Search PubMed⌕ Search

Biomedical subjects

D M Fleming

Publications and source records attributed to D M Fleming.

At least 37 records · Page 2Linked to original sources
PubMed2002

Perceptions of influenza and influenza vaccination in patients attending hospital outpatient clinics.

Influenza remains a major cause of morbidity and disruption to health services during winter. Annual vaccination of risk groups is the mainstay of influenza management policy. Despite much national publicity, vaccine uptake remains below desired levels. We investigated the perceptions of influenzal illness and opinions on vaccination in hospital outpatients attending clinics associated with risk and non-risk (i.e. control) morbidities. There were 270 recruited patients in risk groups: 90 each from diabetic, respiratory and cardiac clinics and equal numbers in three age groups (40-49, 50-59, 60-69 years). Equal numbers of controls were recruited from colorectal, fracture and dermatology clinics. The perceptions of influenza and knowledge of the preventive value of vaccination were fairly accurate in both groups. Fewer people in both groups had been vaccinated than had been specifically advised to be vaccinated. Advice for vaccination had been received by fewer people attending the cardiac clinic than the other two risk associated clinics. More use could be made of the health education opportunity afforded by attendance at hospital outpatient clinics.

Adult↗
PubMed2002

Impact of infections on primary care--greater than expected.

Though infection has declined as a cause of death it consumes a major proportion of primary care resources, and because of antibiotic resistance is increasingly important. We examined the burden of illness attributable to infection in primary care by analysing data from the fourth practice-based national morbidity survey which monitored all consultations by diagnosis in 470,000 persons over a 12 month period from September 1991 to August 1992. Rates of persons consulting, new episodes of illness and consultations were calculated according to the list of infections published by Wilson and Bhopal (W&B list), and as amended by the Communicable Disease Surveillance Centre (CDSC list); selected comparisons were made with national data on hospital derived finished consultant episodes and deaths. Forty-one percent of all registered persons consulted on at least one occasion during the year for infection (estimated by either list). Infections accounted for 40% of all new episodes of illness and 29% of all consultations; respiratory infections accounted for approximately half the infection total. New episode rates were highest in children aged less than 1 year and lowest in males 25-54 years and females 55-64 years. Except in infancy, rates were higher in females. There were 734 episodes of infection annually per 1,000 population reported in general practice compared with 20 per 1,000 finished consultant episodes. The average episode of infection prompted 1.2 general practice consultations. Improved management through more precise diagnosis by near patient tests is desirable, but is unlikely to be obtained cost effectively if consultation numbers or the time spent is substantially increased. These results emphasise the importance of adequate training for general practitioners in the natural history, epidemiology, diagnosis and treatment (pharmacology) of infection.

Adolescent↗
PubMed2001

Influenza diagnosis and treatment: a view from clinical practice.

Influenza is a descriptive term for respiratory epidemic disease presenting with cough and fever. Influenza viruses are probably the most important of the pathogens that cause this condition. Clinical influenza occurs almost every winter in England and Wales and the outbreaks last 8-10 weeks. In recent years, influenza B virus outbreaks have occurred in January and February, whereas influenza H3N2 virus outbreaks have generally started long before Christmas. Influenza H3N2 virus outbreaks pressurize health service resources in winter more than influenza B viruses, that do not have the same impact in elderly people. Infections with influenza H1N1 viruses are also usually less severe in their impact than those with influenza H3N2 viruses, but, unlike influenza B viruses, influenza H1N1 viruses have a pandemic potential along with influenza H3N2 viruses. A diagnosis of respiratory infection in primary care is based on the presenting symptoms set within the context of the current pattern of consultations of patients with similar illness. Measurement of temperature, inspection of the throat and examination of the chest or ears add a little to the diagnostic process, but in general these procedures do not help in identifying the organism. However, if it is known that influenza viruses are circulating in the community, the probability of influenza as the cause is greatly increased, as was shown in clinical trials of neuraminidase antivirals. Maximum confusion occurs when respiratory syncytial virus (RSV) and influenza cocirculate. Although RSV infection can occur throughout the winter in young children, it assumes more of an epidemic character just before Christmas in children and possibly in adults just after. During seven of the last 20 winters, influenza has been prevalent around Christmas/New Year. In routine virological surveillance of influenza-like illness in the community during the winters of 1997, 1998 and 1999, ca. 30% of swab specimens yielded influenza viruses and 20% RSV. Given the limitations for routine surveillance, including variations in the interval between illness onset and specimen capture, the quality of swab, delays in transport, the growth properties of virus culture methods, etc., these figures probably underestimate the impact of both viruses in the community. The impact of influenza is considered against the background of total respiratory infections presenting to general practitioners over the last 10 years and some comparisons are made with the 1969 pandemic experience. Lessons relevant to pandemic planning are drawn. Current options for investigation and treatment are compared with those available in 1969. These include near-patient tests for assisting with diagnosis, widespread use of vaccination as a preventive in patients at increased risk, the availability of amantadine and the newer neuraminidase inhibitor antivirals and changes in the delivery of health care. Major advances in the understanding of influenza and improvements in investigation and treatment have taken place over the last 30 years. However, there are many obstacles before these can be translated into effective management of influenza sufferers and control of major epidemics.

Antiviral Agents↗
PubMed2001

Contribution of influenza and respiratory syncytial virus to community cases of influenza-like illness: an observational study.

BACKGROUND: Respiratory syncytial virus (RSV) is an important cause of lower-respiratory-tract infection in children and elderly people, but its effect in other age-groups is uncertain. We did a community-based observational study of RSV infection in community-dwelling individuals of all ages who presented to general practices in the UK with influenza-like illnesses during three successive winters (1995-96, 1996-97, and 1997-98). METHODS: Nasopharyngeal swabs routinely submitted for virological surveillance were examined by multiplex reverse transcription PCR for influenza A and B viruses and RSV A and B, and findings were related to the clinical incidence of influenza-like illness and acute bronchitis at that time. RSV strains identified were compared with those obtained from hospital admissions. FINDINGS: 480 RSV and 709 influenza viruses were identified from a total of 2226 swabs submitted. Both types of virus were found in all age-groups for between 12 and 20 weeks in each winter. RSV A accounted for 60% of RSV detections. Similar strains of RSV were present in hospital and community patients within the same year, but there were different lineages each year. INTERPRETATION: In individuals diagnosed with influenza-like illness, there is a substantial potential for confusion between illnesses caused by influenza and those caused by RSV. The burden of illness attributable to each needs to be clarified to define optimum management routines.

Adolescent↗
PubMed2001

Excess hospital admissions for pneumonia and influenza in persons > or = 65 years associated with influenza epidemics in three English health districts: 1987-95.

OBJECTIVES: To study the association between community influenza activity and acute hospital admissions for pneumonia and influenza among elderly persons. DESIGN: Multiple regression analysis of acute hospital admissions against community influenza activity, air temperature and seasonal and long-term trends. SETTING: Three English health districts: 1987-95. SUBJECTS: Persons aged > or = 65 years. OUTCOME MEASURES: Acute hospital admissions for pneumonia and influenza (ICD9: 480-487); excess hospital admissions during epidemic periods. RESULTS: The final regression model explained 70% of the total variation in hospital admissions for pneumonia and influenza, including 14% due to community influenza activity. However, most variation was explained by long-term and seasonal changes unrelated to influenza. In the large influenza epidemic of 1989/90 a typical health district (500,000 total population) experienced 56 excess admissions for pneumonia and influenza attributable to epidemic influenza among persons aged > or = 65 years, requiring 672 additional bed-days. However the figure varied widely between seasons and over the whole study period, the average winter excess was 17.5 admissions per health district, requiring an additional 210 bed-days. CONCLUSIONS: Influenza epidemics exert a variable impact on acute hospital admissions for pneumonia and influenza among elderly persons, which in the past have been poorly quantified. Although the absolute numbers of excess admissions is modest, their impact on bed availability may be considerable because of the duration of hospital stay in elderly persons.

Age Factors↗
PubMed2001

The incidence of chickenpox in the community. Lessons for disease surveillance in sentinel practice networks.

Sentinel practice networks have been established in many European countries to monitor disease incidence in the community. To demonstrate the value of sentinel networks an international study on the incidence of chicken pox has been undertaken. Chickenpox was chosen as an acute condition for which incidence data are important to the determination of health policy on vaccine use. The project examined the incidence of chickenpox reported in sentinel networks in England and Wales, The Netherlands, Portugal and Spain (two regional networks) in January-June 2000 and the potential underestimate from patients who did not consult. An investigation of secondary household contact cases was undertaken. Reported incidence of chickenpox (all ages) in England and Wales was 25 per 10,000, in The Netherlands 13 per 10,000, in Portugal 21 per 10,000, in Spain Castilla y Leon 27 per 10,000 and in Spain Basque 55 per 10,000. Analysis of secondary contact cases suggested underestimation of incidence between 2.4% in Spain Castilla y Leon and 32.2% in The Netherlands. There was a trend towards incidence at an earlier age in England and Wales and in The Netherlands compared with Portugal and Spain. Whilst there was little problem in reliably identifying the number of incident cases in the recording networks and relating the non-consulting contact cases to them, the security of the denominator remains a problem where networks are comprised of differing categories of health care provider. It is essential that numerator and denominator information are made available specifically for each category.

Adolescent↗
PubMed2001

Update on influenza and other viral pneumonias.

Major developments during the past 5 years concerning influenza prevention by vaccination and treatment with neuraminidase inhibitors are reviewed. These have been accompanied by increased media interest in related issues: pressures on hospital admissions, ethical concerns and controls on prescribing limiting professional autonomy. The new live attenuated influenza vaccines, adjuvanted vaccines and the emerging recombinant DNA vaccines are discussed. Recent information on neuraminidase inhibitor antivirals, surveillance for resistant viruses, the prospects for near patient tests (i.e. tests that can be used near the patient to improve immediate patient management or in the laboratory to give rapid feedback for physicians) and the clinical significance of other respiratory viruses are highlighted. The benefits of recent advances provide challenges for health care delivery and public acceptance as great as those involved in their scientific development.

Animals↗
PubMed2001

Cost-effectiveness analysis of inhaled zanamivir in the treatment of influenza A and B in high-risk patients.

OBJECTIVE: To evaluate the cost effectiveness of zanamivir 10 mg twice daily for 5 days in the treatment of influenza in high-risk patients. DESIGN: Bootstrap cost-effectiveness analysis incorporating within-trial analysis of pooled patient-level cost and effect data. SETTING: UK unit costs and utilities applied to high-risk patients drawn from 6 multinational clinical trials. PATIENTS: A total of 154 zanamivir and 167 placebo high-risk patients were included in the analysis. MAIN OUTCOME MEASURES: Cost per day of normal activities; cost per symptom-free day; cost per complication averted; cost per quality-adjusted life-year (QALY). RESULTS: The mean benefit was estimated to be 2.5 days [95% confidence interval (CI): 0.68 to 4.27] of normal activities gained; 2.0 (95% CI: 0.56 to 3.51) symptom-free days; and a 9% reduction in complications (95% CI: 0 to 18%). Excluding the effect of rare hospitalisation costs, the cost (1999 values) of gaining a day of normal activities was 9.50 Pounds (95% CI: 5 Pounds to 39 Pounds); cost per symptom-free day was 11.56 Pounds (95% CI: 6 Pounds to 43 Pounds); cost per complication averted was 262 Pounds (95% CI: 90 Pounds to 1574 Pounds). Influenza was estimated to reduce utility by 0.883 per day, demonstrating the debilitating effect of the disease. Extrapolating a day of normal activities to a standard utility measure resulted in a cost per QALY of 3900 Pounds excluding inpatient costs (7490 Pounds including inpatient costs). Cost-effectiveness acceptability curves demonstrated 90% certainty that zanamivir would be cost effective at 8000 Pounds per QALY. CONCLUSIONS: Significant health benefits can be obtained with zanamivir treatment in high-risk patients. The cost per QALY for zanamivir in these patients compares well with that of other commonly used pharmacological interventions.

Administration, Inhalation↗
PubMed2001

Managing influenza: amantadine, rimantadine and beyond.

Amantadine and rimantadine are effective in the treatment and prophylaxis of influenza A. Neither drug, however, has achieved widespread acceptance because of the rapid development of viral resistance, their lack of activity against influenza B and, in the case of amantadine, adverse events. Complete cross-resistance occurs with these compounds and is associated with a single nucleotide change in the M2 protein. Resistant variants are transmissible and fully pathogenic. Zanamivir is the first widely approved neuraminidase inhibitor for the treatment of influenza. It is delivered directly to the primary site of viral replication, the respiratory tract, and is well tolerated and effective in the treatment of both influenza A and B. Data in prophylaxis are also encouraging. During the extensive clinical programme no evidence for the emergence of drug-resistant strains with acute therapy was found. Zanamivir represents a significant advance over older agents in the management of influenza A and B.

Adolescent↗
PubMed2001

Detection of influenza a subtypes in community-based surveillance.

A rapid microtitre cell enzyme immuno assay (cell-EIA) was developed for the detection of influenza A subtypes in nasopharyngeal(NPS) swabs taken for surveillance. During the 1997/1998 influenza season in the United Kingdom, cell-EIA was compared to cell culture for the detection and typing of influenza A viruses in NPS obtained by sentinel general practitioners in community surveillance. The cell EIA can also be used to detect different influenza A subtypes (H3N2, H1N1, H5N3, H5N1, H7N7, and H9N2) and was used as a rapid detection assay for the screening of individuals returning from Hong Kong with influenza-like illness suspected to be due to H5N1 in 1997/98, providing a rapid, efficient, inexpensive method for the screening of influenza A cases during an outbreak or pandemic situation. The cell-EIA results reflected the results obtained by traditional virus culture within the age distribution of samples, clinical symptoms, and time between date of illness onset and sampling of cases, indicating its usefulness in surveillance of human and non-human influenza viruses. During two outbreaks of influenza in schools, Directigen Flu-A, a near patient test, the cell-EIA, and tissue culture were compared. The cell-EIA gave higher sensitivity and specificity (74% and 90%) than Directigen Flu-A (65% and 84.6%) in comparison with cell culture.

Animals↗
PubMed2001

The prevalence of asthma and heart disease in transport workers: a practice-based study.

BACKGROUND: There has been widespread concern that the increasing incidence of asthma observed during the late 1980s might have arisen because of environmental pollution, and in particular vehicle pollution. The General Practice Morbidity Survey in 1991/92 (MSGP4) collected data on occupation, employment status, and smoking habit linked individually to each patient record. OBJECTIVES: To examine whether people with occupations that have high exposure to vehicle exhaust fumes have an increased prevalence of asthma, acute respiratory infections, and ischaemic heart disease (IHD). METHOD: Men aged 16 to 64 years were grouped by Standard Occupational Classification codes; 93,692 employed and 20,858 not-employed men were studied separately. Those with likely high occupational exposure were grouped together ('all-exposed')--the remainder occupations in corresponding chapters of the code were used as controls. We compared 12-month age and smoking standardised disease prevalence ratios for asthma, chronic obstructive pulmonary disease (COPD), acute respiratory infections (IHD), and all circulatory disorders in the all exposed and individual exposed occupations with their matching controls. Also the mean frequency of consultations per person consulting was calculated for each occupational group and disease. RESULTS: For employed persons, the prevalence ratio (PR) for asthma in the all-exposed, (116, 95% confidence interval [95% CI] = 101-130) exceeded that for all employed persons (100); however, the difference compared with chapter-matched controls (PR = 97, 95% CI = 92-103), was not statistically significant. Results for COPD were similar. Prevalence ratios in motor mechanics, a high-exposure group, were 98 (95% CI = 70-127) 96 (95% CI = 70-123) for asthma and COPD respectively. Among the employed, prevalence ratios for IHD in all but one of the individual occupation groups examined did not differ from the average, however among those not employed the ratio in the all-exposed (PR = 152, 95% CI = 128-174) exceeded that in the controls (PR = 112, 95% CI = 104-120). CONCLUSION: Occupational groups exposed to motor vehicle pollution have a marginally increased prevalence of asthma compared with working males generally, though not compared with occupation matched controls. This study has demonstrated a methodology for using GP data to examine occupation-related disease. This could be used in future by augmenting GP data with occupation and smoking information.

Adolescent↗
PubMed2000

Population estimates of persons presenting to general practitioners with influenza-like illness, 1987-96: a study of the demography of influenza-like illness in sentinel practice networks in England and Wales, and in The Netherlands.

Incidence data by age of new episodes of influenza-like illness reported by sentinel general practice networks in England and Wales and in The Netherlands over a 10-year period were examined to provide estimates of the consulting population during influenza epidemic periods. Baseline levels of recording in each age group were calculated from weeks in which influenza viruses were not circulating and the excess over baseline calculated to provide the population estimates during influenza epidemics. Influenza A/H3N2 epidemics were associated with higher population estimates for consultations than influenza B, especially in the age groups 0-4 and 65 years and over. In the intervening age groups, population estimates were more consistent regardless of the virus type. Both networks reported simultaneous peaking of incidence rates in all of the age groups. There were substantial increases in the number of persons reporting other respiratory illnesses during influenza epidemics. Population estimates of the consulting population provide the only secure basis for which health services resource utilization during influenza epidemics can be estimated.

Adolescent↗
PubMed2000

Clinical efficacy and safety of the orally inhaled neuraminidase inhibitor zanamivir in the treatment of influenza: a randomized, double-blind, placebo-controlled European study.

OBJECTIVES: To assess the clinical efficacy and safety of orally inhaled zanamivir in the treatment of influenza in a European primary care setting. METHODS: This was a randomized, double-blind, placebo-controlled trial in primary care and hospital clinics in 11 European countries. Patients aged > or = 12 years were recruited within 2 days of onset of typical influenza symptoms and received orally inhaled zanamivir 10 mg via a Diskhaler twice daily for 5 days or matching placebo. Influenza symptoms and temperature were recorded daily for 14 days. The primary endpoint was time to alleviation of clinically significant symptoms of influenza. Other endpoints included symptom severity, use of relief medications, time to return to normal activities, complications and investigator's assessment of symptoms. RESULTS: A total of 356 patients were recruited; 277 (78%) had laboratory-confirmed influenza and 32 (9%) were considered high-risk (i.e. elderly or with underlying medical conditions). Zanamivir significantly reduced the time to alleviation of symptoms versus placebo (median 5 days versus 7.5 days, P<0.001), a 33% reduction in duration of illness. Zanamivir significantly reduced the severity of several symptoms; improvements versus placebo were discernible after approximately 24 h. The proportion of patients who were afebrile after 24 h increased by 46% versus placebo. Similar treatment benefits were observed in the high-risk patients. Zanamivir was well tolerated, with an adverse event profile similar to that of placebo. CONCLUSIONS: Zanamivir is effective in reducing the duration and severity of influenza illness and is well tolerated. Zanamivir should therefore be a clinically valuable intervention in the management of influenza.

Adolescent↗
PubMed2000

Declining incidence of episodes of asthma: a study of trends in new episodes presenting to general practitioners in the period 1989-98.

BACKGROUND: A study was undertaken to determine trends in the incidence of new episodes of asthma presented to general practitioners participating in the Weekly Returns Service of the Royal College of General Practitioners, comprising 92 practices with a registered population of approximately 680 000 persons well distributed throughout England and Wales. These practices monitor the morbidity presented at every consultation, distinguishing between new episodes of illness and ongoing consultations. METHODS: Age specific weekly rates of new episodes of asthma (and of acute bronchitis) presenting to the general practitioners over the years 1989-98 were examined in four week blocks and analysed by multiple regression, separating secular from seasonal trends. RESULTS: Quadratic trends in episodes of asthma were evident in each of the age groups with peaks in 1993/4. Corresponding analyses for acute bronchitis disclosed similar trends generally peaking in the winter of 1993/4. Mean weekly incidence data (all ages combined) decreased in all quarters since 1993. Regional analysis (North/Central/South) showed similar decreases. CONCLUSIONS: There has been a gradual decrease in the incidence of asthma episodes and of acute bronchitis presenting to general practitioners since 1993. The trend of an increase before 1993 followed by a decrease cannot be explained by changes in the patterns of health care usage or diagnostic preference of doctors.

Adolescent↗
PubMed2000

Comparison of the seasonal patterns of asthma identified in general practitioner episodes, hospital admissions, and deaths.

BACKGROUND: Seasonal variations in asthma are widely recognised. This study was undertaken to investigate the relative differences in seasonal patterns by age as they impact on episodes of care in general practice, hospital admissions, and deaths. METHODS: General practice episode data from the Weekly Returns Service of the Royal College of General Practitioners, hospital admissions for asthma in England, and deaths registered as due to asthma in England and Wales over the years 1990-7 were examined. Age specific weekly rates of new episodes of asthma presenting to general practitioners, numbers of hospital admissions and deaths were analysed by the multiplicative decomposition method to separate secular from seasonal trends. The seasonal indices thereby obtained were plotted as three week moving averages. RESULTS: In children aged 0-4 and 5-14 years general practice episodes and admissions to hospital were strikingly congruent in timing and in magnitude, except in September when particularly high rates of admission (absolute and relative to general practice episodes) occurred. In the 15-44 age group there were marked mid summer peaks of general practice episodes and deaths but admissions to hospital were at about the annual average; in September/October there were peaks of episodes and admissions whereas deaths peaked in November. In the 45-64 age group a peak in general practice episodes of asthma was evident in mid summer when admissions were about average and deaths were at a minimum; all three measures tended to increase gradually with the approach of winter. Finally, in those age over 65 years, general practice episodes of asthma, admissions to hospital, and deaths followed similar 'U' shaped patterns with substantial peaks in mid winter. CONCLUSIONS: The seasonal pattern of asthma evolves with age. There are important differences in the seasonal pattern of general practice episodes, admissions to hospital, and deaths. Individual seasonal histories are important for the management of asthma. The combined analysis of these three data sets provides a new perspective on the epidemiology of asthma.

Adolescent↗
PubMed2000

Impact of zanamivir treatment on productivity, health status and healthcare resource use in patients with influenza. Zanamivir Study Group.

OBJECTIVE: This study examined the impact of zanamivir treatment on patient morbidity in patients with influenza. DESIGN AND SETTING: This was a multicentre, randomised, double-blind, parallel-group study conducted in 14 countries in Europe and North America during the winter of 1995/1996. PATIENTS AND PARTICIPANTS: The study included 722 individuals with virologically confirmed influenza. INTERVENTIONS: Two different zanamivir treatment regimens [twice daily (bid) or 4 times daily (qid) for 5 days] were compared with placebo. MAIN OUTCOME MEASURES AND RESULTS: Efficacy was measured using a number of patient-assessment questionnaires. Results showed that significantly fewer patients with influenza who were treated with zanamivir had additional contacts with healthcare professionals compared with those who received placebo (8 vs 14%; p < or = 0.049, bid and qid vs placebo). Individuals treated with zanamivir also spent fewer days absent from work (placebo: mean = 3.28 days; qid: mean = 2.52 days; p = 0.031) or college/school (placebo: mean = 2.90 days; bid: mean = 2.24 days; p = 0.032), and showed significant improvements in productivity compared with placebo. The health status questionnaire revealed significant improvements in patient well-being over the first 5 days of the study in those treated with zanamivir compared with those who received placebo. CONCLUSIONS: Zanamivir treatment reduced absenteeism, improved patient productivity and well-being, and reduced the additional use of healthcare resources in patients with influenza.

Adult↗
PubMed2000

The contribution of influenza to combined acute respiratory infections, hospital admissions, and deaths in winter.

The impact of influenza is assessed by comparing events during epidemics with those expected outside epidemic periods (defined from incidence data collected by the Weekly Returns Service of the Royal College of General Practitioners from 1989 to 1998 for influenza-like illness, acute otitis media, acute bronchitis, and all respiratory infections combined in the community and virus isolate data). Estimates of the consulting populations for each condition in England and Wales were derived by extrapolating the difference between observed and baseline incidence rates to the total population. Similar methods were applied to data on hospital admissions for cardiac and respiratory diseases and to deaths. Each year an average of 422,000 extra people consulted and were diagnosed with influenza-like illness during the epidemic period; among 1.1 million extra people who presented with acute respiratory infections. There were 3028 excess respiratory admissions (England only) in the age group 65 to 74 years and 6049 who were aged over 75 years, but no excess cardiac admissions. An average of 12,554 deaths occurred in England and Wales during influenza epidemic periods each year. Age specific national data are needed to interpret the economic impact of an illness in relation to the setting for health care delivery.

Acute Disease↗