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Biomedical subjects

D Gunnell

Publications and source records attributed to D Gunnell.

At least 55 records · Page 3Linked to original sources
PubMed2002

Population need for coronary revascularisation: are national targets for England credible?

OBJECTIVE: To estimate the need for coronary revascularisation, by using an incidence of indications approach, among 45-84 year olds with stable angina, unstable angina, and acute myocardial infarction. DESIGN: Modelling exercise. Six key steps along the pathway of care from initial diagnosis in primary or secondary care to revascularisation were defined and the frequency of indications estimated using routine data from hospital admissions and data from studies in the general population, and primary and secondary care. SETTING AND PATIENTS: Mid-1998 population of England. INTERVENTION: Coronary revascularisation. MAIN OUTCOME MEASURE: Ability to benefit (need), defined by randomised trials, expert panel ratings from the ACRE (appropriateness of coronary revascularisation) study, or by informal consensus. RESULTS: The need for coronary revascularisation was estimated to be 92 000 procedures, equivalent to a rate of 1861 per million population. Overall, the model of need exceeded current provision by 3.3:1, although among people aged 75 years and over the ratio was 7.7:1. A plausible upper estimate of need--obtained by assuming that 90% of patients with stable angina were referred from primary care and that angiography would be performed in 65% of patients with acute myocardial infarction and 75% of patients with unstable angina--was 2626 per million population. CONCLUSIONS: The national target of 1500 revascularisation procedures per million population is credibly related to population need, although upper estimates of need are considerably higher. Better understanding is required of the benefits of referring patients with specific indications from primary care. The greatest relative increase in provision is required for those aged 75 and older, among whom trial evidence of benefit is scant.

Aged↗
PubMed2001

International trends in prostate-cancer mortality in the "PSA ERA".

Incidence and mortality from prostate cancer were rising in most countries until the late 1980s. Following a number of advances in the management of prostate cancer, including introduction of the prostate-specific antigen (PSA) test, there have been reports of declines in mortality in Canada, the United States and the United Kingdom. To investigate the extent to which this pattern was seen in other industrialised countries, we used routinely collected data to explore recent changes in prostate-cancer mortality. Trends in age-standardised death rates between 1979 and 1997 for men aged 50 to 79 years in 24 industrialised countries were compared using join point regression. Join point regression allows estimation of the annual percentage change in death rates and tests for significant changes in trend. During the period studied, age-standardised mortality increased at 1% to 2% per year in most countries. In 7 countries (Canada, United States, Austria, France, Germany, Italy and United Kingdom), a significant down-turn in age-standardised mortality was observed over the period 1988-1991. Trends in age-specific rates within these countries support a period effect on prostate-cancer mortality. Declines in mortality could result from any combination of either artefact, reduction in prostate-cancer incidence, a rise in competing causes of death or changes in the risk of death from prostate cancer. There are inconsistencies in the relationship between national mortality trends and uptake of PSA screening; further research is required to determine whether changes in death rates can be explained by international and secular variations in the treatment of prostate cancer.

Age Factors↗
PubMed2001

Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study.

OBJECTIVE: To evaluate the effects on suicidal behaviour of legislation limiting the size of packs of paracetamol and salicylates sold over the counter. DESIGN: Before and after study. SETTING: UK population, with detailed monitoring of data from five liver units and seven general hospitals, between September 1996 and September 1999. SUBJECTS: People who died by suicidal or accidental overdose with paracetamol or salicylates or who died of undetermined causes; patients admitted to liver units with hepatic paracetamol poisoning; patients presenting to general hospitals with self poisoning after taking paracetamol or salicylates. MAIN OUTCOME MEASURES: Mortality from paracetamol or salicylate overdose; numbers of patients referred to liver units or listed for liver transplant; numbers of transplantations; numbers of overdoses and tablets taken; blood concentrations of the drugs; prothrombin times; sales to pharmacies and other outlets of paracetamol and salicylates. RESULTS: Numbers of tablets per pack of paracetamol and salicylates decreased markedly in the year after the change in legislation on 16 September 1998. The annual number of deaths from paracetamol poisoning decreased by 21% (95% confidence interval 5% to 34%) and the number from salicylates decreased by 48% (11% to 70%). Liver transplant rates after paracetamol poisoning decreased by 66% (55% to 74%). The rate of non-fatal self poisoning with paracetamol in any form decreased by 11% (5% to 16%), mainly because of a 15% (8% to 21%) reduction in overdoses of paracetamol in non-compound form. The average number of tablets taken in paracetamol overdoses decreased by 7% (0% to 12%), and the proportion involving >32 tablets decreased by 17% (4% to 28%). The average number of tablets taken in salicylate overdoses did not decrease, but 34% fewer (2% to 56%) salicylate overdoses involved >32 tablets. After the legislation mean blood concentrations of salicylates after overdose decreased, as did prothrombin times; mean blood concentrations of paracetamol did not change. CONCLUSION: Legislation restricting pack sizes of paracetamol and salicylates in the United Kingdom has had substantial beneficial effects on mortality and morbidity associated with self poisoning using these drugs.

Acetaminophen↗
PubMed2001

The influence of the economic and social environment on deliberate self-harm and suicide: an ecological and person-based study.

BACKGROUND: Geographic variations in the incidence of deliberate self-harm (DSH) and suicide have been shown to be associated with area-based measures of socio-economic deprivation and social fragmentation. Previous studies have been subject to methodological limitations. None has investigated whether ecological associations are reflected in characteristics of individuals involved in suicidal behaviour. METHODS: DSH patients presenting to a general hospital between 1985 and 1995 and suicides (including open verdicts) from the same catchment area were studied. Mean annual rates of DSH and suicide by gender were calculated for electoral wards. The wards were amalgamated into 20 groups according to their ranking for socio-economic deprivation (Townsend) and social fragmentation scores. Associations of these variables with DSH and suicide rates were investigated. Characteristics of DSH patients living in ward groups with the highest and lowest socio-economic deprivation and social fragmentation scores were compared. RESULTS: Socio-economic deprivation was associated with DSH rates among males (r = 0.89) and females (r = 0.87). After controlling for social fragmentation the associations remained relatively strong, particularly in young males. Associations with social fragmentation in both genders (males, r = 0.83; females, r = 0.86) were attenuated after controlling for socio-economic deprivation. For suicide, the only significant association was with socio-economic deprivation in males (r = 0.79), but this was attenuated after controlling for social fragmentation. The characteristics of individual DSH patients reflected those of the areas where they lived. CONCLUSIONS: Reducing socio-economic deprivation and its associated problems may be an important strategy in the prevention of suicidal behaviour, especially in young men.

Adolescent↗
PubMed2001

The efficacy of problem-solving treatments after deliberate self-harm: meta-analysis of randomized controlled trials with respect to depression, hopelessness and improvement in problems.

BACKGROUND: Brief problem-solving therapy is regarded as a pragmatic treatment for deliberate self-harm (DSH) patients. A recent meta-analysis of randomized controlled trials (RCTs) evaluating this approach indicated a trend towards reduced repetition of DSH but the pooled odds ratio was not statistically significant. We have now examined other important outcomes using this procedure, namely depression, hopelessness and improvement in problems. METHOD: Six trials in which problem-solving therapy was compared with control treatment were identified from an extensive literature review of RCTs of treatments for DSH patients. Data concerning depression, hopelessness and improvement in problems were extracted. Where relevant statistical data (e.g. standard deviations) were missing these were imputed using various statistical methods. Results were pooled using meta-analytical procedures. RESULTS: At follow-up, patients who were offered problem-solving therapy had significantly greater improvement in scores for depression (standardized mean difference = -0.36; 95% CI -0.61 to -0.11) and hopelessness (weighted mean difference =-3.2; 95% CI -4.0 to -2.41), and significantly more reported improvement in their problems (odds ratio = 2.31; 95% CI 1.29 to 4.13), than patients who were in the control treatment groups. CONCLUSIONS: Problem-solving therapy for DSH patients appears to produce better results than control treatment with regard to improvement in depression, hopelessness and problems. It is desirable that this finding is confirmed in a large trial, which will also allow adequate testing of the impact of this treatment on repetition of DSH.

Cognitive Behavioral Therapy↗
PubMed2001

Secular trends in antidepressant prescribing in the UK, 1975-1998.

BACKGROUND: We have examined secular trends in age- and sex-specific prescribing of antidepressants to determine whether these mirror changes in other population measures of mental health. METHOD: An analysis was carried out of age- and sex-specific rates of antidepressant prescribing by a representative sample or panel of UK general practitioners (GPs) in the period 1975-1998. RESULTS: The number of antidepressant prescriptions issued increased more than twofold in the period 1975-1998 and, in 1998, a total of 23.4 million antidepressant prescriptions were issued by GPs in the United Kingdom. Rates of antidepressant prescribing increased markedly in all age and sex groups with as much as a threefold increase in the older age groups. With the exception of 12-19-year-olds, these increases have been more marked in males, although absolute levels of prescribing are still at least two times higher in females. CONCLUSIONS: Antidepressant prescribing has increased in all age and sex groups. This indicates either that there have been changes in the presentation, recognition and management of depression in general practice or that the prevalence of depression has increased, or a combination of these two phenomena. The higher prescribing rate in females is in keeping with evidence from psychiatric morbidity surveys suggesting that women experience higher levels of psychiatric morbidity than men. Decreases in the ratio of female to male prescribing, however, support other data indicating that, relative to females, the mental health of young males has declined in recent years. Changes in patterns of help-seeking may also contribute to the observed trends.

Adolescent↗
PubMed2001

Childhood housing conditions and later mortality in the Boyd Orr cohort.

STUDY OBJECTIVES: To examine associations between five measures of housing conditions during childhood and subsequent mortality from all causes, coronary heart disease, stroke, and cancer. DESIGN: Historical cohort study. SETTING: Data on housing conditions were collected from survey centres in 16 areas of England and Scotland. PARTICIPANTS: Children of families participating in the Carnegie Survey of Family Diet and Health in pre-war Britain (1937-1939). Analyses are based on a subset of 4168 people who were traced and alive on 1 January 1948. MAIN RESULTS: Poorer housing conditions were generally associated with increased adult mortality. After adjustment for childhood and adult socioeconomic factors, statistically significant associations were only found between lack of private indoor tapped water supply and increased mortality from coronary heart disease (hazard ratio 1.73, (95% CI 1.13, 2.64); and between poor ventilation and overall mortality (hazard ratio for people from households with poorest ventilation relative to best ventilation 1.30, 95% CI 0.97, 1.74). CONCLUSIONS: This study provides evidence that associations between housing conditions in childhood and mortality from common diseases in adulthood are not strong, but are in some respects distinguishable from those of social deprivation.

Adult↗
PubMed2001

Leg length, insulin resistance, and coronary heart disease risk: the Caerphilly Study.

BACKGROUND: Adult height has been inversely associated with coronary heart disease risk in several studies. The mechanism for this association is not well understood, however, and this was investigated by examining components of stature, cardiovascular disease risk factors and subsequent coronary heart disease in a prospective study. METHODS: All men aged 45-59 years living in the town of Caerphilly, South Wales were approached, and 2512 (89%) responded and underwent a detailed examination, which included measurement of height and sitting height (from which an estimate of leg length was derived). Participants were followed up through repeat examinations and the cumulative incidence of coronary heart disease-both fatal and non-fatal-over a 15 year follow up period is the end point in this report. RESULTS: Cross sectional associations between cardiovascular risk factors and components of stature (total height, leg length and trunk length) demonstrated that factors related to the insulin resistance syndrome-the homeostasis model assessment of insulin resistance, fasting triglyceride levels and total to HDL cholesterol ratio-were less favourable in men with shorter legs, while showing reverse or no associations with trunk length. Fibrinogen levels were inversely associated with leg length and showed a weaker association with trunk length. Forced expiratory volume in one second was unrelated to leg length but strongly positively associated to trunk length. Other risk factors showed little association with components of stature. The risk of coronary heart disease was inversely related to leg length but showed little association with trunk length. CONCLUSION: Leg length is the component of stature related to insulin resistance and coronary heart disease risk. As leg length is unrelated to lung function measures it is unlikely that these can explain the association in this cohort. Factors that influence leg length in adulthood-including nutrition, other influences on growth in early life, genetic and epigenetic influences-merit further investigation in this regard. The reported associations suggest that pre-adult influences are important in the aetiology of coronary heart disease and insulin resistance.

Anthropometry↗
PubMed2001

Patterns and predictors of hospitalisation in first-episode psychosis. Prospective cohort study.

BACKGROUND: Little is known about predictors of hospitalisation in patients with first-episode psychosis. AIMS: To identify the pattern and predictors of hospitalisation of patients with a first psychotic episode making their first contact with specialist services. METHOD: Three-year follow-up of a cohort of 166 patients with a first episode of psychosis making contact with psychiatric services in Nottingham between June 1992 and May 1994. RESULTS: Eighty-eight (53.0%) patients were admitted within 1 week of presentation; 32 (19.3%) were never admitted during the 3 years of follow-up. Manic symptoms at presentation were associated with an increased risk of rapid admission and an increased overall risk of admission; negative symptoms and a longer duration of untreated illness had an increased risk of late admission. CONCLUSIONS: Community-oriented psychiatric services might only delay, rather than prevent, admission of patients with predominantly negative symptoms and a longer duration of untreated illness. First-episode studies based upon first admissions are likely to be subject to selection biases, which may limit their representativeness.

Adolescent↗
PubMed2001

Association between schizophrenia and social inequality at birth: case-control study.

BACKGROUND: The association between social inequality at birth and subsequent risk of schizophrenia is uncertain. AIMS: To investigate the relationship between adult-onset schizophrenia and two indicators of social inequality at birth: social class and area of residence. METHOD: A matched case-control design was used with data from birth certificates of first-episode cases and age- and gender-matched controls. RESULTS: Risk increased with increasing levels of deprivation at birth. Subjects whose fathers were social class IV-V or who were born in deprived areas were at increased risk of schizophrenia (odds ratio=2.1; 95% Cl=0.8-5.5). Risk was greater in those with both of these indicators (odds ratio=8.1; 95% Cl=2.7-23.9). There was some evidence that associations were stronger in older subjects. Exclusion of African-Caribbeans or cases with positive family history somewhat attenuated the association. CONCLUSIONS: Indicators of social inequality at birth are associated with increased risk of adult-onset schizophrenia, suggesting that environmental factors are important determinants of schizophrenic disorders.

Age Factors↗
PubMed2001

Guidelines and educational outreach visits from community pharmacists to improve prescribing in general practice: a randomised controlled trial.

OBJECTIVES: To evaluate the effectiveness of guidelines with or without one-to-one educational outreach visits by community pharmacists in improving general practice prescribing for non-steroidal anti-inflammatory drugs (NSAIDs). METHODS: Cluster randomised trial of 20 general practices within Avon, England. Practices were randomised to three groups: control; mailed guidelines; mailed guidelines plus educational outreach visits. General practitioners (GPs) in the latter group received two one-to-one outreach visits from community pharmacists. Changes in prescribing were measured using outcomes derived from prescribing analysis and cost (PACT) data. The primary outcome measure was change in the volume of prescribing for ibuprofen, diclofenac and naproxen as a percentage of total NSAID prescribing. Six secondary outcomes included other measures of prescribing quality and volume. A cost-benefit analysis was performed. RESULTS: No significant differences were observed for the primary outcome measure: practices receiving outreach visits prescribed only 2.1% [95% confidence interval (CI): -0.8 to 5.0] more of the three recommended NSAIDs than the control practices did and 1.6% (95% CI: -1.4 to 4.7) more than practices that received guidelines only. Following adjustment for multiple comparisons, only one secondary outcome showed a statistically significant difference between the groups: the proportion of prescribing of the five most frequently used drugs was 2.2% (95% CI: 0.9 to 3.6) higher in the educational outreach group compared with the control group. A net increase in costs was shown with both interventions. CONCLUSIONS: Although good prescribing at baseline in the participating practices limited the capacity for improvement, this trial provides no evidence that guidelines with or without educational outreach visits from community pharmacists lead to substantial improvements in prescribing behaviour.

Anti-Inflammatory Agents, Non-Steroidal↗