Changes in testing for and incidence of celiac disease in the UK: a population-based cohort study

The diagnosis rates of coeliac disease differ substantially between countries. Intriguingly, there has been recent evidence from Olmstead County, USA and Finland that in the last 5-10 years incidence has plateaued or even declined. In most populations the prevalence also varies widely, serological prevalence from 0% to 1.87% and clinical prevalence from 0.9 to 12.9 per 100000. Understanding of why this variation exists is minimal, yet one of the key aspects governing incidence rates of any disease are “health system drivers”, such as the availability and use of diagnostic tests. We previously reported rising incidence rates of coeliac disease from 1990 to 2011with inequality by deprivation in the UK. Although national guidance on recognition and diagnosis of coeliac disease published in 2009 suggested widening the patient groups that should be tested for coeliac disease, NHS financial constraints could have hindered implementation of these guidelines. Indeed in the USA it has been observed that over the period 2000-2010 there was a marked decrease in treated prevalence of many diseases alongside a sustained period of reduced spending on health care

Risk of first venous thromboembolism in pregnant women in hospital: population based cohort study from England

Objective: To examine the potential for preventing venous thromboembolism during and after antepartum hospital admissions in pregnant women. Design: Cohort study using linked primary (Clinical Practice Research Datalink) and secondary (Hospital Episode statistics) care records. Setting: Primary and secondary care centres, England. Participants: 206 785 women aged 15-44 who had one or more pregnancies from 1997 up to 2010. Main outcome measure: Risk of first venous thromboembolism in pregnant women admitted to hospital for one or more days for reasons other than delivery or venous thromboembolism. Risk was assessed by calculating the absolute rate of venous thromboembolism and comparing these rates with those observed during follow-up time not associated with hospital admission using a Poisson regression model to estimate incidence rate ratios. Results: Admission to hospital in pregnancy was associated with an increased risk of venous thromboembolism(absolute rate 1752/100000 person years; incidence rate ratio 17.5, 95% confidence interval 7.69 to 40.0) compared with time outside hospital. The rate of venous thromboembolism was also high during the 28 days after discharge(absolute rate 676; 6.27, 3.74 to 10.5). The rate during and after admission combined was highest in the third trimester (961; 5.57, 3.32 to 9.34) and in those aged ≥35 years (1756; 21.7, 9.62 to 49.0). While the absolute rate in the combined period was highest for those with three or more days in hospital (1511; 12.2, 6.65 to 22.7), there was also a fourfold increase (558; 4.05, 2.23 to 7.38) in the risk of venous thromboembolism for those admitted to hospital for less than three days. Conclusion: The overall risk of first venous thromboembolism in pregnant women increased during admissions to hospital not related to delivery,and remained significantly higher in the 28 days after discharge. During these periods need for thromboprophylaxis should receive careful consideration

Rheumatic Conditions as Risk Factors for Self-Harm: A Retrospective Cohort Study

Objective To examine the risk of self-harm in rheumatological conditions Methods Retrospective cohort study using data from the Clinical Practice Research Datalink. Patients with ankylosing spondylitis, fibromyalgia, osteoarthritis or rheumatoid arthritis were identified between 1990–2016 and matched to patients without these conditions. Incident self-harm was defined by medical record codes following a rheumatological diagnosis. Incidence rates (per 10,000 person-years(PY)) were reported for each condition, both overall and year-on-year(2000-2016). Cox regression analysis determined risk (hazard ratios(HR), 95% confidence interval(CI)) of self-harm for each rheumatological cohort compared to the matched unexposed cohort. Initial crude analysis was subsequently adjusted and stratified by age and gender. Due to non-proportionality over time, osteoarthritis was also stratified by disease duration(<1 year, =1-<5 years, =5-<10 years, =10 years). Results Incidence of self-harm was highest in patients with fibromyalgia (25.12 (95%CI 22.45,28.11) per 10,000 PY) and lowest for osteoarthritis (6.48 (6.20, 6.76)). There was a crude association with each rheumatological condition and self-harm, except for ankylosing spondylitis. Though attenuated, these associations remained after adjustment for fibromyalgia (HR 2.06(95%CI 1.60,2.65)), rheumatoid arthritis (1.59(1.20,2.11)) and osteoarthritis (1-<5years: 1.12 (1.01,1.24); =5-<10 years: 1.35 (1.18,1.54)). Age and gender were weak effect modifiers for these associations. Conclusions Primary care patients with fibromyalgia, osteoarthritis or rheumatoid arthritis (but not ankylosing spondylitis) are at increased risk of self-harm compared to people without these rheumatological conditions. Clinicians need to be aware of the potential for self-harm in patients with rheumatological conditions (particularly fibromyalgia), explore mood and risk with them, and offer appropriate support and management

Glycaemic, gastrointestinal and appetite responses to breakfast porridges from ancient cereal grains: a MRI pilot study in healthy humans

Cereal grain based porridges are commonly consumed throughout the world. Whilst some data are available for varieties that are popular in the Western world such as oats and rye, other ‘ancient’ grains used in the East and in Africa such as millets are thought to have beneficial health effects, such as a suppression of post prandial hunger and circulating glucose levels. These grains, a sustainable food source due to their tolerance of extreme weather and growing conditions, are commonly found throughout Asia and Africa. However, knowledge of the physiological responses to these grain varieties is very limited. This study aimed to collect initial pilot data on the physiological and gastrointestinal responses to breakfast porridges made with two millet varieties and oats and rye grains. A total of n = 15 completed the oats and rye, n = 9 the finger millet n = 12 the pearl millet meals. MRI scans were undertaken at baseline, immediately after consumption and then hourly postprandially. Blood glucose was measured at baseline, immediately after consumption and then every 15 min until t = 80 min, then every 20 min until t = 120 min, followed on each occasion by completion of VAS. Seven participants completed the entire protocol and were included in the final analysis. A subgroup analysis with the n = 10 paired comparison between the same individuals that completed the oats, rye and pearl millet was also considered. The gastric volume AUC was higher for pearl millet than oats and rye (n = 10, p<0.001). The incremental area under the curve (iAUC) for blood glucose was not significantly different between the meals although this showed a trend to be lower for pearl millet. Hunger was lower for pearl millet compared to oats and rye (n = 10, p = 0.01). There was a significant correlation between total gastric volume AUC and average appetite AUC r = -0.47, p < 0.010. Isoenergetic breakfast porridges from ‘ancient’ varieties of millet grains showed physiological responses that were comparable with those from common Western varieties known to have beneficial health effects. Pearl millet appeared to induce lower postprandial blood glucose response and appetite scores though the differences were not conclusive compared with the other porridges and further work is needed. Improved knowledge of the effects of different cereal grains could help direct dietary advice and ultimately improve health outcomes in the general population worldwide

Narrow band imaging and serology in the assessment of premalignant gastric pathology

Background: Patient outcomes in gastric adenocarcinoma are poor due to late diagnosis. Detecting and treating at the premalignant stage has the potential to improve this. Helicobacter pylori is also a strong risk factor for this disease.Aims: Primary aims were to assess the diagnostic accuracy of magnified narrow band imaging (NBI-Z) endoscopy and serology in detecting normal mucosa, H. pylori gastritis and gastric atrophy. Secondary aims were to compare the diagnostic accuracies of two classification systems using both NBI-Z and white light endoscopy with magnification (WLE-Z) and evaluate the inter-observer agreement.Methods: Patients were prospectively recruited. Images of gastric mucosa were stored with histology and serum for IgG H. pylori and Pepsinogen (PG) I/II ELISAs. Blinded expert endoscopists agreed on mucosal pattern. Mucosal images and serological markers were compared with histology. Kappa statistics determined inter-observer variability for randomly allocated images among four experts and four non-experts.Results: 116 patients were prospectively recruited. Diagnostic accuracy of NBI-Z for determining normal gastric mucosa was 0.87(95%CI 0.82–0.92), H. pylori gastritis 0.65(95%CI 0.55–0.75) and gastric atrophy 0.88(95%CI 0.81–0.94). NBI-Z was superior to serology at detecting gastric atrophy: NBI-Z gastric atrophy 0.88(95%CI 0.81-0.94) vs PGI/II ratio

Antibiotic use and the risk of rheumatoid arthritis: a population-based case-control study

Background: Antibiotic-induced disturbances of the human microbiota have been implicated in the development of chronic autoimmune conditions. This study aimed to assess whether antibiotic use is associated with the onset of rheumatoid arthritis (RA). Methods: A nested case-control study was conducted utilising data from the primary care Clinical Practice Research Datalink (CPRD). Patients with an incident diagnosis of RA were identified (1995–2017). Each case was matched on age, gender, and general practice to ≥ 5 controls without RA. Conditional logistic regression was used to examine previous antibiotic prescriptions and RA onset after controlling for confounding factors. Results: We identified 22,677 cases of RA, matched to 90,013 controls, with a median follow-up of 10 years before RA diagnosis. The odds of developing RA were 60% higher in those exposed to antibiotics than in those not exposed (OR 1.60; 95% CI 1.51–1.68). A dose- or frequency-dependent association was observed between the number of previous antibiotic prescriptions and RA. All classes of antibiotics were associated with higher odds of RA, with bactericidal antibiotics carrying higher risk than bacteriostatic (45% vs. 31%). Those with antibiotic-treated upper respiratory tract (URT) infections were more likely to be RA cases. However, this was not observed for URT infections not treated with antibiotics. Antifungal (OR = 1.27; 95% CI 1.20–1.35) and antiviral (OR = 1.19; 95% CI 1.14–1.24) prescriptions were also associated with increased odds of RA. Conclusion: Antibiotic prescriptions are associated with a higher risk of RA. This may be due to microbiota disturbances or underlying infections driving risk. Further research is needed to explore these mechanisms

Treatments for chronic kidney disease: a systematic literature review of randomized controlled trials

Delaying disease progression and reducing the risk of mortality are key goals in the treatment of chronic kidney disease (CKD). New drug classes to augment renin-angiotensin-aldosterone system (RAAS) inhibitors as the standard of care have scarcely met their primary endpoints until recently. This systematic literature review explored treatments evaluated in patients with CKD since 1990 to understand what contemporary data add to the treatment landscape. Eighty-nine clinical trials were identified that had enrolled patients with estimated glomerular filtration rate 13.9-102.8 mL/min/1.73 m2 and urinary albumin-to-creatinine ratio (UACR) 29.9-2911.0 mg/g, with (75.5%) and without (20.6%) type 2 diabetes (T2D). Clinically objective outcomes of kidney failure and all-cause mortality (ACM) were reported in 32 and 64 trials, respectively. Significant reductions (P &lt; 0.05) in the risk of kidney failure were observed in seven trials: five small trials published before 2008 had evaluated the RAAS inhibitors losartan, benazepril, or ramipril in patients with (n = 751) or without (n = 84-436) T2D; two larger trials (n = 2152-2202) published onwards of 2019 had evaluated the sodium-glucose co-transporter 2 (SGLT2) inhibitors canagliflozin (in patients with T2D and UACR &gt; 300-5000 mg/g) and dapagliflozin (in patients with or without T2D and UACR 200-5000 mg/g) added to a background of RAAS inhibition. Significant reductions in ACM were observed with dapagliflozin in the DAPA-CKD trial. Contemporary data therefore suggest that augmenting RAAS inhibitors with new drug classes has the potential to improve clinical outcomes in a broad range of patients with CKD.</p