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Showing posts from November, 2013

Obesity paradox in people newly diagnosed with type 2 diabetes

Recent studies have raised the issue of ‘obesity paradox’ in patients with type 2 diabetes mellitus (T2DM). Sanjoy Paul and colleagues evaluated the cardiovascular and mortality risks associated with normal and overweight patients compared to obese at diagnosis of diabetes, separately for patients with and without cardiovascular disease (CVD) before diagnosis. The study was published in the journal Diabetes, Obesity and Metabolism.

They carried out a retrospective study with two study cohorts with/without prior CVD with complete measures of body mass index (BMI) at diagnosis of T2DM from UK General Practice Research Database. Primary outcomes were long-term risks of cardiovascular events (CVEs) and all-cause mortality in patients with normal weight, overweight and obesity at diagnosis.

They reported that mortality rates per 1000 person-years in normal weight, overweight and obese patients among patients without prior CVD were 13.1, 8.6 and 6.0, respectively, during 5 years of median …

Increasing the use of statins in people at low cardiovascular risk is difficult

Although statins reduce cardiovascular events even in people at low risk,[1] population benefits from their more widespread use will occur only if a sufficiently high proportion of people at lower cardiovascular risk (whether based on a formal risk assessment or on age alone) are prescribed statins.[2] Some of these issues were discussed in a commentary published in the BMJ.

Early evidence from the NHS Health Check programme suggests that it will be difficult to achieve high statin uptake in people at low cardiovascular risk. NHS Health Check is a population-wide primary prevention programme that was established in England by the Department of Health in 2009.[3] The programme represents a major investment in the prevention and early detection of cardiovascular disease.

In early results from the programme, prescription of statins in people at high cardiovascular risk (≥20%) increased from around 25% to only 45%.[4] The prescription of statins is likely to be substantially lower than 4…

Deprivation, risk of emergency readmission and inpatient mortality in people with sickle cell disease

Sickle cell disease (SCD) is a frequent cause of emergency readmissions. In a paper published in the Journal of Public Health, Ghida Aljuburi and colleages examined trends in SCD emergency readmissions and inpatient mortality in England in relation to socio-economic status.

Data from Hospital Episode Statistics were extracted for all SCD patients admitted in 2005/06. The financial year 2005/06 was taken as the index year for analysis. We calculated readmission rates and inpatient mortality for patients admitted with a primary or secondary diagnosis of sickle cell anaemia with crisis and without crisis in the index year during the subsequent 5 years (2006/07–2010/11). Charlson Score was used to measure comorbidity. Using Cox proportional hazards models, we also examined the relationship between patient characteristics and both emergency readmissions and inpatient mortality.

In 2005/06, there were 7679 SCD index admissions. Over the subsequent 5-year period, patients living in the most…

Ethnicity and prediction of cardiovascular disease

Risk prediction is one of the key strategies for the prevention of cardiovascular disease (CVD). Two of the main CVD risk calculators in use in the United Kingdom are QRISK2 and Framingham. In a paper published in Heart, the SABRE Study Group evaluated the performance of the QRISK2 and Framingham scores as predictors of CVD outcomes over 10 years of follow-up in European, South Asian, and African Caribbean men and women in a UK population based cohort in West London. The sample was obtained by randomly selecting from local general practices. Follow-up data were available for 87% of traced participants, comprising 1866 white Europeans, 1377 South Asians, and 578 African Caribbeans.

The outcome measures included in the study were myocardial infarction, coronary revascularisation, angina, transient ischaemic attack or stroke reported by participant, primary care or hospital records or death certificate. During follow-up, 387 CVD events occurred in men (14%) and 78 in women (8%). Both QRI…

Unscheduled care in the UK and USA

In a publication in the Annals of Internal Medicine, Thomas Cowling and colleagues describe how discussion of acute unscheduled care in the United States resembles the debate on the same topic in England, where the National Health Service is conducting a comprehensive review of unscheduled care services.

In England, general practices staffed by primary care physicians and hospital emergency departments (EDs) form the 2 “silos of acute care delivery”. Approximately 9% of patients who try but are unable to obtain a convenient appointment at their general practice office subsequently visit an emergency department. Consequently, recent national policies have attempted to improve access to general practice, using financial incentives to reduce demand for acute unscheduled care at emergency departments.

A potential unintended consequence of expanding alternative care settings is that the “question of where patients with acute care needs should go for unscheduled care” becomes more confusin…