.80 (0.67, 0.95), respectively. For household income, the adjusted ORs for prevalent diabetes, comparing highest vs lowest categories, were 1.45 (1.34, 1.56) in men and 1.26 (1.19, 1.34) in women; for incident diabetes, the HRs were 1.36 (1.19, 1.55) and 1.06 (0.95, 1.17), respectively. CONCLUSIONS/INTERPRETATION: Among Chinese adults, the associations between education and diabetes prevalence and incidence differed qualitatively between men and women, whereas higher household income was positively associated with diabetes prevalence and incidence in both sexes, with a stronger relationship in men than in women.

Antipsychotic drug use and risk of stroke and myocardial infarction: a systematic review and meta-analysis.

BACKGROUND: The effect of antipsychotic (AP) drugs on risk of stroke and myocardial infarction (MI) remains unclear due to methodological limitations of, and inconsistencies across, existing studies. We aimed to systematically review studies reporting on the associations between AP drug use and stroke or MI risk, and to investigate whether associations differed among different sub-populations. METHODS: We searched Medline, EMBASE, PsychINFO and Cochrane Library (from inception to May 28, 2017) for observational studies reporting on AP drug use and MI or stroke occurrence. We performed random-effects meta-analyses for each outcome, performing sub-groups analyses by study population - specifically general population (i.e. those not restricted to patients with a particular indication for AP drug use), people with dementia only and psychiatric illness only. Where feasible we performed subgroup analyses by AP drug class. RESULTS: From 7008 articles, we included 29 relevant observational studies, 19 on stroke and 10 on MI. Results of cohort studies that included a general population indicated a more than two-fold increased risk of stroke, albeit with substantial heterogeneity (pooled HR 2.31, 95% CI 1.13, 4.74, I2 = 83.2%). However, the risk among patients with dementia was much lower, with no heterogeneity (pooled HR 1.16, 95% CI 1.00, 1.33, I2 = 0%) and there was no clear association among studies of psychiatric populations (pooled HR 1.44, 95% CI 0.90, 2.30; substantial heterogeneity [I2 = 78.8])). Associations generally persisted when stratifying by AP class, but few studies reported on first generation AP drugs. We found no association between AP drug use and MI risk (pooled HR for cohort studies: 1.29, 95% CI 0.88, 1.90 and case-control studies: 1.07, 95% CI 0.94, 1.23), but substantial methodological and statistical heterogeneity among a relatively small number of studies limits firm conclusions. CONCLUSIONS: AP drug use may be associated with an increased risk of stroke, but there is no clear evidence that this risk is further elevated in patients with dementia. Further studies are need to clarify the effect of AP drug use on MI and stroke risk in different sub-populations and should control for confounding by indication and stratify by AP drug class.

Body mass index and socioeconomic position are associated with 9-year trajectories of multimorbidity: A population-based study.

Multimorbidity is a growing public health problem and is more common in women than men. However, little is known about multimorbidity trajectories, in terms of the accumulation of disease over time, or about the determinants of these trajectories. We sought to identify lifestyle and socioeconomic factors related to multimorbidity trajectories in mid-aged women. Participants were from the Australian Longitudinal Study on Women's Health, a nationally representative population-based study. We included 4865 women born 1946-51, without chronic disease in 1998, followed triennially for 12 years. We used latent class growth analysis to identify 9-year multimorbidity trajectories and multinomial regression to calculate relative risk ratios (RRRs) for associations between baseline lifestyle and socioeconomic factors and trajectories. We identified five multimorbidity trajectories: 'no morbidity, constant'; 'low morbidity, constant'; 'moderate morbidity, constant'; 'no morbidity, increasing'; and 'low morbidity, increasing'. Overweight and obesity were associated with an increased risk of the 'no morbidity, increasing' (RRR 1.70, 95% CI 1.16 to 2.50 and 2.69, 95% CI 1.69 to 4.28, respectively) and the 'low morbidity, increasing' (RRR 2.57, 95% CI 1.56 to 4.24 and 4.28, 95% CI 2.41 to 7.60, respectively) trajectories, as compared to the 'no morbidity, constant' group. Low education and difficulty managing on income were also associated with trajectories of poorer health. Among mid-aged women, overweight/obesity and lower socioeconomic status are major risk factors for trajectories characterised by accumulation of chronic disease. These highlight key target areas for preventive approaches aimed at reducing the risk of accumulation of morbidities in mid-aged women.

Moderate agreement between self-reported stroke and hospital-recorded stroke in two cohorts of Australian women: a validation study.

BACKGROUND: Conflicting findings on the validity of self-reported stroke from existing studies creates uncertainty about the appropriateness of using self-reported stroke in epidemiological research. We aimed to compare self-reported stroke against hospital-recorded stroke, and investigate reasons for disagreement. METHODS: We included participants from the Australian Longitudinal Study on Women's Health born in 1921-26 (n = 1556) and 1946-51 (n = 2119), who were living in New South Wales and who returned all survey questionnaires over a defined period of time. We determined agreement between self-reported and hospitalised stroke by calculating sensitivity, specificity and kappa statistics. We investigated whether characteristics including age, education, area of residence, country of birth, language spoken at home, recent mental health at survey completion and proxy completion of questionnaire were associated with disagreement, using logistic regression analysis to obtain odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Agreement between self-report and hospital-recorded stroke was fair in older women (kappa 0.35, 95% CI 0.25 to 0.46) and moderate in mid-aged women (0.56, 95% CI 0.37 to 0.75). There was a high proportion with unverified self-reported stroke, partly due to: reporting of transient ischaemic attacks; strokes occurring outside the period of interest; and possible reporting of stroke-like conditions. In the older cohort, a large proportion with unverified stroke had hospital records of other cerebrovascular disease. In both cohorts, higher education was associated with agreement, whereas recent poor mental health was associated with disagreement. CONCLUSION: Among women who returned survey questionnaires within the period of interest, validity of self-reported stroke was fair to moderate, but is probably underestimated. Agreement between self-report and hospital-recorded stroke was associated with individual characteristics. Where clinically verified stroke data are unavailable, self-report may be a reasonable alternative method of stroke ascertainment for some epidemiological studies.

Multimorbidity patterns are differentially associated with functional ability and decline in a longitudinal cohort of older women.

BACKGROUND: we aimed to identify multimorbidity patterns and relate these patterns to functional ability and decline. METHODS: we included 7,270 participants of the older cohort of the Australian Longitudinal Study on Women's Health, who were surveyed every 3 years from 2002 to 2011. We used factor analysis to identify multimorbidity patterns from 31 self-reported chronic conditions among women aged 76-81 in 2002. We applied a linear increments model to account for attrition and related the multimorbidity patterns to functional ability and decline at subsequent surveys, as measured by activities of daily living (ADL) and instrumental activities of daily living (IADL). For each pattern, we determined mean ADL and IADL scores in the middle and highest third of factor score in comparison to a reference group. RESULTS: we identified three multimorbidity patterns, labelled musculoskeletal/somatic (MSO), neurological/mental health (NMH) and cardiovascular (CVD). High factor scores for NMH, MSO and CVD were associated with significantly higher mean ADL and IADL scores (poorer functional ability) in 2005 compared with the reference group of low factor scores for all three factors. The CVD pattern was associated with the greatest decline in ADL between 2005 and 2011, whereas the NMH pattern was associated with the greatest decline in IADL. CONCLUSIONS: distinct multimorbidity patterns were differentially associated with functional ability and decline. Given the paucity of studies on multimorbidity patterns, future studies should seek to assess the reproducibility of our findings in other populations and settings, and investigate the potential implications for improved prediction of functional decline.

Educational and homeownership inequalities in stroke incidence: a population-based longitudinal study of mid-aged women.

BACKGROUND: We aimed to determine which socioeconomic status measures are associated with stroke risk in mid-aged women and assess the contribution of lifestyle, biological and psychosocial factors to observed associations. METHODS: We included women born in 1946-51 from the Australian Longitudinal Study on Women's Health, who were surveyed every 3 years. Using generalized estimating equation analysis, we determined the association between socioeconomic status and stroke at the subsequent survey, adjusting for time-varying covariates. For significant associations, we calculated the contribution of individual mediating factors in explaining these associations. RESULTS: Among 11 468 women aged 47-52 years, 177 strokes occurred during a 12-year follow-up. Education (odds ratio lowest vs. highest 2.45, 95% confidence interval: 1.40-4.30) and homeownership, but not occupation or managing on income, were significantly associated with stroke. After full adjustment, the overall association between education and stroke was non-significant. Lifestyle (smoking, exercise, alcohol and body mass index), biological (hypertension, diabetes, heart disease and hysterectomy/oophorectomy) and psychosocial (depression and marital status) factors explained 38% of the association in the lowest versus highest education groups. Lifestyle and biological factors together accounted for 34%. Mediators accounted for 29% of the association between homeownership and stroke, with lifestyle and psychosocial factors responsible for most of this attenuation. However, a significant association remained in fully adjusted models (odds ratio non-homeowner vs. homeowner 1.63, 95% confidence interval: 1.12-2.38). CONCLUSIONS: Lower education level is associated with increased stroke risk in mid-aged women, and is partially mediated by known risk factors, particularly lifestyle and biological factors. Non-homeownership is associated with increased stroke risk, but the underlying mechanism is unclear.

Severe mental illness and cardioprotective medication prescribing: a qualitative study in general practice.

BACKGROUND: Patients with severe mental illness (SMI) die 10-20 years earlier than the general population. They have a higher risk of cardiovascular disease (CVD) yet may experience lower cardioprotective medication prescribing. AIM: To understand the challenges experienced by GPs in prescribing cardioprotective medication to patients with SMI. DESIGN & SETTING: A qualitative study with 15 GPs from 11 practices in two Scottish health boards, including practices servicing highly deprived areas (Deep End). METHOD: Semi-structured one-to-one interviews with fully qualified GPs with clinical experience of patients with SMI. Interviews were transcribed verbatim and analysed thematically. RESULTS: Participants aimed to routinely prescribe cardioprotective medication to relevant patients with SMI but were hampered by various challenges. These structural and contextual barriers included the following: lack of funding for chronic disease management; insufficient consultation time; workforce shortages; IT infrastructure; and navigating boundaries with mental health services. Patient-related barriers included patients' complex health and social needs, their understandable prioritisation of mental health needs or existing physical conditions, and presentation during crises. Professional barriers comprised GPs' desire to practise holistic medicine rather than treating via cardioprotective prescribing in isolation, and concerns about patients' medication concordance if patients were not prioritising this aspect of their health care at that particular time. In terms of enablers for cardioprotective prescribing, participants emphasised continuity of care as fundamental in engaging this patient group in effective cardiovascular health management. A cross-cutting theme was the current GP workforce crisis leading to 'firefighting' and diminishing capacity for primary prevention. This was particularly acute in Deep End practices, which have a high proportion of patients with complex needs and greater resource challenges. CONCLUSION: Although participants aspire to prescribe cardioprotective medication to patients with SMI, professional-, system- and patient-level barriers often make this challenging, particularly in deprived areas owing to patient complexity and the inverse care law.