Vincent Connolly

Diabetes prevalence and socioeconomic status: a population based study showing increased prevalence of type 2 diabetes mellitus in deprived areas

OBJECTIVE To establish the relation between socioeconomic status and the age-sex specific prevalence of type 1 and type 2 diabetes mellitus. The hypothesis was that prevalence of type 2 diabetes would be inversely related to socioeconomic status but there would be no association with the prevalence of type 1 diabetes and socioeconomic status. SETTING Middlesbrough and East Cleveland, United Kingdom, district population 287 157. PATIENTS 4313 persons with diabetes identified from primary care and hospital records. RESULTS The overall age adjusted prevalence was 15.60 per 1000 population. There was a significant trend between the prevalence of type 2 diabetes and quintile of deprivation score in men and women (χ2 for linear trend, p<0.001). In men the prevalence in the least deprived quintile was 13.4 per 1000 (95% confidence intervals (95% CI) 11.44, 15.36) compared with 17.22 per 1000 (95% CI 15.51, 18.92) in the most deprived. For women the prevalence was 10.84 per 1000 (95% CI 9.00, 12.69) compared with 15.48 per 1000 (95% CI 13.84, 17.11) in the most deprived. The increased prevalence of diabetes in the most deprived areas was accounted for by increased prevalence of type 2 diabetes in the age band 40–69 years. There was no association between the prevalence of type 1 diabetes and socioeconomic status. CONCLUSION These data confirm an inverse association between socioeconomic status and the prevalence of type 2 diabetes in the middle years of life. This finding suggests that exposure to factors that are implicated in the causation of diabetes is more common in deprived areas.

Excess mortality in a population with diabetes and the impact of material deprivation: longitudinal, population based study

Abstract Objectives: To establish the age and sex specific mortality for people with diabetes in comparison with local and national background populations; to investigate the relationship between mortality and material deprivation in an unselected population with diabetes. Design: Longitudinal study, using a population based district diabetes register. Setting: South Tees, United Kingdom. Participants: All people known to have diabetes living in Middlesbrough and Redcar and Cleveland local authorities on 1 January 1994. Main outcome measure: Death, from any cause, between 1 January 1994 and 31 December 1999. Results: Over the six years of the study 1205 (24.9%) of 4842 participants died. All cause standardised mortality ratios for type 1 diabetes were 641 (95% confidence interval 406 to 962) in women and 294 (200 to 418) in men, and those for type 2 diabetes were 160 (147 to 174) in women and 141 (130 to 152) in men. Cause specific standardised mortality ratios were increased for ischaemic heart disease, cerebrovascular disease, and renal disease; no reductions in mortality from other causes were seen. The risk of premature death increased significantly with increasing material deprivation (P<0.001). Conclusions: Diabetes is associated with excess mortality, even in an area with high background death rates from cardiovascular disease. This excess mortality is evident in all age groups, most pronounced in young people with type 1 diabetes, and exacerbated by material deprivation. Aggressive approaches to the management of cardiovascular risk factors could reduce the excess mortality in people with diabetes. What is already known on this topic Mortality, mainly from cardiovascular disease, is increased in people with diabetes, but this excess varies considerably by country and ethnic group Previous British studies have reported no excess mortality in old age, a reduction in deaths from non-cardiovascular causes, and that mortality may be adversely affected by deprivation What this study adds Mortality is increased, across all ages, in an unselected population with diabetes compared with the local population without diabetes, which itself has high mortality Most of the excess is from cardiovascular causes, but there are no reductions in other causes of death Mortality among people with diabetes is increased even in the most affluent group, and this excess increases with worsening material deprivation

Pituitary Apoplexy: A Review of Clinical Presentation, Management and Outcome in 45 Cases

Objective: To review clinical presentation, management and outcomes following different therapies in patients with pituitary apoplexy. Methods: Retrospective analysis of case-records of patients with classical pituitary apoplexy treated in our hospitals between 1983–2004. Results: Forty-five patients (28 men; mean age 49 years, range 16–72 years) were identified. Only 8 (18%) were known to have pituitary adenomas at presentation. Thirty-four (81%) patients had hypopituitarism at presentation. CT and MRI identified pituitary apoplexy in 28% and 91% cases, respectively. Twenty-seven (60%) patients underwent surgical decompression, whilst 18 (40%) were managed conservatively. Median time from presentation to surgery was 6 days (range 1–121 days). Patients with visual field defects were more likely than those without these signs to be managed surgically (p = 0.01). Complete or near-complete resolution occurred in 93% (13/14), 94% (15/16) and 93% (13/14) of the surgically treated patients with reduced visual acuity, visual field deficit and ocular palsy, respectively. All patients with reduced visual acuity (4/4), visual field deficit (4/4) and ocular palsy (8/8) in the conservative group had complete or near-complete recovery. Only 5 (19%) patients in the surgical group and 2 (11%) in the conservative group had normal pituitary function at follow up. One (4%) patient in the surgical group and 4 (22%) in the conservative group had a recurrence of pituitary adenoma. Conclusions: This large series suggests that the patients with classical pituitary apoplexy, who are without neuro-ophthalmic signs or exhibit mild and non-progressive signs, can be managed conservatively in the acute stage.

Diabetes- and Nondiabetes-Related Lower Extremity Amputation Incidence Before and After the Introduction of Better Organized Diabetes Foot Care: Continuous longitudinal monitoring using a standard method

OBJECTIVE—There is a lack of continuous longitudinal population-based data on lower extremity amputation (LEA) in the U.K. We present here accurate data on trends in diabetes-related (DR) LEAs and non-DRLEAs in the South Tees area over a continuous 5-year period. RESEARCH DESIGN AND METHODS—All cases of LEA from 1 July 1995 to 30 June 2000 within the area were identified. Estimated ascertainment using capture-recapture analysis approached 100% for LEAs in the area. Data were collected longitudinally using the standard method of the Global Lower Extremity Amputation Study protocol. RESULTS—Over 5 years there were 454 LEAs (66.3% men) in the South Tees area, of which 223 were diabetes related (49.1%). Among individuals with diabetes, LEA rates went from 564.3 in the first year to 176.0 of 100,000 persons with diabetes in the fifth year. Over the same period, non-DRLEAs increased from 12.3 to 22.8 of 100,000 persons without diabetes. The relative risk of a person with diabetes undergoing an LEA went from being 46 times that of a person without diabetes to 7.7 at the end of the 5 years. The biggest improvement in LEA incidence was seen in the reduction of repeat major DRLEAs. CONCLUSIONS—Our data show that in the South Tees area at a time when major non-DRLEA rates increased, major DRLEA rates have fallen. These diverging trends mark a significant improvement in care for patients with diabetic foot disease as a result of better organized diabetes care.

Statins as potential treatment for cholesterol gallstones: an attempt to understand the underlying mechanism of actions

Introduction: Statin therapy is widely used across the globe for the treatment and prevention of cardiovascular disease (CVD). It is well established that statin therapy is associated with significant decreases in low-density lipoprotein cholesterol (LDL-C) and plasma cholesterol levels. Cholesterol gallstones are a common problem, resulting in hospital admission and surgery, throughout western healthcare systems. Areas covered: This review describes the mechanisms, and addresses the potential, for statins to be used as a treatment for gallstones. Medline was searched for the risk factors and treatment of cholesterol gallstones. Expert opinion: Obesity, metabolic syndrome, non-alcoholic fatty liver disease (NAFLD), insulin resistance and high-fat diets (unsaturated fats) rich in cholesterol are all associated risk factors for cholesterol gallstones. In view of the high prevalence of cholesterol gallstones, there is an urgent need to understand whether pharmacological therapies can be harnessed for the treatment of cholesterol gallstones. Gallstones are shown to be associated with an increased risk, not only of mortality, but also of CVD. Statins, widely used in prevention of CVD and hypercholesteremia, have been shown to dissolve cholesterol gallstones in animal models and human studies, highlighting the potential for a pharmacological therapy for gallstones. More studies are required to understand the role of statins in the treatment of gallstones and for comparison with current treatment strategies.

Relationship between non-alcoholic fatty liver disease and kidney function: A communication between two organs that needs further exploration

Non-alcoholic fatty liver disease (NAFLD) is now regarded as hepatic component of the metabolic syndrome. In addition, NAFLD has emerged as a growing public health problem worldwide and an important challenge for health authorities. NAFLD is associated with insulin resistance and hyperlipidaemia and this appears as the potential pathogenic role of NAFLD in the development and progression of chronic kidney disease (CKD). Interestingly, NAFLD and CKD may share common pathogenic mechanisms like obesity, abdominal obesity, insulin resistance, hyperlipidaemia, hypertension and inflammation. Importantly, the association between NAFLD and CKD is also being shown to be independent of obesity, hypertension, and other potentially confounding features of the metabolic syndrome, and it occurs both in patients without diabetes and in those with diabetes. How the liver communicates with kidney in individuals with NAFLD is not well known and indeed an urgent research is needed to further elucidate the complex and intertwined mechanisms that link NAFLD and CKD. One potential pathway for future exploration may be inflammatory mediators in NAFLD that may lead to deterioration in renal function. In addition, large clinical studies are needed to study the impact of NAFLD on the progression of CKD and in particular during dialysis and transplant and importantly how treatment of NAFLD and weight loss will have reversible potential benefit in improving renal function.

Risk factors for diabetes in men. Risk factors are closely linked with socioeconomic status.

Risk factors are closely linked with socioeconomic status EDITOR,--The association between risk factors and diabetes described by Eric B Rimm and colleagues1 is unlikely to be simple, and both smoking and obesity are linked to socioeconomic status. Our studies on diabetic …

Ambulatory emergency care – improvement by design

ABSTRACT Ambulatory emergency care (AEC) has been developed by clinicians as a means of providing emergency care without the traditional bed base of a hospital. Given that AEC is provided in a clinic-style setting, it can continue to operate during periods of high bed occupancy, alleviating bed pressures and continuing to provide timely care for selected patients. Although different models of AEC have developed according to local context, there are common principles that apply to AEC services, including early access to senior decision-makers, opening hours matching demand, access to diagnostics, close collaboration with other clinical services, a mixed workforce and patient selection processes. Some of the key AEC developments have been related to technology, including high-sensitivity troponin, low-molecular-weight heparins and computer tomography (CT) pulmonary angiography. Risk stratification tools are useful for assessing the appropriateness of using AEC as a care model for patients.

Author's reply: statins and cholesterol gallstones: what we know, thought we knew and hope to gain

We thank the author for his comments [1]. Human studies have shown potential benefit of statins in treating cholesterol gallstones [2,3]. A summary of the mechanisms involved have been reviewed by Ahmed et al. [4]. Research to assess the impact of lipid-lowering medication on cholesterol gallstones is urgently needed due to various reasons, which include the association between cholesterol gallstones and cardiovascular disease [4]. The wide use of statins as treatment for cardiovascular disease may allow easy recruitment to studies looking at the effects of statins on cholesterol gallstones. The adverse effect of statins on insulin sensitivity and how that may modulate the formation of cholesterol gallstones is an exciting area for research [5]. It is well known that obesity and excess lithogenic diet are associated with formation of cholesterol gallstones [6]. Medication that prevents the absorption of intestinal lipid may provide an additional potential benefit in treating cholesterol gallstones. For example, the administration of ezetimibe (acts by decreasing intestinal cholesterol absorption) was associated with significant reduction in gallbladder stones in human and animal studies. Ezetimibe reduces intestinal cholesterol absorption by inhibiting the action of NiemannPick C1-like 1 (NPC1-L1), the main transporter of intestinal cholesterol which is highly expressed in the jejunum [7]. NPC1-L1 is also expressed in human liver. Administration of ezetimibe in a mouse gallstone model decreased serum cholesterol, prevented biliary crystals, normalized gallbladder wall fat and function, reduced intestinal cholesterol absorption by 35% and prevented the appearance of cholesterol crystals and gallstones [5]. Studies are needed to assess the effect of ezetimibe and the combination of statin and ezetimibe on cholesterol gallstones. The list of questions can be extended but at least finding an answer for these and the author’s [1] questions is what we hope to achieve in the near future.

Diagnostic approach to pulmonary embolism and lessons from a busy acute assessment unit in the UK

The diagnosis of pulmonary embolism (PE) can be very elusive and, if missed, may have fatal consequences. Conversely, PE can be over-diagnosed, with the concomitant risks associated with unnecessary anticoagulation. Although there are many tests that used in the diagnosis of PE, no test can exclude this condition with 100% certainty, and PE has been reported even after a negative pulmonary angiography. The diagnosis of PE depends on the interpretation of the available tests in the context of pre-test clinical probabilities. Ventilation/perfusion (V′/Q′) scan and computerised tomographic pulmonary angiography (CTPA) are the main screening tests used for patients with suspected PE. However, both V′/Q′ scan and CTPA have to be supplemented by other diagnostic modalities because of their diagnostic limitations. This article reviews the literature concerning the diagnosis of PE, with particular reference to the approach in our acute assessment unit. We conclude by describing two learning points from real cases presenting with suspected PE, in order to highlight how the diagnosis can be missed or made inaccurately.