Scientific
publications

OBJECTIVES: We compared incidence of dementia diagnosis by white, black, and Asian ethnic groups and estimated the proportion of UK white and black people developing dementia in 2015 who had a diagnosis for the first time in a UK-wide study. METHODS: We analyzed primary care electronic health records from The Health Improvement Network database between 2007 and 2015 and compared incidence of dementia diagnosis to dementia incidence from community cohort studies. The study sample comprised of 2,511,681 individuals aged 50-105 years who did not have a dementia diagnosis prior to the start of follow-up. RESULTS: A total of 66,083 individuals had a dementia diagnosis (4.87/1,000 person-years at risk, 95% CI 4.83-4.90); this incidence increased from 3.75 to 5.65/1,000 person-years at risk between 2007 and 2015. Compared with white women, the incidence of dementia diagnosis was 18% lower among Asian women (adjusted incidence rate ratio (IRR) 0.82, 95% CI 0.72-0.95) and 25% higher among black women (IRR 1.25, 95% CI 1.07-1.46). For men, incidence of dementia diagnosis was 28% higher in the black ethnic group (IRR 1.28, 95% CI 1.08-1.50) and 12% lower in the Asian ethnic group (IRR 0.88, 95% CI 0.76-1.01) relative to the white ethnic group. Based on diagnosis incidence in The Health Improvement Network data and projections of incidence from community cohort studies, we estimated that 42% of black men developing dementia in 2015 were diagnosed compared with 53% of white men. CONCLUSION: People from the black ethnic group had a higher incidence of dementia diagnosis and those from the Asian ethnic group had lower incidence compared with the white ethnic group. We estimated that black men developing dementia were less likely than white men to have a diagnosis of dementia, indicating that the increased risk of dementia diagnosis reported in the black ethnic group might underestimate the higher risk of dementia in this group. It is unclear whether the lower incidence of dementia diagnosis in the Asian ethnic group reflects lower community incidence or underdiagnosis. A cohort study to determine this is needed.

The risk of infection among patients with psoriasis of varying severity in a broadly representative population remains poorly understood. Using The Health Improvement Network (THIN), an electronic medical records database representative of the general UK population, we performed a cohort study to determine the risks of serious infection, opportunistic infection, and herpes zoster among patients with versus without psoriasis and according to psoriasis severity. We identified 187,258 patients with mild and 12,442 patients with moderate to severe psoriasis based on treatment patterns. Using Cox proportional hazards regression, the adjusted hazard ratios (95% confidence intervals) for serious infection were 1.18 (1.16-1.21) and 1.63 (1.52-1.75) for the mild and moderate to severe psoriasis groups, respectively. Among a nested cohort of 8,569 psoriasis patients with disease severity classified by body surface area involvement, similar results were obtained with the exception of an attenuated but significantly increased risk of serious infection among the moderate to severe psoriasis group (1.27 [1.10-1.47]). Overall, the risks of opportunistic infection and herpes zoster were significantly increased only among the moderate to severe psoriasis group and were associated with immunosuppressive therapy. Our analyses suggest that psoriasis is associated with an increased risk of serious infection, and psoriasis severity is a predictor of serious infection risk.

OBJECTIVES: Spondyloarthritis (SpA) is associated with an increased risk of myocardial infarction (MI) due to underlying inflammation and possibly due to medications such as certain non-steroidal anti-inflammatory drugs (NSAIDs). We sought to describe MI risk among patients with SpA who were prescribed NSAIDs, and to compare the pattern of risk in SpA with that in osteoarthritis (OA). METHODS: Nested case-control studies were performed using The Health Improvement Network (THIN). Underlying cohorts included adults with incident SpA or OA who had 1 NSAID prescription and no history of MI. Within each cohort, we matched each MI case to four controls without MI. NSAID use was categorised as: (a) current (prescription date 0-180 days prior to index date), (b) recent (181-365 days) or (c) remote (>365 days). We performed conditional logistic regression to compare the odds of current or recent NSAID use relative to remote use of any NSAID, considering diclofenac and naproxen specifically. RESULTS: Within the SpA cohort of 8140 and the OA cohort of 244 339, there were 115 and 6287 MI cases, respectively. After adjustment, current diclofenac use in SpA was associated with an OR of 3.32 (95% CI 1.57 to 7.03) for MI. Naproxen was not associated with any increase (adjusted OR 1.19, 95% CI 0.53 to 2.68). A ratio of ORs for SpA/diclofenac relative to OA/diclofenac was 2.64 (95% CI 1.24 to 5.58). CONCLUSIONS: MI risk in SpA is increased among current users of diclofenac, but not naproxen. The MI risk with diclofenac in SpA appears to differ from that in OA.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease worldwide. It affects an estimated 20% of the general population, based on cohort studies of varying size and heterogeneous selection. However, the prevalence and incidence of recorded NAFLD diagnoses in unselected real-world health-care records is unknown. We harmonised health records from four major European territories and assessed age- and sex-specific point prevalence and incidence of NAFLD over the past decade. METHODS: Data were extracted from The Health Improvement Network (UK), Health Search Database (Italy), Information System for Research in Primary Care (Spain) and Integrated Primary Care Information (Netherlands). Each database uses a different coding system. Prevalence and incidence estimates were pooled across databases by random-effects meta-analysis after a log-transformation. RESULTS: Data were available for 17,669,973 adults, of which 176,114 had a recorded diagnosis of NAFLD. Pooled prevalence trebled from 0.60% in 2007 (95% confidence interval: 0.41-0.79) to 1.85% (0.91-2.79) in 2014. Incidence doubled from 1.32 (0.83-1.82) to 2.35 (1.29-3.40) per 1000 person-years. The FIB-4 non-invasive estimate of liver fibrosis could be calculated in 40.6% of patients, of whom 29.6-35.7% had indeterminate or high-risk scores. CONCLUSIONS: In the largest primary-care record study of its kind to date, rates of recorded NAFLD are much lower than expected suggesting under-diagnosis and under-recording. Despite this, we have identified rising incidence and prevalence of the diagnosis. Improved recognition of NAFLD may identify people who will benefit from risk factor modification or emerging therapies to prevent progression to cardiometabolic and hepatic complications.

PURPOSE: Our goal was to describe the management of pregestational diabetes in pregnant women in the United Kingdom. METHODS: We used electronic medical records from The Health Improvement Network database between January 1995 and June 2012 to identify the first pregnancy in women 15 to 45 years of age with pregestational diabetes type 1 or type 2. Information on lifestyle factors, demographic characteristics, prescription of specific antidiabetic medications, and glycemic control measures (HbA1c) was obtained from primary care provider records. We evaluated treatment patterns and HbA1c levels within 90 days before the last menstrual period (prepregnancy period) and within each trimester of pregnancy. RESULTS: In a cohort of 1511 pregnant women with pregestational diabetes, 60% had type 1 and 40% type 2 diabetes. Among women with type 1 diabetes, 90% received antidiabetic medication (primarily insulin) prepregnancy and 92% during the first trimester. Among women with type 2 diabetes, 54% received antidiabetic medication (primarily metformin) during the prepregnancy period and 60% during the first trimester. Among women with nontreated diabetes type 2 before pregnancy, 22% initiated treatment by the first trimester (primarily insulin); those on noninsulin antidiabetic medications often switched to insulin. The proportion of women with at least 1 HbA1c value recorded within the prepregnancy period was 33% for type 1 (n = 299) and 31% for type 2 diabetes (n = 189); the corresponding proportions within the first trimester were 48% and 40%, respectively. Among women with recorded HbA1c, the prevalence of HbA1c > 7% prepregnancy was 70% for type 1 and 52% for type 2 diabetes; the proportions within the first trimester were 73% and 46%, respectively. CONCLUSIONS: Management of pregnant women with diabetes seems to follow recommendations for pharmacological treatment. However, there is substantial room for improvement in HbA1c control, that is, in the planning of pregnancy in women with diabetes, in the initiation of antidiabetic medication among women with diabetes type 2 who may need it, and likely in the compliance with treatments in women with type 2 and type 1 diabetes.