Raphael Goldacre

Risk of fractures in patients with multiple sclerosis: record-linkage study

BackgroundPatients with multiple sclerosis (MS) have been reported to be at higher risk of fracture than other people. We sought to test this hypothesis in a large database of hospital admissions in England.MethodsWe analysed a database of linked statistical records of hospital admissions and death certificates for the whole of England (1999–2010). Rate ratios for fractures were determined, comparing fracture rates in a cohort of all people in England admitted with MS and rates in a comparison cohort.ResultsSignificantly elevated risk for all fractures was found in patients with MS (rate ratio (RR) = 1.99, 95% confidence interval (CI) = 1.93-2.05)). Risks were particularly high for femoral fractures (femoral neck fracture RR = 2.79 (2.65-2.93); femoral shaft fracture RR 6.69 (6.12-7.29)), and fractures of the tibia or ankle RR = 2.81 (2.66-2.96).ConclusionsPatients with MS have an increased risk of fractures. Caregivers should aim to optimize bone health in MS patients.

The falling rates of hospital admission, case fatality, and population-based mortality for subarachnoid hemorrhage in England, 1999–2010

OBJECTIVE In this study, the authors examined trends in population-based hospital admission rates, patient-level case fatality rates (CFRs), and population-based mortality rates for nontraumatic (spontaneous) subarachnoid hemorrhage (SAH) in England. METHODS Population-based admission and mortality data (59,599 people admitted to a hospital with SAH, 1999-2010; 37,836 people whose death certificates mentioned SAH, 1995-2010) were analyzed. RESULTS Hospital admission rates for SAH per million population declined by 18.3%, from 100.4 (95% CI 97.6-103.1) in 1999 to 82.0 (95% CI 79.7-84.4) in 2010. CFRs at less than 30 days per 100 patients decreased by 18.2%, from 29.7 (95% CI 28.5-31.0) in 1999 to 24.3 (95% CI 23.2-25.5) in 2010. Population-based mortality rates per million population, where SAH was recorded as underlying cause of death on the death certificate, declined by 39.8%, from 41.2 (95% CI 39.5-43.0) in 1999 to 24.8 (95% CI 23.6-26.1) in 2010. CONCLUSIONS Population-based hospital admission rates, patient-level CFRs, and population-based mortality rates all declined between 1999 and 2010. Part of the decline in mortality rates for SAH is likely to be attributable to a decline in incidence. It is also, in part, attributable to increased survival after SAH. The available data do not allow us to compare the effects of different treatment methods for SAH on case fatality and mortality. During the period of study, mortality rates declined by almost 40%, and it is likely that there are a number of factors contributing to this substantial improvement in outcomes for SAH patients in England.

Hospital admissions for viral meningitis in children in England over five decades: a population-based observational study

BACKGROUND A substantial reduction in bacterial meningitis has occurred in the UK following successful implementation of immunisation programmes. Most childhood meningitis in developed countries is now caused by viruses. Long-term trends in paediatric viral meningitis in England have not previously been reported. The objective of this study is to report on epidemiological trends over time in childhood viral meningitis in England. METHODS In this population-based observational study, we used routinely collected hospital discharge records from English National Health Service hospitals from 1968-2011 to analyse annual age-specific admission rates for viral meningitis, including specific viral aetiologies, in children younger than 15 years. FINDINGS We analysed hospital discharge records from Jan 1, 1968, to Dec 31, 2011. Hospital admission rates for viral meningitis from Jan 1, 1968, to Dec 31, 1985, varied annually, with a mean of 13·5 admissions per 100 000 children aged less than 15 years, per year (95% CI 13·0-14·0). Admission rates declined during the late 1980s, and the mean number of admissions from 1989-2011 was 5·2 per 100 000 per year (5·1-5·3). This decrease was entirely in children aged 1-14 years. Admission rates for infants aged less than 1 year increased since 2005, to 70·0 per 100 000 (63·7-76·2) in 2011, which was driven by an increase in admission of infants aged 90 days or less. In 1968-85, the majority of cases in children were in those aged 1-14 years (22 150 [89%] of 24 920 admissions). In 2007-11, 1716 (72%) of 2382 cases were in infants. Admissions for mumps-related meningitis almost disappeared following introduction of the measles-mumps-rubella (MMR) vaccine in 1988. Admissions with a specified viral aetiology have increased since 2000. INTERPRETATION Trends in viral meningitis admissions have changed substantially over the past 50 years, and probably reflect the impact of the MMR vaccine programme and the use of more sensitive diagnostic techniques. FUNDING None.

30-year trends in admission rates for encephalitis in children in England and effect of improved diagnostics and measles-mumps-rubella vaccination: a population-based observational study

BACKGROUND Encephalitis is a serious neurological disorder, yet data on admission rates for all-cause childhood encephalitis in England are scarce. We aimed to estimate admission rates for childhood encephalitis in England over 33 years (1979-2011), to describe trends in admission rates, and to observe how these rates have varied with the introduction of vaccines and improved diagnostics. METHODS We did a retrospective analysis of hospital admission statistics for encephalitis for individuals aged 0-19 years using national data from the Hospital Inpatient Enquiry (HIPE, 1979-85) and Hospital Episode Statistics (HES, 1990-2011). We analysed annual age-specific and age-standardised admission rates in single calendar years and admission rate trends for specified aetiologies in relation to introduction of PCR testing and measles-mumps-rubella (MMR) vaccination. We compared admission rates between the two International Classification of Diseases (ICD) periods, ICD9 (1979-94) and ICD10 (1995-2011). FINDINGS We found 16 571 encephalitis hospital admissions in the period 1979-2011, with a mean hospital admission rate of 5·97 per 100 000 per year (95% CI 5·52-6·41). Hospital admission rates declined from 1979 to 1994 (ICD9; annual percentage change [APC] -3·30%; 95% CI -2·88 to -3·66; p<0·0001) and increased between 1995 and 2011 (ICD10; APC 3·30%; 2·75-3·85; p<0·0001). Admissions for measles decreased by 97% (from 0·32 to 0·009) and admissions for mumps encephalitis decreased by 98% (from 0·60 to 0·01) after the introduction of the two-dose MMR vaccine. Hospital admission rates for encephalitis of unknown aetiology have increased by 37% since the introduction of PCR testing. INTERPRETATION Hospital admission rates for all-cause childhood encephalitis in England are increasing. Admissions for measles and mumps encephalitis have decreased substantially. The numbers of encephalitis admissions without a specific diagnosis are increasing despite availability of PCR testing, indicating the need for strategies to improve aetiological diagnosis in children with encephalitis. FUNDING None.

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.

Cataract Surgery in People with Dementia: An English National Record Linkage Study.

Three hundred sixty-three elderly adults with DM and CKD were included; 67% had low or very low economic status. Proliferative retinopathy was observed in 47.4% of women and 38.2% of men (P = .08). Diabetic neuropathy was observed in 47.2% of women and 42.7% of men (P = .41). Table 1 compares clinical and biological parameters, blood pressure goals, lipid and glycemic levels, renal disease progression, and incidence of cardiovascular events of men and women at enrollment and end of follow-up.

Primary Malignancy in Patients with Nonmelanoma Skin Cancer—Response

Our recent study ([1][1]) is the largest of many of different designs aimed at investigating the relationship between Nonmelanoma skin cancer (NMSC) and subsequent primary malignancies. Our results are in line with the most comprehensive systematic review on this relationship: it reported

OP28 Trends in Mortality from Stroke, and Stroke Subtypes, in the Oxford Region 1979-2011

Background A decline in mortality rates from stroke has been observed in many industrialised countries in recent decades. We were interested in whether any of the observed decline in stroke, and its subtypes, might be artefactual rather than real. In particular, we wanted to determine whether any of the trends over time might be attributable to shifts in death certification practice between underlying cause and contributory cause, and/or shifts over time between certification of specific subtypes (haemorrhagic and ischaemic stroke) and stroke without specification of type. Methods We analysed mortality data from the former Oxford NHS region 1979–2011. This has a longer run of multiple-cause coded mortality data than all-England mortality (though findings from the latter will also be shown). We calculated age-standardised rates, presented as mortality rates per million population, in each year from 1979–2011 and in grouped years for periods defined by national changes to the rules for selection of underlying cause (the rules changed in 1984, 1992 and 2001). Results Mortality rates based on any mention of stroke on the death certificate, and on underlying cause, showed broadly similar trends. Mortality rates for each code for stroke – ischaemic, haemorrhagic and ‘unspecified’ – and for stroke overall fell at a broadly similar rate between 1979–1992. Thereafter, trends diverged. The average annual rate for mortality in men from ischaemic stroke in 2001–2011, at 72.7 per million, was 11% lower than that in 1993–2000 at 84.2. The corresponding rates for haemorrhagic stroke were 93.6 and 92.7, i.e. they did not fall at all. By contrast, the average annual rate for stroke ‘unspecified’ in men was 355.9 in 2001–11 which was 56% lower than the rate of 600.8 in 1993–2000. Stroke mortality, overall, fell from 768.1 to 504.5 between 1993–2000 and 2001–2011. In recent years, when national multiple-cause coding data were available, national trends were similar to those in Oxford in these respects. Rates for women will also be shown (they exhibited the same pattern). Conclusion There have been substantial changes in certification practice with a shift in recent years away from specifying stroke type. Studies of trends in mortality from ischaemic stroke alone, or haemorrhagic stroke alone, without being put into the broader context of all stroke, would be seriously misleading. They would suggest a levelling off of the decline in ischaemic and haemorrhagic stroke mortality in recent years which is, in fact, an artefact of certification and coding practice.