Hypertension and cardiovascular risk factor management in a multi-ethnic cohort of adults with CKD: a cross sectional study in general practice

Background: Hypertension, especially if poorly controlled, is a key determinant of chronic kidney disease (CKD) development and progression to end stage renal disease (ESRD). Aim: To assess hypertension and risk factor management, and determinants of systolic blood pressure control in individuals with CKD and hypertension. Design and setting: Cross-sectional survey using primary care electronic health records from 47/49 general practice clinics in South London. Methods: Known effective interventions, management of hypertension and cardiovascular disease (CVD) risk in patients with CKD Stages 3–5 were investigated. Multivariable logistic regression analysis examined the association of demographic factors, comorbidities, deprivation, and CKD coding, with systolic blood pressure control status as outcome. Individuals with diabetes were excluded. Results: Adults with CKD Stages 3–5 and hypertension represented 4131/286,162 (1.4%) of the total population; 1984 (48%) of these individuals had undiagnosed CKD without a recorded CKD clinical code. Hypertension was undiagnosed in 25% of the total Lambeth population, and in patients with CKD without diagnosed hypertension, 23.0% had systolic blood pressure > 140 mmHg compared with 39.8% hypertensives, p < 0.001. Multivariable logistic regression revealed that factors associated with improved systolic blood pressure control in CKD included diastolic blood pressure control, serious mental illness, history of cardiovascular co-morbidities, CKD diagnostic coding, and age < 60 years. African ethnicity and obesity were associated with poorer systolic blood pressure control. Conclusion: We found both underdiagnosed CKD and underdiagnosed hypertension in patients with CKD. The poor systolic blood pressure control in older age groups ≥ 60 years and in Black African or obese individuals is clinically important as these groups are at increased risk of mortality for cardiovascular diseases

The influence of bag2 and chain intrafusal muscle fibres on secondary spindle afferents in the cat

Static γ-motor activity is strongly modulated by a particular phase relationship to the cyclic movements of locomotion, and this has a profound effect on the firing patterns of muscle spindle afferents. Whilst primary afferents are affected by both static and dynamic γ-motor output, secondary afferents are affected significantly only by the static system acting via the intrafusal bag2 and chain fibres. It is therefore important to know how fluctuating patterns of static γ-motor activity affect secondary afferents and to relate this to the actions of bag2 and chain fibres. We have studied the action of single static γ axons on secondary afferents in cat hindlimb muscles. Various physiological methods were explored to identify which of the intrafusal muscle fibres were being activated in each case, including the use of random stimulation and ramp frequency stimulation. The effects were also recorded of 1 Hz sinusoidally frequency-modulated γ-axon stimuli and the amplitude and phase of the resulting afferent modulation related to the involvement of the bag2 and chain fibres. It was found that bag2 fibres are effective in biasing the secondary discharge, but their modulating action is relatively weak and involves a marked phase lag. Chain fibres acting alone cause strong modulation with very little phase lag. Mixed bag2 and chain-fibre action is most effective in modulating afferent discharge and causes intermediate values of phase lag. The results are discussed in relation to the control of natural movements and it is concluded that an important function of the static γ motor system is to provide a signal to sum algebraically with the length-related signal. The results do not suggest that it could also usefully control stretch sensitivity

Proportion of young people in the general population consulting general practitioners: Potential for mental health screening and prevention

Aim: One of the main obstacles with prevention in psychiatry is low detection of young subjects at risk for psychosis. The aim of the present work is to test whether general practitioners' (GP) offices are a possible setting for prevention of mental illness. Methods: We used an Electronic Health Record database (Datanet) representing South-London (Lambeth), where frequency of GP visits were available for each registered subject. Results: We show that in 2018 out of almost 175 000 subjects aged 12 to 35, almost six out of ten people were seen by their General practitioner at least once in 2018, and considering those subjects with at least one medical condition, around nine subjects out of ten did the same. Conclusions: A high proportion of adolescents and young adults are seen by GPs at least once per year. GP offices should be tested as possible setting for detection of subjects at risk for mental illness, in particular in subjects with risk factors for mental illness

Does COPD risk vary by ethnicity? A retrospective cross-sectional study

Alexander Gilkes, Mark Ashworth, Peter Schofield, Timothy H Harries, Stevo Durbaba, Charlotte Weston, Patrick White Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, Kings College London, London, UK Background: Lower risk of COPD has been reported in black and Asian people, raising questions of poorer recognition or reduced susceptibility. We assessed prevalence and severity of COPD in ethnic groups, controlling for smoking. Method: A retrospective cross-sectional study using routinely collected primary care data in London. COPD prevalence, severity (% predicted forced expiratory volume in 1 second [FEV1]), smoking status, and treatment were compared between ethnic groups, adjusting for age, sex, smoking, deprivation, and practice clustering. Results: Among 358,614 patients in 47 general practices, 47.6% were white, 20% black, and 5% Asian. Prevalence of COPD was 1.01% overall, 1.55% in whites, 0.58% in blacks, and 0.78% in Asians. COPD was less likely in blacks (adjusted odds ratio [OR], 0.44; 95% confidence interval [CI] 0.39&ndash;0.51) and Asians (0.82; CI, 0.68&ndash;0.98) than whites. Black COPD patients were less likely to be current smokers (OR, 0.56; CI, 0.44&ndash;0.71) and more likely to be never-smokers (OR, 4.9; CI, 3.4&ndash;7.1). Treatment of patients with similar disease severity was similar irrespective of ethnic origin, except that long-acting muscarinic antagonists were prescribed less in black COPD patients (OR, 0.53; CI, 0.42&ndash;0.68). Black ethnicity was a predictor of poorer lung function (% predicted FEV1: B coefficient, -7.6; P&lt;0.0001), an effect not seen when ethnic-specific predicted FEV1 values were used. Conclusion: Black people in London were half as likely as whites to have COPD after adjusting for lower smoking rates in blacks. It seems likely that the differences observed were due either to ethnic differences in the way cigarettes were smoked or to ethnic differences in susceptibility to COPD. Keywords: COPD, smoking, ethnicit

Distinctive patterns of static and dynamic gamma motor activity during locomotion in the decerebrate cat

Simultaneous recordings were made from gamma (γ) motor axons and from muscle spindle afferents of the medial gastrocnemius (MG) muscle during locomotion in decerebrate cats. The γ-neurons were identified as static or dynamic (γs or γd) by correlating their behaviour during midbrain stimulation with changes in muscle spindle afferent responses to muscle stretch.On the basis of their behaviour during locomotion, γs neurons could be divided into two groups. One group (type-1) showed strongly and smoothly modulated discharge increasing in parallel with the active muscle shortening in ankle extension, but with phase advance. The other group (type-2) also showed a modulated pattern, but with increased firing centred on the flexion phase. The proportions of the two were 13 type-1 and 7 type-2.The type-1 firing pattern accurately predicted the difference in firing frequency for secondary afferents obtained by subtracting from the recordings made during active movements the response of the same units to the movements repeated passively in the absence of fusimotor activity.The type-2 pattern also became consistent with the difference signal, when operated on by a phase lag appropriate to the effects of bag2 intrafusal fibres. These results suggest that there may be some degree of separate control of chain and bag2 intrafusal fibres.The discharge of γd axons was also found to fluctuate with the locomotor cycle, with a pattern very distinct from that of the γs records. The γd firing frequency rose very suddenly from zero to a maximum at the onset of muscle shortening and continued into the beginning of lengthening. The term ‘interrupted’ discharge is suggested as a useful description. The timing of this discharge was shown to be appropriate for sensitising the primary afferents to detect the onset of stretch

Early diagnostic suggestions improve accuracy of family physicians:a randomized controlled trial in Greece

BACKGROUND: In a recent randomized controlled trial, providing UK family physicians with 'early support' (possible diagnoses to consider before any information gathering) was associated with diagnosing hypothetical patients on computer more accurately than control. Another group of physicians, who gathered information, gave a diagnosis, and subsequently received a list of possible diagnoses to consider ('late support'), were no more accurate than control, despite being able to change their initial diagnoses. OBJECTIVE: To replicate the UK study findings in another country with a different primary health care system. METHODS: All study materials were translated into Greek. Greek family physicians were randomly allocated to one of three groups: control, early support and late support. Participants saw nine scenarios in random order. After reading some information about the patient and the reason for encounter, they requested more information to diagnose. The main outcome measure was diagnostic accuracy. RESULTS: One hundred fifty Greek family physicians participated. The early support group was more accurate than control [odds ratio (OR): 1.67 (1.21-2.31)]. Like their UK counterparts, physicians in the late support group rarely changed their initial diagnoses after receiving support. The pooled OR for the early support versus control comparison from the meta-analysis of the UK and Greek data was 1.40 (1.13-1.67). CONCLUSION: Using the same methodology with a different sample of family physicians in a different country, we found that suggesting diagnoses to consider before physicians start gathering information was associated with more accurate diagnoses. This constitutes further supportive evidence of a generalizable effect of early support

Determinants of lipid clinic referral and attendance in a multi-ethnic adult population in south London:a cross-sectional study

BACKGROUND: Primary dyslipidaemias, including familial hypercholesterolaemia, are underdiagnosed genetic disorders that substantially increase risk for premature coronary artery disease in adults. Early identification of primary dyslipidaemias via lipid clinic referral optimises patient management and enables cascade screening of relatives. Improving the identification of primary dyslipidaemias, and understanding disparities in ascertainment and management, is an NHS priority. We aimed to assess determinants of lipid clinic referral or attendance (LCR) in ethnically diverse adults. METHODS: We did a retrospective cross-sectional study using the Lambeth DataNet containing anonymised data from 41 general practitioner (GP) practices in south London. We looked at referral data for adult patients aged 18 years and older from Jan 1, 1995, until May 14, 2018. LCR was the main outcome. We used sequential multilevel logistic regression models adjusted for practice effects to estimate the odds of LCR assessed across six ethnic groups (reference group White) and patient-level factors (demographic, socioeconomic, lifestyle, comorbidities, total cholesterol [TC] &gt;7·5mmol/L, statin prescription, and practice factors). The study was approved by NHS South East London Clinical Commissioning Group (CCG) and NHS Lambeth CCG. FINDINGS: 780 (0·23%) of 332 357 adult patients were coded as referred (n=538) or seen (n=252) in a lipid clinic. 164 487 (46·49%) were women (appendix). The fully adjusted model for odds of LCR showed the following significant associations for age (odds ratio [OR] 0·96, 95% CI 0·96-0·97, p&lt;0·001); Black, African, Caribbean, or Black-British ethnicity (0·67, 0·53-0·84, p=0·001); ex-smoker status (1·29, 1·05-1·57, p=0·014); TC higher than 7·5 mmol/L (12·18, 9·60-15·45, p&lt;0·001); statin prescription (14·01, 10·85-18·10, p&lt;0·001); diabetes (0·72, 0·58-0·91, p=0·005); high-frequency GP attendance at seven or more GP consultations in the past year (1·49, 1·21-1·84, p&lt;0·001); high GP-density (0·5-0·99 full-time equivalent GPs per 1000 patients; 2·70, 1·23-5·92, p=0·013). Sensitivity analyses for LCR restricted to familial hypercholesterolaemia-coded patients (n=581) found associations with TC higher than 7·5 mmol/L (4·26, 1·89-9·62, p&lt;0·001), statin prescription (16·96, 2·19-131·36, p=0·007), and high GP-density (5·73, 1·27-25·93, p=0·023), with no significant associations with ethnicity. The relative contribution of GP practices to LCR was 6·32% of the total variance. There were no significant interactions between ethnicity and deprivation, age, or obesity. INTERPRETATION: While interpretation is limited by the accuracy and completeness of coded records, the study showed factors associated with a higher likelihood of LCR included individuals recorded as having TC higher than 7·5 mmol/L, statin prescription, ex-smoker status, high-frequency GP attendance, and registration at a GP practice with 0·5-0·99 GP density. Patients with increasing age; Black, African, Caribbean, or Black-British ethnicity patients; and patients with diabetes had lower odds of LCR. Finally, the difference in odds of LCR between Black and White patients highlights potential health inequalities. FUNDING: NHS Race &amp; Health Observatory.</p