Ross Lawrenson

High Risk of Cardiovascular Disease in Patients With Type 1 Diabetes in the U.K. A cohort study using the General Practice Research Database

OBJECTIVEnTo estimate the absolute and relative risk of cardiovascular disease (CVD) in patients with type 1 diabetes in the U.K.nnnRESEARCH DESIGN AND METHODSnSubjects with type 1 diabetes (n = 7,479) and five age- and sex-matched subjects without diabetes (n = 38,116) and free of CVD at baseline were selected from the General Practice Research Database (GPRD), a large primary care database representative of the U.K. population. Incident major CVD events, comprising myocardial infarction, acute coronary heart disease death, coronary revascularizations, or stroke, were captured for the period 1992-1999.nnnRESULTSnThe hazard ratio (HR) for major CVD was 3.6 (95% CI 2.9-4.5) in type 1 diabetic men compared with those without diabetes and 7.7 (5.5-10.7) in women. Increased HRs were found for acute coronary events (3.0 and 7.6 in type 1 diabetic men and women, respectively, versus nondiabetic subjects), coronary revascularizations (5.0 in men, 16.8 in women), and for stroke (3.7 in men, 4.8 in women). Type 1 diabetic men aged 45-55 years had an absolute CVD risk similar to that of men in the general population 10-15 years older, with an even greater difference in women.nnnCONCLUSIONSnDespite advances in care, these data show that absolute and relative risks of CVD remain extremely high in patients with type 1 diabetes. Women with type 1 diabetes continue to experience greater relative risks of CVD than men compared with those without diabetes.

Risk of stroke in people with type 2 diabetes in the UK: a study using the General Practice Research Database

Aims/hypothesisRisk estimates for stroke in patients with diabetes vary. We sought to obtain reliable risk estimates for stroke and the association with diabetes, comorbidity and lifestyle in a large cohort of type 2 diabetic patients in the UK.Materials and methodsUsing the General Practice Research Database, we identified all patients who had type 2 diabetes and were aged 35 to 89xa0years on 1 January 1992. We also identified five comparison subjects without diabetes and of the same age and sex. Hazard ratios (HRs) for stroke between January 1992 and October 1999 were calculated, and the association with age, sex, body mass index, smoking, hypertension, atrial fibrillation and duration of diabetes was investigated.ResultsThe absolute rate of stroke was 11.91 per 1,000 person-years (95% CI 11.41–12.43) in people with diabetes (nu2009=u200941,799) and 5.55 per 1,000 person-years (95% CI 5.40–5.70) in the comparison group (nu2009=u2009202,733). The age-adjusted HR for stroke in type 2 diabetic compared with non-diabetic subjects was 2.19 (95% CI 2.09–2.32) overall, 2.08 (95% CI 1.94–2.24) in men and 2.32 (95% CI 2.16–2.49) in women. The increase in risk attributable to diabetes was highest among young women (HR 8.18; 95% CI 4.31–15.51) and decreased with age. No investigated comorbidity or lifestyle characteristic emerged as a major contributor to risk of stroke.Conclusions/interpretationThis study provides risk estimates for stroke for an unselected population from UK general practice. Patients with type 2 diabetes were at an increased risk of stroke, which decreased with age and was higher in women. Additional risk factors for stroke in type 2 diabetic patients included duration of diabetes, smoking, obesity, atrial fibrillation and hypertension.

High Risk of Cardiovascular Disease in Patients With Type 1 Diabetes in the U.K.

OBJECTIVEnTo estimate the absolute and relative risk of cardiovascular disease (CVD) in patients with type 1 diabetes in the U.K.nnnRESEARCH DESIGN AND METHODSnSubjects with type 1 diabetes (n = 7,479) and five age- and sex-matched subjects without diabetes (n = 38,116) and free of CVD at baseline were selected from the General Practice Research Database (GPRD), a large primary care database representative of the U.K. population. Incident major CVD events, comprising myocardial infarction, acute coronary heart disease death, coronary revascularizations, or stroke, were captured for the period 1992-1999.nnnRESULTSnThe hazard ratio (HR) for major CVD was 3.6 (95% CI 2.9-4.5) in type 1 diabetic men compared with those without diabetes and 7.7 (5.5-10.7) in women. Increased HRs were found for acute coronary events (3.0 and 7.6 in type 1 diabetic men and women, respectively, versus nondiabetic subjects), coronary revascularizations (5.0 in men, 16.8 in women), and for stroke (3.7 in men, 4.8 in women). Type 1 diabetic men aged 45-55 years had an absolute CVD risk similar to that of men in the general population 10-15 years older, with an even greater difference in women.nnnCONCLUSIONSnDespite advances in care, these data show that absolute and relative risks of CVD remain extremely high in patients with type 1 diabetes. Women with type 1 diabetes continue to experience greater relative risks of CVD than men compared with those without diabetes.

Risk of myocardial infarction in men and women with type 2 diabetes in the UK: a cohort study using the General Practice Research Database

Aims/hypothesisOur primary aim was to establish reliable and generalisable estimates of the risk of myocardial infarction (MI) for men and women with type 2 diabetes in the UK compared with people without diabetes. Our secondary aim was to investigate how the MI risk associated with diabetes differs between men and women.MethodsA cohort study using the General Practice Research Database (1992–1999) was carried out, selecting 40,727 patients with type 2 diabetes and 194,913 age and sex-matched patients without diabetes. Rates of MI in men and women with and without diabetes were derived, as were hazard ratios for MI adjusted for known risk factors.ResultsThe rate of MI in men with type 2 diabetes was 19.74 (95% CI 18.83–20.69) per 1,000 person-years compared with 16.18 (95% CI 15.33–17.08) per 1,000 person-years in women with type 2 diabetes. The overall adjusted relative risk of MI in diabetes versus no diabetes was 2.13 (95% CI 2.01–2.26) in men and 2.95 (95% CI 2.75–3.17) in women and decreased with age in both sexes. Women with type 2 diabetes aged 35 to 54xa0years were at almost five times the risk of MI compared with women of the same age without diabetes (HR 4.86 [95% CI 2.78–8.51]).Conclusions/interpretationThis study has demonstrated that women with type 2 diabetes are at a much greater relative risk of MI than men even when adjusted for risk factors.

Ethnic differences in the natural progression of nephropathy among diabetes patients in New Zealand: hospital admission rate for renal complications, and incidence of end-stage renal disease and renal death

Aims/hypothesisWe estimated the incidence of chronic renal failure, the incidence of end-stage renal disease (ESRD) and renal mortality rates among New Zealand European and Maori patients with diabetes and estimated the ethnic difference in the risk of developing renal failure.MethodsA renal complication-free cohort of adult diabetes patients registered with Waikato regional diabetes service, diagnosed with diabetes before 2003, were retrospectively followed for 4xa0years. Events of interest were renal hospital admission, ESRD and death coded with renal disease. Incidences of renal hospital admission, ESRD and death from renal disease were calculated for NZ Europeans and Maori patients with diabetes. Ethnic and sex differences in the risks of these renal outcomes were estimated using a Cox proportional hazards model.ResultsOf the 7,900 patients followed up, 116 (1.5%) had a renal admission, 42 (0.5%) started dialysis/transplantation and 21 (0.27%) died from renal disease. Maori diabetes patients had significantly higher incidences of dialysis or transplantation and rates of renal admission and renal death. Adjusted hazard ratios indicate that, compared with NZ Europeans with diabetes, Maori diabetes patients had a significantly higher risk of ESRD, renal admission and renal death (46-fold, seven-fold and four-fold increases, respectively). Maori patients progressed at a significantly faster rate from first hospital admission for chronic renal disease to ESRD.Conclusions/interpretationThere were huge ethnic disparities in outcomes from renal disease. Screening for early kidney disease among Maori diabetes patients, intensive management of risk factors and further research on the aetiology of renal disease among Maoris is recommended.

Use of hormonal contraceptive methods by women with diabetes

BACKGROUND AND METHODOLOGYnThis study sought to establish use of hormonal contraception in UK women aged between 15 and 44 years with type 1 or type 2 diabetes compared with comparison groups with no diabetes. A cross sectional study design was used to compare 947 cases of type 1 diabetes and 365 cases of type 2 diabetes with comparison groups matched for age. Subjects were selected from the General Practice Research Database (GPRD).nnnRESULTSnWomen with diabetes were less likely to use hormonal contraception than women without diabetes--type 1 RR 0.83 (95% CI 0.59-0.93), type 2 RR 0.60 (95% CI 0.42-0.83). Women with type 1 diabetes were more likely to be prescribed a combined pill than a progestogen only pill (POP), but were significantly more likely to be prescribed the POP than were women without diabetes RR 1.65 (95% CI 1.26-2.13). Women with type 2 diabetes were less likely to be prescribed a combined oral contraceptive RR 0.39 (95% CI 0.24-0.62). The injectable contraceptive Depo Provera was significantly more likely to be given to women with diabetes than the comparison group--type 1 RR 1.56 (95% CI 1.12-2.11), type 2 RR 3.57 (95% CI 2.15-5.60).nnnDISCUSSION AND CONCLUSIONSnThe study highlighted significant variation in prescribing of hormonal contraception to women with type 1 and type 2 diabetes in comparison to those without diabetes. It is now recognised that hormonal contraception is a safe and effective option for women with uncomplicated diabetes. Possibly there are significant numbers of young women with poorly controlled diabetes or other risk factors for cardiovascular disease that have influenced clinicians in avoiding the use of hormonal contraception. Paradoxically it is these women who are at most risk from unplanned pregnancy.

Use of mobile phone cameras for after-hours triage in primary care.

Mobile phone images might be useful in after-hours triage of primary care. We conducted a study to identify population access to mobile phone cameras and to assess the clinical usefulness of mobile phone cameras. The survey was conducted among 480 patients attending two rural New Zealand practices. There were significantly more Maori owners compared to non-Maori (P = 0.002). Age was a significant factor influencing the ownership of mobile phones. We also conducted a clinical quiz among health professionals to assess how the provision of images on a mobile phone and on CD-ROM (to simulate the image that would be seen if email was used to transmit the images) influenced diagnostic confidence. Ten photographable clinical conditions were used to quiz 30 health professionals who were randomized into three groups of 10 each on diagnostic confidence. Images were found to significantly increase diagnostic confidence in all cases except one. It appears that mobile phone cameras are generally acceptable to patients and likely to be of practical use to rural practitioners in a range of clinical scenarios.

Epidemiology of thyroid disease in Hamilton (New Zealand) general practice

Objective: To retrospectively review health records in two general practices in Hamilton, New Zealand (NZ) linking three data sources to estimate the prevalence of diagnosed thyroid dysfunction (TD).

High risk of cardiovascular disease in patients with type 1 diabetes mellitus in the UK, a cohort study using the General Practice Research Database

OBJECTIVEnTo estimate the absolute and relative risk of cardiovascular disease (CVD) in patients with type 1 diabetes in the U.K.nnnRESEARCH DESIGN AND METHODSnSubjects with type 1 diabetes (n = 7,479) and five age- and sex-matched subjects without diabetes (n = 38,116) and free of CVD at baseline were selected from the General Practice Research Database (GPRD), a large primary care database representative of the U.K. population. Incident major CVD events, comprising myocardial infarction, acute coronary heart disease death, coronary revascularizations, or stroke, were captured for the period 1992-1999.nnnRESULTSnThe hazard ratio (HR) for major CVD was 3.6 (95% CI 2.9-4.5) in type 1 diabetic men compared with those without diabetes and 7.7 (5.5-10.7) in women. Increased HRs were found for acute coronary events (3.0 and 7.6 in type 1 diabetic men and women, respectively, versus nondiabetic subjects), coronary revascularizations (5.0 in men, 16.8 in women), and for stroke (3.7 in men, 4.8 in women). Type 1 diabetic men aged 45-55 years had an absolute CVD risk similar to that of men in the general population 10-15 years older, with an even greater difference in women.nnnCONCLUSIONSnDespite advances in care, these data show that absolute and relative risks of CVD remain extremely high in patients with type 1 diabetes. Women with type 1 diabetes continue to experience greater relative risks of CVD than men compared with those without diabetes.