D. T. Steinke

Diabetes and Lower-Limb Amputations in the Community: A retrospective cohort study

OBJECTIVE There are few U.K. data on the incidence rates of amputation in diabetic subjects compared with the nondiabetic population. RESEARCH DESIGN AND METHODS We performed a historical cohort study of first lower-extremity amputations based in Tayside, Scotland (population 364,880) from 1 January 1993 to 31 December 1994. The Diabetes Audit and Research in Tayside Scotland (DARTS) database was used to identify a prevalence cohort of 7,079 diabetic patients on 1 January 1993. We estimated age-specific and standardized incidence rates of lower-limb amputations in the diabetic and nondiabetic cohorts. Results were compared with a previous study that evaluated lower-extremity amputations in diabetic patients in Tayside in 1980–1982. RESULTS There were 221 subjects who underwent a total of 258 nontraumatic amputations. Of the 221 subjects, 60 (27%) patients were diabetic (93% NIDDM), and 63% were first amputations. The median duration of diabetes was 6 years (range: newly diagnosed to 41 years). Nonhealing ulceration (31%) and gangrene (29%) were the two main indications for amputation in the diabetic subjects. Of the 161 nondiabetic subjects, 140 (80%) underwent first amputations. The adjusted incidences in the diabetic and nondiabetic groups were 248 and 20 per 100,000 person-years, respectively. Tayside patients with diabetes thus had a 12.3-fold risk of an amputation compared with nondiabetic residents (95% Cl 8.6–17.5). The estimated proportion of diabetic patients in the population rose from 0.81% in 1980–1982 to 1.94% in 1993–1994, whereas the absolute rate of amputation in diabetic subjects was unchanged from that in 1980–1982. CONCLUSIONS These population-based U.K. amputation data are similar to amputation rates in the U.S. Amputation rates appear to have decreased significantly since 1980–1982. The impact of diabetes education and prevention programs that target the processes leading to amputation can now be evaluated.

Presence of bacteriuria caused by trimethoprim resistant bacteria in patients prescribed antibiotics: multilevel model with practice and individual patient data

Abstract Objective To look for evidence of a relation between antibiotic resistance and prescribing by general practitioners by analysis of prescribing at both practice and individual patient level. Design Repeated cross-sectional study in 1995 and 1996. Setting 28 general practices in the Ninewells Hospital laboratory catchment area, Tayside, Scotland. Subjects reviewed 8833 patients registered with the 28 practices who submitted urine samples for analysis. Main outcome measures Resistance to trimethoprim in bacteria isolated from urine samples at practice and individual level simultaneously in a multilevel model. Results Practices showed considerable variation in both the prevalence of trimethoprim resistance (26-50% of bacteria isolated) and trimethoprim prescribing (67-357 prescriptions per 100 practice patients). Although variation in prescribing showed no association with resistance at the practice level after adjustment for other factors (P = 0.101), in the multilevel model resistance to trimethoprim was significantly associated with age, sex, and individual-level exposure to trimethoprim (P < 0.001) or to other antibiotics (P = 0.002). The association with trimethoprim resistance was strongest for people recently exposed to trimethoprim, and there was no association for people with trimethoprim exposure more than six months before the date of the urine sample. Discussion Analysis of practice level data obscured important associations between antibiotic prescribing and resistance. The results support efforts to reduce unnecessary prescribing of antibiotics in the community and show the added value of individual patient data for research on the outcomes of prescribing.

Changes in treatment after the start of oral hypoglycaemic therapy in Type 2 diabetes: a population-based study

Aims To determine the changes in oral hypoglycaemic therapy and the time to incidence of insulin therapy in people with Type 2 diabetes.

Selegiline and mortality in subjects with Parkinson’s disease A longitudinal community study

Objective: To estimate mortality by drug use in a cohort of patients with PD relative to age- and sex-matched comparators. Methods: two longitudinal cohorts of patients with 7 and 11 years’ duration of PD were constructed with matched comparators in Tayside, Scotland. Subjects were eligible for inclusion if they received a first prescription for an anti-Parkinson’s drug from July 1989 to December 1995, with no PD drug prescription in the previous 6 months. Those who had previously taken a neuroleptic drug or were younger than 40 years of age were excluded. Results: Overall, subjects with PD in relation to comparators had higher mortality with a rate ratio (RR) of 1.76 (95% CI 1.11, 2.81) in the 7-year cohort. There was significantly greater mortality in patients with PD who received levodopa monotherapy (RR = 2.45, 95% CI 1.42, 4.23) relative to the comparators, adjusting for previous cardiovascular drug use and diabetes. However, there was no significant difference in mortality in those with PD receiving combination therapy of selegiline with levodopa and other drugs in relation to the comparators (RR = 0.92, 95% CI 0.37, 2.31). Conclusions: Subjects with PD had twice the rate of mortality relative to age- and sex-matched comparators. However, those subjects who received selegiline at any time in combination with co-careldopa or co-beneldopa showed no significant difference in mortality compared with the comparators. Monotherapy with levodopa was associated with the highest mortality.

Epidemiology and economic burden of viral hepatitis: an observational population based study

Objective: To describe the epidemiology and estimate the health resource use of patients with viral hepatitis in Tayside, Scotland, using record linkage techniques. Design: A retrospective observational study. Setting: Liver disease database, Tayside, Scotland. Patients: All subjects resident in Tayside in the study period 1989–1999 and registered on the Epidemiology of Liver Disease in Tayside (ELDIT) database. Main outcome measures: Incidence and prevalence of known viral hepatitis in Tayside, survival of subjects diagnosed with viral hepatitis, and the health resource use with respect to hospital admissions compared with the general population. Results: There were 4992 patients identified with viral hepatitis in the study period 1989–1999; 86 were IgM positive anti-hepatitis A, 187 patients were hepatitis B surface antigen (HBsAg) positive, and 469 were anti-hepatitis C (HCV) positive. HCV and HBsAg seropositive patients were more likely to be hospitalised and stay in hospital longer, less likely to survive after six years, and used more drugs of potential abuse than the general population. There was an increase in cost per admission and per patient as a consequence of liver disease. Conclusions: A record linkage population based study of viral hepatitis allows outcomes to be identified and costed. Those at risk of viral hepatitis infection in the Tayside population should be informed about the future implication to their health and costs to society. The health service should investigate the cost effectiveness of vaccination and opportunity costs to the health service of viral hepatitis taking into consideration the increasing incidence and prevalence of disease.

The epidemiology of liver disease in Tayside database: a population-based record-linkage study

BACKGROUNDnThe true incidence and prevalence of liver disease is difficult to ascertain because there are few, if any, population-based registers of liver disease available to ensure proper case and comparator selection. The epidemiology of liver disease in Tayside (ELDIT) is a specially built register of liver disease for a well-defined geographical area of Scotland.nnnAIMSnThis paper describes the electronic linkage of multiple data sources to form ELDIT and provides initial results from the database.nnnPATIENTSnAll subjects resident in Tayside and registered with a general practitioner in the study period 1980-1999, approximately 400,000 people.nnnMETHODSnElectronic record-linkage techniques were employed to include anonymised data from primary and secondary sources. Hospital admissions, dispensed medication, and laboratory results from immunology, virology, and biochemistry were used to identify cases of liver disease. Diagnostic algorithms were used to verify and classify subjects with liver disease. A validation of the algorithms against the clinical diagnosis was used to determine the measure of agreement (true positive rate) of ELDIT.nnnRESULTSnAt present approximately 10,000 subjects have been identified with liver disease or abnormal liver function. The data set is nearing completion with cases of rarer liver disease being identified last. Incidence densities for the population were calculated. From the validation study, agreement between electronic and clinical diagnosis was 0.98 and positive predictive value was 0.83 showing electronic diagnostic algorithms are sensitive enough to identify liver disease using para-clinical data.nnnCONCLUSIONSnELDIT demonstrates how clinical information can be harnessed electronically to provide a better understanding of liver disease in a population.

Do H2-receptor antagonists cause acute pancreatitis?

The aim of this study was to investigate the association between H2‐receptor antagonists and acute pancreatitis. The automated database of the Medicines Monitoring Unit (MEMO) was used to carry out a case‐control study, supplemented with information on possible confounding factors from hospital and GP medical records. Cases were patients hospitalized with a computerized diagnosis of acute pancreatitis, and two sets of controls were drawn from (1) the study population and from (2) the same GP practice as the case. Current or 60‐day exposure to cimetidine and ranitidine was analysed. In adjusted analyses, cimetidine exposure and ranitidine exposure were associated with an increased risk of hospitalization for acute pancreatitis, as were alcohol abuse and cholelithiasis. The risks were lower in unadjusted analyses, suggesting that the association is confounded, although they did not disappear completely. A possible explanation is that data on confounding were incomplete. This study cannot discount the existence of an association between H2‐antagonists and acute pancreatitis, and highlights the difficulties involved in obtaining complete and accurate data on confounding factors that are not collected routinely. Copyright