Objectives To determine the risk of death, haematological disease, liver disease, and other adverse outcomes in individuals with incidentally detected thrombocytopenia with or without anaemia, and to provide clinically applicable absolute risk estimates supporting evidence based shared decision making.Design Prospective cohort study.Setting UK Biobank and an independent Danish replication cohort (from the Copenhagen General Population Study and Danish General Suburban Population Study), with individuals enrolled from December 2006 to October 2010 (UK) or November 2003 to November 2018 (Denmark).Participants 485 103 individuals from the general population (380 951 from the UK and 104 152 from Denmark) who attended a health examination, and platelet count, haemoglobin level, leucocyte count, and differential count were measured.Main outcome measures Risk of death from any cause, receiving a diagnosis of haematological disease, and death from haematological disease. Secondary endpoints (UK only) were liver disease, bleeding, non-haematological cancer, thrombosis, and cause specific death.Results Isolated thrombocytopenia was detected in 8350 UK individuals (2.2%) and 1408 Danish individuals (1.4%). Median follow-up was 14 years in UK individuals and 11 years in Danish individuals. In both cohorts, the relative risk of death from any cause was increased in isolated mild (platelet count 100-149×109/L) or moderate-severe (platelet count <100×109/L) thrombocytopenia. In the oldest UK individuals aged 65-70 years, the absolute 10 year risk of all cause death was 7% in women with a normal platelet count and haemoglobin level, 10% in women with isolated mild thrombocytopenia, and 14% in women with isolated moderate-severe thrombocytopenia; the corresponding risks for men were 11%, 15%, and 22%, respectively. Although the relative risk of haematological disease and death from haematological disease was increased in isolated mild or moderate-severe thrombocytopenia, all age and sex categories with isolated mild thrombocytopenia had absolute 10 year risks of receiving a diagnosis of haematological disease of ≤4% in UK individuals and ≤7% in Danish individuals, whereas the 10 year risk was ≤2% for individuals with a normal platelet count and haemoglobin level. The absolute risk of death from haematological disease was much lower, and all age and sex categories with isolated mild thrombocytopenia had 10 year risks <1%. The relative risk of non-malignant liver disease, liver cancer, and death from liver disease was increased in UK individuals with isolated thrombocytopenia. The absolute risk was highest for non-malignant liver disease with 10 year risks of <1-2% in individuals with a normal platelet count (depending on age and sex), 2-4% in isolated mild thrombocytopenia, and 3-7% in isolated moderate-severe thrombocytopenia. For most endpoints, risks were generally similar or higher in individuals with thrombocytopenia with anaemia.Conclusions Individuals with isolated mild thrombocytopenia had only a modest absolute risk of haematological disease and death from haematological disease, which may inform shared decision making about haematology referral, investigations, and follow-up.
Objective To examine current population level changes in prescriptions for stimulant drugs in Ontario, Canada.Design Population based repeated cross sectional study.Setting Ontario, Canada.Participants 15 091 342 Ontario residents, aged 5-105 years, who were eligible for the Ontario Health Insurance Plan between 1 January 2015 and 31 December 2024; 563 632 (3.7%) participants had at least one prescription for a stimulant during the study period.Main outcome measures Annual incidence of stimulant prescriptions in Ontario, defined as the number of individuals each year with a newly dispensed prescription for a stimulant drug, with no record of any stimulant prescription in the previous three years, by use of the Narcotics Monitoring System database, which captures all stimulant drug prescribing in Ontario. Secondary outcome was percentage of individuals with a past year stimulant prescription.Results Incident stimulant prescriptions increased by 170.1% between 2015 and 2024 (275.3 to 743.4 per 100 000 individuals). Incident prescriptions increased by 7.4% each year (95% confidence interval (CI) 3.3% to 11.7%) between 2015 and 2019, and increased further between 2020 and 2024 by 22.6% each year (17.8% to 27.7%). Increases were greater in female individuals than in male individuals, with the largest increases between 2015 and 2024 occurring in those aged 35-44 years (434.4% in women and 261.4% in men), and the smallest increases occurring in adults aged ≥65 years (40.0% in women and 13.5% in men) and in young people aged 5-9 years (79.5% in girls and 45.2% in boys). In 2024, the prevalence of past year stimulant prescriptions was 3.0% for the whole population, with the highest level at 8.3% in boys aged 10-14 years and 7.3% in women aged 18-24 years. Comparable increases in incident prescriptions were observed in both urban and rural settings, across neighbourhood income groups, and by immigration status, and increases were greater in individuals without a history of care for comorbid mental health conditions (183.0% v 92.5%).Conclusions The rate of stimulant prescriptions in Ontario nearly tripled over the past nine years, with the largest increases occurring in female individuals and adults since 2020. Further research is needed to understand the possible causes of these trends, which include an increase in the number of individuals with attention deficit/hyperactivity disorder (ADHD) or related symptoms, improved identification of undiagnosed ADHD, or overdiagnosis of ADHD, along with health effects associated with increasing use of stimulants.
Objectives To assess the proportions of processed and ultraprocessed products in the UK that are high in fat, salt, and sugar, and energy density, defined by two systems used to regulate unhealthy food products in the UK (Food Standards Agency (FSA) nutrient profiling model (NPM) and front-of-pack traffic lights labelling system), and compared with UK dietary guidance based on new NPMs.Design Cross sectional analysis of a nationally representative database of food and drink items.Setting UK National Diet and Nutrition Survey database.Population Food and drink items (262 processed products and 1636 ultraprocessed products) from the National Diet and Nutrition Survey database.Main outcome measures Proportion of processed and ultraprocessed products identified as unhealthy based on three Eatwell Guide NPMs, the FSA NPM, and the front-of-pack traffic lights labelling system. Three new nutrient profile models based on UK dietary guidance were constructed to identify excess saturated fat, free sugar, sodium, total fat, and energy density in processed and ultraprocessed products: NPM1 identified excess saturated fat, free sugar, and sodium; NPM2 identified excess saturated fat, free sugar, sodium, and total fat; and NPM3 identified excess saturated fat, free sugar, sodium, total fat, and energy density.Results The proportion of ultraprocessed products identified as unhealthy differed significantly (P<0.05) between the NPMs. The FSA NPM identified as unhealthy 57.6% of ultraprocessed products (95% confidence interval 55.2% to 60.0%), whereas the traffic lights labelling system identified fewer than half of all ultraprocessed products as unhealthy (48.2%, 45.8% to 50.6%). NPM1 identified 91.5% (95% CI 90.2% to 92.9%) of all ultraprocessed products as unhealthy, model No 2 identified 94.9% (93.9% to 96.0%), and model No 3 identified 98.7% (98.2% to 99.3%) of all ultraprocessed products.Conclusions Food and drink products that, according to UK government dietary guidance, contain excess amounts of harmful nutrients are not identified by current systems for regulating UK food and drink (FSA NPM and front-of-pack traffic lights labelling system). The most conservative new NPM, based on current UK government dietary guidance, identified significantly greater proportions of processed and ultraprocessed products as unhealthy than the current two systems. These findings have important implications for food policy and the appropriateness of UK dietary guidance to identify unhealthy products.
Mitral valve disease is a major global contributor to cardiovascular morbidity and mortality, with its epidemiology shaped by regional characteristics and changing causes. In high income countries, degenerative mitral regurgitation predominates, resulting from ageing populations, although functional mitral regurgitation is increasingly recognised and constitutes an increasing proportion of the burden of mitral regurgitation. In contrast, rheumatic mitral stenosis and regurgitation affect younger patients in low and middle income areas. Advances in multimodality cardiac imaging have enhanced the precision of diagnostic and prognostic evaluation, and periprocedural planning and guidance. Management strategies are evolving, with surgical repair or replacement remaining the standard for eligible patients, supported by minimally invasive approaches and optimal timing and indications. Transcatheter edge-to-edge repair and transcatheter mitral valve replacement are new treatment options for patients at high risk or previously considered to be inoperable. This review summarises the contemporary perspectives of the epidemiology of mitral valve disease, the pathophysiology, diagnostic imaging modalities, and treatments for mitral regurgitation and stenosis, and outlines future directions.
