They were at heightened risk of dying from psychiatric causes and being murdered
Uncoordinated appointment schedules added to the many disadvantages they already faced
Changes to maternity care practice and policy now urgently required, say researchers

The involvement of children’s social care services was a common factor in nearly a third of UK maternal deaths occurring during, or within a year of, pregnancy between 2014 and 2022, finds research published in the open access journal BMJ Medicine.

These women were at heightened risk of dying from psychiatric causes and being murdered, the findings indicate.

But uncoordinated appointment schedules across a wide number of services added to the many disadvantages these women already faced. Changes to maternity care practice and policy are now urgently required, say the researchers.

In the UK, children’s social care services might become involved during pregnancy or after birth when concerns are raised that the infant might be at significant risk of harm. And the number of such cases has steadily risen over the past decade, note the researchers.

Although maternal deaths in the UK are relatively rare, recent evidence indicates a substantial increase in deaths from all causes compared with previous years, even allowing for the effects of the COVID-19 pandemic, they add.

To explore this further, in the context of children’s social care services involvement, and analyse the quality of maternity care women received, the researchers drew on national surveillance data—MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK)—for all mothers who died between 2014 and 2022 either during, or up to a year after, pregnancy.

During this period, 1695 women died, but involvement with children’s social care services wasn’t known for 244, so 1451 women were included in the final analysis.

Children’s social care services had been involved in the care of nearly a third (420; 29%) of the women who died, an involvement that has steadily increased since 2014, reaching 34% in 2019-21, the data show.

Three out of four (75%) of these women died between six weeks and 12 months after the end of pregnancy.

Women with children’s social care involvement were more likely than those with no known involvement with these services to die by suicide (20% vs 10%), other mental health related causes, including drug overdose (30% vs 3%), and murder (5% vs 2%).

And they were nearly twice as likely to be young (aged 20 or below), twice as likely to be living in the most deprived areas, and significantly less likely to be of Black or Asian ethnicity.

A higher proportion of them were unemployed, living alone, and reported to have been subjected to domestic abuse before or during their pregnancy than women with no known involvement with children’s social services: 65% (205) vs 3% (23).

And a higher proportion of them had pre-existing medical problems (75% vs 59%), mental health issues (75% vs 27%), smoked during pregnancy (73% vs 21%), and were known to have substance misuse issues (55% vs 5%).

But they also received antenatal care less often during pregnancy (89% vs 94%). And of those who did, a higher proportion started this after 13 weeks of pregnancy (32% vs 19%).

A review (confidential enquiry) of the care of a random sample of 47 women with children’s social care services involvement showed that these women tended to have complex social risk factors, with almost half having five or more (45%; 21).

Multiple personal barriers hindered their access to, and engagement with, healthcare. These included previous trauma and poor experiences of children’s services involvement (including previous removal of older children); domestic abuse; financial hardship; insecure housing; and challenges related to mental health, neurodiversity, learning disabilities, and language needs.

They also faced barriers in service provision. For example, healthcare professionals often didn’t explore the interplay between medical and social complexity and didn’t consistently consider the wider social circumstances that affected engagement and treatment compliance. And they didn’t always understand the impact of trauma.

Access to appropriate and timely advice about drug treatments was challenging for many women, both before conception and during the perinatal period, with evidence of judgment and stigma in some women’s records.

For most women, coexistence of complex social adversity and medical or obstetric problems triggered a range of health and social care referrals, resulting in a high volume of appointments—more than 30 for some women—across different services and agencies.

These appointments were often uncoordinated and lacked a collective approach to safeguard both women and their babies.

“The complexity of a multi-agency system with various professionals was compounded by communication gaps, uncertainty about professional roles, and disjointed processes, resulting in a rigid system unable to tailor care to the needs of women,” point out the researchers.

They identified risk assessment and recognition, medication management, coordination of care, and staff competencies as essential components of personalised, holistic, and responsive (to trauma) care when dealing with medical and social complexity.

This is an observational study, and as such, no firm conclusions can be drawn about cause and effect. The researchers acknowledge that data for some important demographic variables were missing. The study also only considered women who died: the findings might therefore not be applicable to women with children’s social care services involvement during and after their pregnancy who didn’t die.

But the researchers nevertheless conclude that: “While some women received excellent, coordinated care, we identified that urgent changes to practice, clinical guidance, and policy are required to prioritise this group of marginalised women.

“A critical review of current maternity care pathways is needed to adjust and customise care to the needs of women with complex social adversity, and to look at the existing health inequalities that disproportionately affect [them].”

11/07/2025

Notes for editors
Research: Characteristics, outcomes, and maternity care experiences of women with children’s social care involvement who subsequently died: national cohort study and confidential enquiry  Doi: 10.1136/bmjmed-2025-001464

Journal: BMJ Medicine

External funding: National Institute for Health and Care Research (NIHR); Healthcare Quality Improvement Partnership (HQIP)

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: People

The post Children’s social care involvement common to nearly third of UK mums who died during perinatal period first appeared on BMJ Group.

Findings highlight importance of healthy body weight before and after pregnancy

Children born to mothers who are very obese with a BMI of 35 or higher are at heightened risk of being admitted to hospital for an infection, finds a long term study published in the open access journal BMJ Medicine.

The findings highlight the importance of maintaining a healthy body weight before and after the pregnancy, say the researchers.

On current trends, the global prevalence of maternal obesity is projected to reach nearly 1 in 4 (23%) by 2030, point out the researchers. This is of particular concern, given that obesity is characterised by a state of chronic inflammation, which increases the risk of a disordered immune system response, changes in gene expression, and unfavourable changes to the gut microbiome alterations, all of which can influence the long term health of the developing fetus, they add.

Previously published studies on whether maternal weight is associated with childhood infection have failed to reach consensus, and it’s unclear if various potentially modifiable factors, such as breastfeeding, method of delivery, and pregnancy weight gain, might influence outcomes, say the researchers.

To find out, the researchers drew on participants in the Born in Bradford study, which has been looking at the potential impact of social, environmental, and genetic factors on short and long term mother and child health outcomes.

Women (9037) who had given birth to a living child at the Bradford Royal Infirmary between March 2007 and December 2010, and for whom information on their height and weight was available, were included in the analysis.

Some 4196 (45%) women were of Pakistani, and 3742 (40%) of white British, ethnicity. And 37% of the entire sample lived in the most socioeconomically deprived areas of the UK.

Their children’s (9540) health—specifically, number of admissions to hospital for an infection and number of infections within their first 5 years—was tracked from birth until the age of 15, they withdrew from the study, or died, whichever came first by October 2022.

Infections were categorised as: upper respiratory tract; lower respiratory tract; skin and soft tissue; genitourinary; gastrointestinal; invasive bacterial; and multisystem viral.

The authors looked at whether particular factors might affect the association between maternal BMI and childhood infection. These included: breastfeeding for 6 or more weeks after birth; caesarean (C) section delivery; preterm birth under 37 weeks; excessive weekly average weight gain and excessive total weight gain while pregnant; and child obesity.

The mums-to-be were weighed at the first antenatal (booking) appointment; again between 26-28 weeks of pregnancy, together with height; and during a routine third trimester appointment. About 30% of the women were overweight and 26% were obese, which included 10% who were grades 2-3 obese (BMI of 35 or above), based on first trimester BMI.

In all, there were 5009 hospital admissions for infection between birth and the age of 15. About 30% of the children were admitted to hospital for infection at least once up to the age of 15: 19% were admitted once; 6% twice; and 4% 3 or more times.

The highest admission rates were among infants under a year of age (134.6 admissions/1000 person years, which fell to 19.9/1000 person years among 5-15 year olds.

Crude admission rates rose in tandem with BMI: 39.7 admissions/1000 person years among children whose mothers were a healthy weight compared with 60.7/1000 person years among those whose mothers were obese (grades 2-3).

After adjusting for potentially influential factors, maternal BMI was positively associated with rates of hospital admission for infection across all ages, but the results were statistically significant only for children whose mothers were the heaviest (obesity grades 2-3).

These children were 41% more likely to be admitted to hospital for an infection when they were under 1 year old after accounting for potentially influential factors, such as mother’s age, ethnicity, and area deprivation level compared with those with mothers of a healthy weight. And they were 53% more likely to do so between the ages of 5 and 15.

The observed associations were slightly stronger in boys than in girls, and in Pakistani women than in white British women. Respiratory, gastrointestinal, and multisystem viral infections accounted for most of the excess hospital admissions.

Of the potentially modifiable factors assessed, preterm birth accounted for a modest proportion of the association (7%) between obesity grades 2-3 and childhood infections during the first five years.

But C-section birth accounted for 21% and child obesity at age 4-5 accounted for 26%, suggesting these might be potentially modifiable risk factors, suggest the researchers. Breastfeeding for 6 or more weeks and excessive pregnancy weight gain (both average weekly and total) weren’t significantly associated.

This is an observational study, and as such, can’t establish cause and effect. The researchers also acknowledge that their study relied on data from only one hospital and substantial amounts of information on breastfeeding and child BMI were missing. Nor were they able to factor in environmental and lifestyle factors.

But they nevertheless conclude: “The findings of our study highlight the need for public health campaigns and additional support for healthcare professionals to help women of reproductive age achieve and maintain a healthy body weight.

“Although the results indicated a modest effect of maternal obesity, and only in those with obesity grades 2-3, the potential effect on a large number of children globally is substantial.”

04/06/2025

Research: Association between maternal body mass index and hospital admissions for infection in offspring: longitudinal cohort study Doi: 10.1136/bmjmed-2024-001050
Journal: BMJ Medicine

External funding: None declared

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: People

The post Mum’s obesity linked to child’s heightened hospital admission risk for infection first appeared on BMJ Group.

But longer term effects unclear and bias likely in much of the existing research 

Relaxation techniques may help lower high blood pressure—at least in the short term—but the longer term effects are unclear, finds a pooled data analysis of the existing research published in the open access journal BMJ Medicine.

And the risk of bias in the existing body of research means that further, more rigorously designed and longer studies are needed to confirm whether these techniques have a constructive role in the treatment of high blood pressure, conclude the researchers.

High blood pressure affects around a third of 30-79 year olds and is one of the leading attributable causes of deaths in both men and women, note the researchers.

While drugs are available to treat the condition, adherence to them is poor, generating interest in alternative approaches, such as relaxation techniques, to reduce one of the major risk factors for high blood pressure—high stress levels.

But it’s far from clear which of these methods, which can include breath control, mindfulness, yoga, Tai Chi, and biofeedback, among others, might be most effective.

To build on the evidence base, the researchers scoured research databases for studies, published in English up to February 2024 that looked at the potential impact of relaxation techniques on high blood pressure (140/90 mm Hg and above) and elevated blood pressure (120/80 mm Hg and above).

They included 182 studies, 166 of which looked at high blood pressure, and 16 of which looked at elevated blood pressure (pre-hypertension).

Where possible, the researchers deployed network meta analysis, a statistical technique used to simultaneously compare the effects of several different ‘treatments’.

The pooled results of 54 studies showed that most relaxation techniques seemed to lower both systolic and diastolic blood pressure for people with high blood pressure after 3 or fewer months. The most commonly included interventions were breath control (13 studies), yoga/tai chi (11), biofeedback (8), progressive muscle relaxation (7), and music (7).

Compared with no intervention, breath control achieved a reduction of 6.65 mm Hg in systolic blood pressure (the first and higher number in a blood pressure reading), meditation a drop of 7.71 mm Hg, meditative movement, such as tai chi and yoga, a drop of 9.58 mm Hg, and mindfulness a drop of 9.90 mm Hg.

Music was also associated with a fall of 6.61 mm Hg, progressive muscle relaxation with a fall of 7.46 mm Hg, and psychotherapy with a reduction of 9.83 mm Hg. Combined techniques were associated with a drop of 6.78 mm Hg in blood pressure.

There was no statistical evidence of effectiveness for any technique after 3 to 12 months and the certainty of the evidence was very low. The most commonly included techniques at this timepoint were biofeedback (7 studies), yoga/tai chi (4), and progressive muscle relaxation (4).

Very few studies included long term follow up of 12 months or more, and of the 3 included in the network analysis, the results showed that compared with no treatment autogenic (self directed) training might lower both systolic and diastolic blood pressure, but the certainty of the evidence was low.

There was no statistical evidence of effectiveness for other treatments assessed at this time point, including biofeedback, progressive muscle relaxation, and techniques involving a combined approach.

Limited data were available for elevated blood pressure: only two studies compared relaxation techniques with no treatment/usual care and the effects on systolic blood pressure were small.

The researchers note that the descriptions of relaxation interventions were sometimes incomplete or sparse, there were few data on costs and cost effectiveness, and most of the included studies didn’t report information on the risk of cardiovascular disease/events/deaths.

But they suggest: “The results of our systematic review and network meta-analysis indicate that relaxation or stress management techniques might result in meaningful reductions in blood pressure at up to three months of follow-up.”

But they caution: “Uncertainty exists about this effect, however, because of the risk of bias in the primary studies, the potential for publication bias in this area, and imprecision in the effect estimates, meaning that the observed changes in blood pressure might be too small to affect cardiovascular or cerebrovascular outcomes.”

And they add: “Hypertension is a chronic condition, likely to require long term drug treatments or behavioural changes. As such, interventions that are used for a brief period, or provide only short term benefits, are unlikely to be clinically useful.

“Too few studies exist, however, to assess whether the beneficial effects of relaxation are maintained when the techniques are practised for longer than three months. Future studies must clearly report whether participants were still using relaxation methods at the time of the outcome assessment, with details on adherence to the relaxation schedule. These factors might strongly influence the effectiveness of the different relaxation and stress management techniques.”

09/04/2025

Notes for editors
Research: Effectiveness of stress management and relaxation interventions for management of hypertension and prehypertension: systematic review and network meta-analysis  Doi: 10.1136/bmjmed-2024-001098
Journal: BMJ Medicine

External funding: National Institute for Health and Care Research (NIHR) Evidence Synthesis programme

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes
Evidence type: Systematic review + meta analysis
Subjects: People

The post Relaxation techniques may help lower high blood pressure—at least in the short term first appeared on BMJ Group.

Cardiovascular disease, cancer, kidney disease, diabetes quartet linked to 11-fold higher hospital admission risk
Kidney disease + cardiovascular disease + dementia + osteoarthritis linked to 24-fold higher death risk

Specific combinations of long term conditions have a major role in the additional pressures the NHS faces every winter, because they are associated with significantly higher risks of  hospital admissions and death, finds research published in the open access journal BMJ Medicine.

The risk of hospital admission was 11 times higher among those with the quartet of cancer, kidney disease, cardiovascular disease, and type 2 diabetes than it was among those without any of these long term conditions, the findings show.

And people with kidney disease, cardiovascular disease, dementia, and osteoarthritis were 24 times more likely to die as those who didn’t have these conditions.

Winter pressures are prompted by the worsening of health issues as a result of colder weather, seasonal viruses, increased isolation and loneliness, plus systems level difficulties caused by higher bed occupancy and staff absences, explain the researchers. These additional pressures usually cover the period from December 1 to March 31.

The number of people in England with 2 or more long term conditions is projected to include almost 70% of the population by 2035. And while previously published research has established the increased health service demand related to multiple long term conditions during the winter, it’s not clear exactly which combinations might be the most critical, say the researchers.

To try and find out, they reviewed routinely collected and linked primary and secondary care health data for adults in England, during the winter pressures period of 2021-22, to identify the reasons for hospital admission. This period coincided with the COVID-19 pandemic when health and social care services were substantially disrupted.

Complete data were available for 48.3 million people, just over half of whom were women (51%). Their average age was 49, and 81% of them were White.

The researchers selected 59 long term conditions which were categorised into 19 groups, based on feedback from clinicians, patients, and policy-makers.

During the study period, 4,710,675 hospital admissions and 176,895 deaths were recorded. Overall, nearly 20 million people (40.5%) had no long term conditions; 13.5 million (28%)  had one; and nearly a third (15 million; 31%) had 2 or more.

Analysis of the data showed that particular combinations of long term conditions were associated with heightened risks of hospital admission and death.

After factoring in age, sex, ethnicity, and area based socioeconomic deprivation, people with cancer, kidney disease, cardiovascular disease, and type 2 diabetes were 11 times more likely to be admitted to hospital during the winter than those who didn’t have this combination.

Similarly, this risk was nearly 10 times higher for those with cancer, chronic kidney disease, cardiovascular disease, and osteoarthritis, and those with cancer, chronic kidney disease, and cardiovascular disease.

Among the 10 combinations that contributed to the highest rates of hospital admissions, cardiovascular disease featured in all but 1, chronic kidney disease in 8, and cancer in 6.

Analysis of the deaths linked to particular combinations of long term conditions showed that people with cardiovascular disease and dementia were nearly 15 times more likely to die than those with neither of these conditions.

And those with the combination of kidney disease, cardiovascular disease, dementia, and osteoarthritis were more than 24 times more likely to do so.

Cardiovascular disease featured in all 10 of the riskiest combinations, while chronic kidney disease featured in 7 of them.

Cardiovascular disease plus dementia also featured in all of the top 5 riskiest combinations, and this duo was associated with a substantially higher rate of death than many 3, 4, and 5 long term condition combinations.

This is an observational study, precluding firm conclusions to be drawn about causal factors. And the researchers acknowledge various limitations to their findings, including the lack of information about the length or severity of illness or frailty among those with long term conditions.

But they point out: “Current policy and clinical guidance consider the risk of hospital admission and death for multiple long term conditions during the winter season as one homogenous condition,” when this is clearly not the case.

And they suggest that the findings could help inform more targeted planning for winter pressures, enabling resources to be allocated where they are needed the most.

“Multimorbidity patterns are a major determinant of hospital admission and mortality during winter,” agree Dr Jonathan Batty and colleagues of the University of Leeds, in a linked editorial.

“In the broader context of winter pressures and increasing multimorbidity, [the study] underscores the need for methods that can identify individuals at high risk of preventable hospital admission and mortality, and strategies to mitigate the risk observed for those people with the most adverse combinations of long term conditions,” they conclude.

13/11/2024

Notes for editors
Research: Combinations of multiple long term conditions and risk of hospital admission or death during winter 2021-22 in England: population based cohort study Doi: 10.1136/bmjmed-2024-001016
Editorial: Impact of multiple long term conditions on hospital admission and mortality during winter: importance of linked, population scale healthcare data Doi: 10.1136/bmjmed-2024-001114
Journal: BMJ Medicine

External funding: National Institute for  Health and Care Research (NIHR); British Heart Foundation

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes (research); No (editorial)
Evidence type: Observational; Opinion
Subjects: People

The post Specific long term condition combinations have major role in NHS ‘winter pressures’ first appeared on BMJ Group.

But may slow progression of existing poor cardiovascular health and lessen risk of death

Regular use of fish oil supplements might increase, rather than lessen, the risk of first time heart disease and stroke among those in good cardiovascular health, but may slow progression of existing poor cardiovascular health and lower the risk of death, suggest the results of a large long term study, published in the open access journal BMJ Medicine.

Fish oil is a rich source of omega 3 fatty acids, and as such, is recommended as a dietary preventive to ward off the development of cardiovascular disease. But the evidence on how much protection it affords is inconclusive, explain the researchers.

To strengthen the evidence base, they set out to estimate the associations between fish oil supplements and new cases of atrial fibrillation; heart attack, stroke, and heart failure; and death from any cause in those with no known cardiovascular disease. 

And they assessed the potential role of these supplements on the risk of progressing from good heart health (primary stage), to atrial fibrillation (secondary stage), to major cardiovascular events, such as a heart attack (tertiary stage), and death (end stage).

They drew on 415,737 UK Biobank study participants (55% women), aged 40-69, who were surveyed between 2006 and 2010 to gather basic background information. This included their usual dietary intake of oily and non-oily fish and fish oil supplements.

The participants’ health was tracked until the end of March 2021 or death, whichever came first, using medical records data.

Nearly a third (130,365; 31.5%) of the participants said they regularly used fish oil supplements. This group included higher proportions of older and White people, and women. Alcohol intake and the ratio of oily to non-oily fish eaten were also higher, while the proportions of current smokers and those living in deprived areas were lower.

During an average monitoring period of nearly 12 years, 18,367 participants developed atrial fibrillation, 22,636 had a heart attack/stroke or developed heart failure, and 22,140 died—14,902 without atrial fibrillation or serious cardiovascular disease.

Among those who progressed from good cardiovascular health to atrial fibrillation, 3085 developed heart failure, 1180 had a stroke, and 1415 a heart attack. And 2436 of those with heart failure died, as did 2088 of those who had had a stroke, and 2098 of those who had had a heart attack.

Regular use of fish oil supplements had different roles in cardiovascular health, disease progression, and death, the findings indicated.

For those with no known cardiovascular disease at the start of the monitoring period, regular use of fish oil supplements was associated with a 13% heightened risk of developing atrial fibrillation and a 5% heightened risk of having a stroke.

But among those who had cardiovascular disease at the start of the monitoring period, regular use of fish oil supplements was associated with a 15% lower risk of progressing from atrial fibrillation to a heart attack, and a 9% lower risk of progressing from heart failure to death.

Further in-depth analysis revealed that age, sex, smoking, consumption of non-oily fish, high blood pressure, and use of statins and blood pressure lowering drugs changed the associations observed. 

Regular use of fish oil supplements and the risk of transitioning from good health to heart attack, stroke, or heart failure was 6% higher in women and 6% higher in non-smokers. And the protective effect of these supplements on the transition from good health to death was greater in men (7% lower risk) and older participants (11% lower risk).

As this is an observational study, no conclusions can be drawn about causal factors, acknowledge the researchers. And no potentially influential information was available on either dose or formulation of the fish oil supplements. And given that most of the participants were White, the findings might not be applicable to people of other ethnicities, they add.

But they conclude: “Regular use of fish oil supplements might have different roles in the progression of cardiovascular disease. Further studies are needed to determine the precise mechanisms for the development and prognosis of cardiovascular disease events with regular use of fish oil supplements.”

22/05/2024 

Notes for editors
Research: Regular use of fish oil supplements and course of cardiovascular diseases: prospective cohort study Doi:10.1136/bmjmed-2022-000451
Journal: BMJ Medicine

External funding: Bill and Melinda Gates Foundation

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes
Evidence type: Observational cohort study
Subjects: People

The post Regular fish oil supplement use might boost first time heart disease and stroke risk first appeared on BMJ Group.

Evident in all age groups in general practice, but highest rise among 16-29 year olds
Recorded transgender identify more common in areas of social and economic deprivation

UK rates of transgender identity have risen 5-fold since 2000, with the highest rise observed among 16 to 29 year olds, although the overall numbers are still small, suggests an analysis of nearly 20 years of anonymised general practice records, published online in the open access journal BMJ Medicine.

And rates of people identifying as transgender were more than twice as high in the most socially and economically deprived areas as they were in less deprived areas, the analysis shows. 

A solid grasp of the numbers and ages of those identifying as transgender is essential for appropriate service design, resource allocation, and staff training, emphasise the researchers. But there’s little in the way of recent good quality data, with the last UK primary care records study that attempted to estimate these figures, published in 1998, they note.

In a bid to strengthen the evidence base, the researchers analysed the diagnostic codes recorded in anonymised general practice medical records from the start of 2000 to the end of 2018 to track changes over time in the proportion of transgender 10 to 99 year olds seen at 649 general practices across the UK.

The analysis included more than 7 million people with at least one full calendar year of medical records information during the study period.

During this time, the overall number of people coded for the first time in their medical record as transgender was small: 2462 (0.03%), equivalent to 1 in every 3300 people.

A lack of comprehensive information meant that the researchers were only able to estimate the direction of transition for 1340 (54%) people: 923 had been assigned male gender at birth; 417 had been assigned female gender at birth.

Overall, newly recorded transgender identity codes increased five-fold between 2000 and 2018: roughly 1 person in every 70,000 was newly identified as transgender in 2000; by 2018, this had risen to around 1 in every 13,000 people.

But the proportion of people with recorded transgender identity differed by age group. It was highest in 16-17 year olds (about 1 in 4300 people) and in 18-29 year olds (about 1 in 3700 people).

Over time, the largest increase occurred in 16-17 year olds, among whom the rate of newly recorded trans identity rose from zero and 4 per 100,000 people in 2000, respectively, to 78 per 100,000 people in 2018. Similar patterns were evident among 18-29 year olds.

In 2018, the proportion of people identifying as transgender, and coded as such in their medical records, had reached roughly 1 in 600 among 16-17 year olds and around 1 in 800 among 18-29 year olds. 

Recorded transgender identity was associated with social and economic deprivation, the data showed, with the rates of people identifying as transgender more than twice as high in the most deprived areas as they were in the least deprived areas.

This is an observational study, and the researchers acknowledge that a key limitation of their study was its reliance on coding of transgender identity in general practice clinical records, which may not always have been done accurately or done at all. 

Similarly, the coding doesn’t capture the full range of gender identity or decisions made not to transition or to detransition, and it contains terms that are now outdated or often misapplied, they explain.

The data also only go up to 2018: recording rates of transgender identity in general practice may very well have changed since then, they add.

“Increasing rates of transgender codes in records may represent increasing numbers of people presenting to primary care with gender related concerns. Reasons for such may include increased availability of information, support and resources and increased societal awareness and acceptance, all of which have partially destigmatised transgender identities and may make coming out as transgender easier for individuals,” explain the researchers.

As to the observed link between deprivation and transgender identity, the researchers suggest that this is more difficult to fathom. “We cannot confidently explain the association from our data,” they write. 

“Transgender individuals in wealthier areas may be more able to afford specialist gender care privately, which can be accessed entirely independently of NHS primary care. This trend may be increasing with longer NHS waiting lists. Therefore, individuals from a wealthier background might bypass NHS services entirely,” they suggest.

29/11/2023 

Notes for editors
Research: Transgender identity in young people and adults recorded in UK primary care electronic patient records: retrospective, dynamic, cohort study doi 10.1136/bmjmed-2023-000499
Journal: BMJ Medicine

Funding: National Institute for Health and Care Research (NIHR)

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes
Evidence type: Observational
Subjects: People

The post Five-fold rise in UK rates of transgender identity since 2000, medical records suggest first appeared on BMJ Group.

Rise in proportion surviving to discharge, but overall survival remains low
And there are major implications for additional resource needs, say researchers

The number of very premature babies (22 weeks) given respiratory life support  (survival focused care) and/or admitted to neonatal units in England and Wales has increased 3-fold, following changes in 2019 to national guidance, finds research published in the open access journal BMJ Medicine.

While the proportion of these babies surviving to discharge has also increased, overall survival remains low, and there are “major implications for additional resource needs,” highlight the researchers.

The updated national guidance from the British Association of Perinatal Medicine focuses on a risk based approach, setting out various pregnancy and birth factors that should inform decision making and parental discussions for premature babies, including those born at 22 weeks. But its impact on neonatal care provision hasn’t been evaluated.

The researchers therefore drew on retrospective data from two national datasets in England and Wales: MBRRACE-UK and the National Neonatal Research Database (NNRD) from January 2018 to December 2021.

Between them, these datasets include: all live births from 22 weeks onwards In England and Wales: data on those who die before, during, and within 28 days of birth; and details of care provision and outcomes up to NHS hospital discharge. 

The researchers focused on survival to admission for neonatal care; length of neonatal unit stay in days; survival to discharge home or to other healthcare settings; and survival to discharge without major health issues, such as retinopathy (eye disease) of prematurity and severe brain injury. 

Overall, 5623 premature babies were born at 22-24 weeks, 1604 of whom were stillborn. Of the 4019 babies alive when care was started in labour, 1001 (25%) were born at 22 weeks, 1380 (34%) at 23 weeks, and 1638 (41%) at 24 weeks. 

Among those alive at the start of labour at 22 weeks, the number and percentage receiving respiratory life support tripled from 59 out of 524 (11%) in 2018-19 to 183 out of 477 (38%) in 2020-21. 

Similarly, admissions to neonatal units for babies alive at the start of labour at 22 weeks rose from nearly 7.5% to just over 28% while survival to discharge from neonatal care rose from 2.5% (13 babies) to just over 8% (39).

The numbers of these babies admitted to neonatal care units who died before discharge also increased from 26 to 95.

This may be because the characteristics of those receiving respiratory life support changed between 2018-19 and 2020-21, with increases in smaller–weighing under 500g–(46% vs 64%), and more immature—born in the earlier part of the 22nd week—(19% vs 31%) babies, say the researchers.

The total number of care days provided to all babies born at 22 weeks increased, rising from 2535 in 2018-19 (1268/year) to 6840 in 2020-21 (3420/year).

This is an observational study, and the researchers acknowledge various limitations to their findings. For example, their definition of survival focused care was mainly limited to provision of active respiratory care because this information was uniformly available.  And they were only able to assess short term outcomes.

But they say: “Our analysis suggests that these rapid and substantial changes were associated with the introduction of the British Association of Perinatal Medicine guidance. 

“Although the recommendation was intended to be risk based, we speculate that, on the contrary, approaches have moved from being selective to more widespread provisions of survival focused care. This change would explain the increase in the proportion of babies at high risk who received survival focused care.” 

They conclude: “While survival for babies born at 22 weeks remains low, the numbers receiving survival focused care and being admitted to neonatal units has tripled. Although this finding suggests that the total number of survivors has increased, this result also means that the number of babies who died after intensive care also increased. 

“Maternity care was also affected because of likely increases in in-utero transfers (ie, moved to a specialist hospital before birth), as well as impacts on paediatric and educational services to provide for long term health and developmental needs. This change represents an important increase in workload and need for specialised health care and educational resources.”

As clinical experience caring for this vulnerable group of babies grows, more international research is needed to improve outcomes and identify early prognostic factors so that prolonged intensive care can be avoided for babies who are unlikely to survive, they add. 

8/11/2023 

Notes for editors
Research: Effect of national guidance on survival for babies born at 22 weeks’ gestation in England and Wales: population based cohort study doi 10.1136/bmjmed-2023-000579
Journal: BMJ Medicine

Funding: National Institutes for Health Research (NIHR)

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes
Evidence type: Observational; data analysis
Subjects: Premature babies

The post Three-fold rise in babies born at 22 weeks given respiratory life support in England and Wales after guidelines change first appeared on BMJ Group.

But further study needed to tease out the possible biological pathways,say study authors

High levels of lean muscle might protect against Alzheimer’s disease, suggests a large study published in the open access journal BMJ Medicine. But further research is needed to tease out the underlying biological pathways, along with the clinical and public health implications, say the study authors.

Obesity has been associated with a heightened risk of Alzheimer’s disease in numerous studies, possibly explained by the attendant increased inflammation, insulin resistance, and higher levels in fat tissue of the protein harmful to brain health, amyloid β.

Lower levels of lean muscle have also been associated with a heightened risk of the disease, but it’s not clear if this might precede or succeed a diagnosis.

To try and find out, the researchers used Mendelian randomisation, a technique that uses genetic variants as proxies for a particular risk factor—in this case lean muscle—to obtain genetic evidence in support of a particular outcome—in this study, Alzheimer’s disease risk.

They drew on 450, 243 UK Biobank participants; an independent sample of 21,982 people with, and 41,944 people without, Alzheimer’s disease; a further sample of 7329 people with, and 252,879 people without, Alzheimer’s disease to validate the findings; and 269,867 people taking part in a genes and intelligence study.

Bioimpedance—an electric current that flows at different rates through the body depending on its composition—was used to estimate lean muscle and fat tissue in the arms and legs, the results of which were adjusted for age, sex, and genetic ancestry. 

Some 584 genetic variants were associated with lean muscle mass; none was located in the APOE gene region that is associated with vulnerability to Alzheimer’s disease. These genetic variants combined explained 10% of the difference in lean muscle mass in the arms and legs of the study participants. 

On average, higher (genetically proxied) lean muscle mass was associated with a modest, but statistically robust, reduction in Alzheimer’s disease risk.

This finding was replicated in the further sample of 7329 people with, and 252,879 people without, Alzheimer’s disease, using different measures of lean muscle mass—trunk and whole body.

Lean mass was also associated with better performance on cognitive tasks, but this association didn’t explain the protective effect of lean mass on Alzheimer’s disease risk. 

Nor was body fat, adjusted for lean mass, associated with the risk of Alzheimer’s disease, but it was associated with poorer cognitive task performance.

“These analyses provide new evidence supporting a cause-and-effect relation between lean mass and risk of Alzheimer’s disease,” say the researchers.

The findings also “refute a large effect of fat mass on the risk of Alzheimer’s disease and highlight the importance of distinguishing between lean mass and fat mass when investigating the effect of adiposity measures on health outcomes,” they add.

But they caution: “Our findings need to be replicated with independent lines of complementary evidence before informing public health or clinical practice. Also, more work is needed to determine the cut-off values for age and degree of pathology of Alzheimer’s disease after which modifications of lean mass might no longer reduce the risk.” 

Nor is it clear whether increasing lean mass could reverse the pathology of Alzheimer’s disease in patients with preclinical disease or mild cognitive impairment, they add.

But they conclude that if future studies back their findings, “public health efforts to shift the population distribution of lean mass, potentially through campaigns to promote exercise and physical activity, might reduce the population burden of Alzheimer’s disease.”

29/06/2023

Notes for editors
Research: Genetically proxied lean mass and risk of Alzheimer’s disease: mendelian randomisation study doi 10.1136/bmjmed-2022-000354
Journal: BMJ Medicine

Funding: None declared

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes
Evidence type: Mendelian randomisation
Subjects: People

The post Higher levels of lean muscle might protect against Alzheimer’s disease first appeared on BMJ Group.

Risk highest for Bangladeshis, Pakistanis, Muslims, Sikhs, and disadvantaged in wave 2
Highest for White British, Christians, the healthy, and relatively well off in wave 3

There were major ethnic, religious, and social differences in the risk of testing positive for SARS-CoV-2, the virus responsible for COVID-19 infection, between the second and third waves of the pandemic in England, finds research published in the open access journal BMJ Medicine.

The risks were highest for people of Bangladeshi and Pakistani ethnicities, Muslims, Sikhs, and those who were materially and socially disadvantaged in wave 2.

But in wave 3 the risks were highest for people of White British ethnicity, Christians, those with no underlying conditions or disabilities, and those who were relatively affluent. 

These differences aren’t fully explained by geography, social or demographic factors, or a person’s state of health before the pandemic, say the researchers.

While the pandemic has affected all areas of the UK, some groups have been more affected than others. But rather less is known about the social and demographic inequalities underpinning the infection rates.

In a bid to plug this knowledge gap, the researchers drew on national population linked census, health, death registration and SARS-CoV-2 test data for 39 million people aged 10+ in England, to calculate the relative risk of testing positive for the virus during the second and third waves of the pandemic.

Social and demographic information for each person—sex, age, ethnicity, religion, disability status, educational attainment, job title, English language proficiency, and country of birth—were obtained from the 2011 census.

Positive test results from 1 September 2020 up to and including 22 May 2021 were classified as occurring during the second wave, and those from 23 May 2021 to 10 December 2021 as occurring in the third wave.

Just over half (52%) of the study participants were female; the average age was 47; and most (82%) identified as White British. Just under 5% identified as White other, nearly 3% as Indian, 59.5% as Christian, 25.5% as having no faith, and 5% as Muslim.

During the study period, 5,767,584 people (nearly 15%) tested positive for SARS-CoV-2. 

In the second wave the risk of testing positive was highest for people of Bangladeshi (75% higher) and Pakistani (69% higher) ethnicities than it was for people of White British ethnicity, after accounting for potentially influential factors. 

Similarly, those identifying as Muslim and Sikh were 51% and 64% more likely to test positive than were Christians. Case rates were lowest for those with no religion or who identified as Buddhist: their risks were 12% and 16%, lower, respectively, than for Christians.

Adjusting for geography, social and demographic characteristics, and state of health before the pandemic explained only 27% and 32% of the excess risk, respectively, for Bangladeshi and Pakistani ethnicities, and only 27% and 16% of the excess risk, respectively, for Muslim and Sikh faiths.

Greater area deprivation, social and economic disadvantage, living in a care home or urban area, and a low level of English language proficiency were also associated with higher relative risks of testing positive. 

But during the third wave, identifying as Christian (average weekly rate of 353.8 per 100,000 people), White British (359.7), or as having no concurrent condition or disability (337.6), and being relatively affluent were all associated with a higher risk of testing positive.

Case rates were highest among people born in the UK (345 compared to 238.2 for those born outside the UK) and whose first language was English during this wave (342.2).

Once again, adjusting for geography, social and demographic characteristics, and state of health before the pandemic explained some, but not all, of the excess risk. 

This is an observational study, and as such, can’t establish cause. And the researchers acknowledge that the information for the study was restricted to people in the 2011 census, from which all the social and demographic definitions were taken, and these might have changed since then.

National SARS-CoV-2 test data don’t represent the true extent of infections either because people are more likely to get tested if they have symptoms, add the researchers.

But they suggest that a possible explanation for the observed differences in case rates by ethnicity, religion, and social and economic factors during the two waves is that “levels of population immunity were higher for the groups that had the highest case rates in the first and second waves, even considering the potential for reinfection.” 

They add: “Changes in the rate ratios observed in wave three compared with wave two could also be due to changes in testing behaviours in response to rollout of vaccination, changes in the perceived risk of infection or reinfection, and policy changes related to isolation periods and compensation after testing positive for SARS-CoV-2.”

They conclude: “Further research is needed to understand why these inequalities exist and how they can best be addressed through policy interventions. Continued surveillance is essential to ensure that changes in the patterns of infection are identified early to inform [future] public health interventions.”

03/04/2023

Notes for editors
Research: Inequalities in SARS-CoV-2 case rates by ethnicity, religion, measures of socioeconomic position, English proficiency, and self-reported disability: cohort study of 39 million people in England during the alpha and delta waves Doi: 10.1136/bmjmed-2022-000187
Journal: BMJ Medicine

Link to AMS press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed? Yes
Evidence type: Observational; data analysis
Subjects: People

The post Ethnic, religious, social differences in case rates between covid-19 waves first appeared on BMJ Group.

Social factors may explain fewer pregnancies than among naturally conceived peers

There’s little evidence to suggest that children conceived as a result of fertility treatment are at any greater risk of pregnancy complications or worse birth outcomes than their naturally conceived peers, finds a long term study, published in the open access journal BMJ Medicine.

Although this method of conception is associated with fewer pregnancies, social rather than clinical factors may very well explain this, suggest the researchers.

The use of fertility treatment is increasing. And more than 10 million babies have been born worldwide using assisted reproduction techniques.

It’s known that the resulting pregnancies are at higher risk of several pregnancy and birth complications, although it’s not clear if these risks are associated with the treatment involved or the lower fertility. 

Similarly, whether these risks might also affect the children conceived this way when they want to become parents themselves, isn’t clear either.

To explore this further, the researchers drew on the reproductive histories of more than 1 million Norwegian residents born between 1984 and 2002 and a pregnancy registered with the Medical Birth Registry of Norway up to the end of 2021.

They focused on various key indicators of newborn and maternal health. These included: average birth weight; gestational age; placental weight; risk of congenital birth defects; vital signs at birth (Apgar score); need for neonatal intensive care; caesarean section delivery; use of fertility treatment; high blood pressure and pre-eclampsia during pregnancy; premature birth; and the baby’s sex. 

Among 1,092,151 people born in Norway from 1984 to 2002, some 180,652 were registered at least once as mothers and 137,530 as fathers. 

Of these, 399 men out of a total 5083 (8%) conceived after fertility treatment and 553 women out of a total of 4763 (12%) had at least one registered pregnancy.  

Analysis of the data showed little evidence that people conceived as a result of fertility treatment were themselves at heightened risk of the studied pregnancy or birth complications, or of assisted reproduction. 

But conception after fertility treatment was associated with an 86% heightened risk of a low neonatal Apgar score among women conceived in this way, although the actual numbers were small.  And the odds of having a boy were also 21% lower in this group. 

People conceived after fertility treatment were also slightly (9-12%) less likely to have a registered pregnancy within the monitoring period (2002-21).

The researchers acknowledge certain limitations to the study findings, including the small number of pregnancies among people conceived after fertility treatment and the lack of information on potentially influential sociodemographic factors.

And given that all parents were born in Norway, the findings may not be more widely applicable to a more ethnically diverse population, they point out.

But they nevertheless state: “People conceived by assisted reproductive technologies were not at increased risk of obstetric or perinatal complications when becoming parents.”

And they explain: “Men and women who were conceived by assisted reproductive technologies had fewer pregnancies compared with their peers who were naturally conceived, which might be attributable to social factors.” 

Larger studies with a longer monitoring period and more direct assessment of time to pregnancy are needed to confirm their findings and evaluate the pregnancy outcomes for older parents who were conceived after fertility treatment, they suggest.

“Meanwhile, these early results are reassuring for the increasing number of adolescents and young adults who were conceived by [assisted reproduction] and are entering their reproductive years,” they conclude.

20/03/23

Notes for editors
Research: Reproductive outcomes in women and men conceived by assisted reproductive technologies in Norway: prospective registry based study DOI 10.1136/bmjmed-2022-000318
Journal: BMJ Medicine

Funding: Research Council of Norway; European Research Council; Norwegian Institute of Public Health; Telemark Hospital Trust, Porsgrunn, Norway

Link to Academy of Medical Sciences press release labelling system
http://press.psprings.co.uk/AMSlabels.pdf 

Externally peer reviewed?Yes
Evidence type: Observational
Subjects: People

The post Little evidence that IVF conception heightens future pregnancy risks first appeared on BMJ Group.