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Biomedical subjects

M C Gulliford

Publications and source records attributed to M C Gulliford.

At least 19 recordsLinked to original sources
PubMed2006

Incidence of common compressive neuropathies in primary care.

Apart from carpal tunnel syndrome, there are no population based studies of the epidemiology of compressive neuropathies. To provide this information, new presentations of compressive neuropathies among patients registered with 253 general practices in the UK General Practice Research Database with 1.83 million patient years at risk in 2000 were analysed. The study revealed that in 2000 the annual age standardised rates per 100 000 of new presentations in primary care were: carpal tunnel syndrome, men 87.8/women 192.8; Morton's metatarsalgia, men 50.2/women 87.5; ulnar neuropathy, men 25.2/women 18.9; meralgia paraesthetica, men 10.7/women 13.2; and radial neuropathy, men 2.97/women 1.42. New presentations were most frequent at ages 55-64 years except for carpal tunnel syndrome, which was most frequent in women aged 45-54 years, and radial nerve palsy, which was most frequent in men aged 75-84 years. In 2000, operative treatment was undertaken for 31% of new presentations of carpal tunnel syndrome, 3% of Morton's metatarsalgia, and 30% of ulnar neuropathy.

Adult↗
PubMed2005

Intraclass correlation coefficient and outcome prevalence are associated in clustered binary data.

BACKGROUND AND OBJECTIVE: To describe the association between values for a proportion and the intraclass correlation coefficient (ICC). METHODS: Analysis of data obtained from the General Practice Research Database (GPRD) for variation between United Kingdom general practices and results from a Health Technology Assessment (HTA) review for a range of outcomes in community and health services settings. RESULTS: There were 188 ICCs from the GPRD, the median prevalence was 13.1% (interquartile range IQR 3.5 to 28.4%) and median ICC 0.051 (IQR 0.011 to 0.094). There were 136 ICCs from the HTA review, with median prevalence 6.5% (IQR 0.4 to 20.7%) and median ICC 0.006 (IQR 0.0003 to 0.036). There was a linear association of log ICC with log prevalence in both datasets (GPRD, regression coefficient 0.61, 95% confidence interval 0.53 to 0.69, P < 0.001; HTA, 0.91, 0.81 to 1.01, P < 0.001). When the prevalence was 1% the predicted ICC was 0.008 from the GPRD or 0.002 from the HTA, but when the prevalence was 40% the predicted ICC was 0.075 (GPRD) or 0.046 (HTA). CONCLUSION: The prevalence of an outcome may be used to make an informed assumption about the magnitude of the intraclass correlation coefficient.

Data Interpretation, Statistical↗
PubMed2005

Trends in antihypertensive and lipid-lowering therapy in subjects with type II diabetes: clinical effectiveness or clinical discretion?

Hypertension and lipid disorders in type II diabetes contribute to increased coronary risk, but optimal drug therapy has not been defined. We investigated primary care physicians choices of antihypertensive and lipid-lowering therapy for subjects with type II diabetes diagnosed with hypertension. Subjects were registered with 105 UK general practices in the General Practice Research Database and prescribed oral hypoglycaemic drugs for the first time between January 1993 and December 2001. We evaluated prescriptions for antihypertensive drugs in subjects with secondary diagnoses of hypertension in the first year following initiation of oral hypoglycaemic therapy. Data were analysed for 4519 diabetic subjects with diagnosed hypertension. Between 1993 and 2001, the proportion prescribed thiazide diuretics increased from 20 to 30%; angiotensin-converting enzyme (ACE) inhibitors from 35 to 45% and angiotensin receptor blockers from 0 to 8%. The proportion of subjects prescribed lipid-lowering therapy increased from 8% in 1993 to 33% in 2001, with the proportion prescribed statins increasing from 1 to 30%. At different general practices, the proportion prescribed thiazide diuretics ranged from 0 to 52%, beta-blockers from 5 to 60%, ACE inhibitors from 15 to 81%, and statins from 0 to 50%. Variation between practices was not explained by adjusting for age, sex, prevalent coronary heart disease or study year. Trends in drug utilisation were consistent with the evolving evidence base but there were wide variations in drug utilisation between practices. A more consistent approach to drug selection might be associated with improved patient outcomes.

Adrenergic beta-Antagonists↗
PubMed2005

Changing patterns of primary care for diabetes in Trinidad and Tobago over 10 years.

OBJECTIVE: To evaluate standards of preventive medical care for Type 2 diabetes in the context of high prevalence and limited resources. METHODS: Surveys of records for diabetic subjects attending 23 government primary care health centres in Trinidad and Tobago in 2003 and 1998 and nine health centres in 1993. Records were compared by study year for blood glucose and blood pressure, surveillance for complications, appropriate management advice and drug prescriptions. Relevant interventions included new clinical guidelines, training workshops for clinical staff and reports to the Ministry of Health. During this time, investment in primary care increased in the context of health sector reform policies and a favourable macroeconomic environment. RESULTS: Comparing 1993 with 2003, the proportion with a blood glucose test in the past 12 months increased from 33% to 91%, urea or creatinine ever recorded increased from 14% to 61%, diet advice recorded in the first 12 months of follow-up from 35% to 67%, exercise advice from 3% to 61%. The proportion prescribed metformin increased from 25% to 65%, while chlorpropamide decreased from 48% to 0%. The proportion of all subjects treated with antihypertensive drugs increased from 49% to 70%, and the proportion of treated patients prescribed angiotensin-converting enzyme inhibitors increased from 8% to 72%. Most recent ever records of blood glucose, blood pressure and body weight showed no decrease. CONCLUSIONS: Repeated surveillance of processes of care provided information to stimulate and plan change. Process changes were associated with intervention at several levels and increased availability of resources.

Attitude of Health Personnel↗
PubMed2004

Socioeconomic inequality in blood pressure and its determinants: cross-sectional data from Trinidad and Tobago.

We evaluated income- and education-related inequalities in blood pressure, hypertension and hypertension treatment in the general population of Trinidad and Tobago. The design included survey of 300 households in north central Trinidad, including 631 adults in 2001. Measurements of blood pressure, weight, height, waist and hip circumferences, and educational attainment, household income and alcohol intake by questionnaire. The slope index of inequality (SII) was used to estimate the difference in blood pressure between those with highest, as compared to lowest, socioeconomic status. Complete measurements and questionnaires were obtained for 461 (73%) including 202 men and 259 women. In women, after adjusting for age and ethnicity, the SII for systolic blood pressure by income was -12.6, 95% confidence interval -22.6 to -2.6 mmHg (P=0.013); and -10.8 (-21.4 to -0.2) mmHg (P=0.045) by educational attainment. After additionally adjusting for body mass index, waist-hip circumference ratio and self-reported diabetes, the SII for income was -7.3 (-16.5 to 1.9) mmHg (P=0.120) and for educational attainment was -3.0 (-13.0 to 6.9) mmHg (P=0.551). In men, after adjusting for age and ethnicity, the SII for systolic blood pressure by income was -4.3 (-15.4 to 6.8) mmHg (P=0.447) and for education -8.1 (-19.0 to 2.8) (P=0.145). There is a negative association of systolic blood pressure with increasing income or education in women. This is associated with body mass index, abdominal obesity and diabetes. There is no consistent association between education or income and blood pressure in men.

Adult↗
PubMed2004

Diabetes-related inequalities in health status and financial barriers to health care access in a population-based study.

AIMS: We evaluated the relationship between diabetes, health status, household income and expenditure on health care in the general population in Trinidad. METHODS: Multistage sampling of 300 households was used to select a sample of 548 adults aged > or = 25 years. There were 64 (12%) who reported a diagnosis of diabetes. Comparison was made with 128 non-diabetic controls who were frequency matched for age and sex. RESULTS: Subjects with diabetes had lower income levels than non-diabetic controls [income < or = US dollars 533 per month for 66% diabetes cases and 48% controls, test for trend P = 0.007]. Compared with controls, subjects with diabetes were less likely to have good or very good self-rated health (diabetes 32%, controls 67%; P < 0.001), and more frequently reported long-standing illness, limitation of activities, visual impairment, or self-reported history of high blood pressure, angina or heart attack. Subjects with diabetes (11%) were less likely than controls (30%) to have private health insurance (P = 0.005). Diabetic subjects (35%) were more likely than controls (16%) to have incurred expenditure on doctors' services in the last 4 weeks (P = 0.021). CONCLUSIONS: Diabetes is associated with worse health status and more frequent expenditure on medical services but greater financial barriers to access in terms of low income and lack of health insurance. Policies for diabetes should specifically address the problem of income-related variations in risk of diabetes, health care needs and barriers to uptake of preventive and treatment services, otherwise inequalities in health from this condition may increase.

Adult↗
PubMed2003

Geographical inequalities in lung cancer management and survival in South East England: evidence of variation in access to oncology services?

This study aimed to determine whether the management and survival of patients with lung cancer varied among 26 health authorities in South East England. The Thames Cancer Registry identified patients diagnosed with lung cancer (ICD-10 codes C33-C34) between 1995 and 1999. After excluding death certificate only patients, 32,818 (81%) patients were analysed. The proportions of patients receiving active treatment varied among health authorities between 5 and 17% for non-investigative surgery, 4 and 17% for any chemotherapy, 8 and 30% for any radiotherapy and 15 and 42% for any active treatment. One-year patient survival ranged from 11 to 34%. There was evidence of health authority level variation even after adjusting for case mix. Patients whose first hospital attendance was at a radiotherapy centre were more likely to receive active treatment (OR 1.72, 95% CI 1.21-2.46), chemotherapy (1.38, 1.06-1.79) or radiotherapy (1.86, 1.28-2.71). There was some evidence that patients whose first hospital attendance was at a radiotherapy centre survived longer. This study shows there is geographical inequality in the treatment given to lung cancer patients and patient survival in South East England. There was some evidence to suggest that these inequalities might be explained by variations in access to oncology services. Future studies should investigate the pathways and barriers to specialist care in this condition.

Adult↗
PubMed2003

Cigarette smoking, health status, socio-economic status and access to health care in diabetes mellitus: a cross-sectional survey.

BACKGROUND: In diabetes mellitus, cigarette smoking is associated with increased risk of cardiovascular mortality and microvascular complications. We evaluated cigarette smoking in people with diabetes mellitus in a socio-economically deprived area. METHODS: We carried out a cross-sectional survey of people registered with diabetes mellitus at 29 general practices in inner London. Responses were analysed for 1,899 (64%) respondents out of 2,983 eligible. RESULTS: There were 1,899 respondents of whom 968 (51%) had never smoked, 296 (16%) were current smokers and 582 (31%) were ex-smokers. Smoking was more frequent in white Europeans (men 22%, women 20%), than in African Caribbeans (men 15%, women 10%) or Africans (men 8%, women 2%). Smoking prevalence decreased with age. Smokers were more likely to be living in rented accommodation (odds ratio, OR 2.02, 95% confidence interval 1.48 to 2.74). After adjusting for confounding, current smokers had lower SF-36 scores than subjects who had never smoked (mean difference in physical functioning score -5.6, 95% confidence interval -10.0 to -1.2; general health -6.1, -9.7 to -2.5). Current smokers were less likely to have attended a hospital diabetic clinic in the last year (OR 0.59, 0.44 to 0.79), and their hypertension was less likely to be treated (OR 0.47, 0.30 to 0.74). CONCLUSIONS: Compared with non-smokers, smokers had lower socio-economic status and worse health status, but were less likely to be referred to hospital or treated for their hypertension. People with diabetes who smoke can be regarded as a vulnerable group who need more intensive support and treatment.

Adult↗
PubMed2003

Social inequalities and children's height in Trinidad and Tobago.

OBJECTIVE: The aim of the study was to report the association of socio-economic factors with child's height. DESIGN: Cross-sectional study based on a representative national sample of government schools. SETTING: Trinidad and Tobago in 1999. SUBJECTS: A total of 2608 boys and girls mean age 5.8 y, range 4.38-6.99 y and 3080 mean age 8.6 y, range 7.00-10.44 y olds. OUTCOME: Measurement of height and a questionnaire completed by parents. In the analysis height was expressed as standard deviation scores (s.d.s.) based on the British height curves (1990) or height below -1.5 s.d.s. RESULTS: Ethnicity, parental heights, birthweight, maternal age at child's birth and number of children in the family were the main factors associated with children's height. Lack of piped water supply in the home was the only socio-economic factor consistently associated with height (mean difference in s.d.s. adjusted only for age group, gender and ethnicity -0.192, 95% CI -0.257 to -0.127 and in addition adjusted for the variables listed above -0.080, 95% CI -0.141 to -0.019). Parental education, household overcrowding and employment status were weakly associated with height in the partially adjusted model only. Analysis of severe growth failure gave similar results. CONCLUSION: The impact of socio-economic factors on height is marginal in Trinidad and Tobago. As socio-economic factors may have an impact on a broad range of health indicators, height and rates of undernutrition should not be used as sole criteria for assessing progress in decreasing health differentials caused by social inequalities.

Birth Weight↗
PubMed2002

Free school meals and children's social and nutritional status in Trinidad and Tobago.

OBJECTIVE: To evaluate the provision of free school meals in Trinidad and Tobago in relation to children's social and nutritional status. DESIGN AND METHODS: Cross-sectional survey of a nationally representative sample of 66 government schools, including children in the admissions classes (aged 4 to 7 years) and classes for 'rising nines' (aged 7-10 years). Data included questionnaire details of free school meals and children's social background, and measurements of children's heights, weights and skinfold thicknesses. RESULTS: Of 6731 eligible children, data were analysed for 5688 (85%). There were 2386 (42%) children receiving free meals provided at school. At different schools the proportion of all children receiving free meals ranged from 20% to 100%, Receipt of free meals was associated with larger family size (one child, 32% received free meals; > or =6 children, 63%), lower paternal educational attainment (primary, 52% free; university, 30%), father's employment (employed, 39% free meals; unemployed >12 months, 59%) as well as maternal education and employment and household amenities. After adjusting for age, sex and ethnic group, children who received free meals were shorter (mean difference in height standard deviation score (SDS) -0.12, 95% confidence interval (CI) -0.17 to -0.06), lighter (body mass index SDS -0.21, -0.28 to -0.14) and thinner (subscapular skinfold SDS -0.13, -0.18 to -0.09). CONCLUSIONS: Free school meals were widely available, with some targeting of provision to children with less favourable social and nutritional status. Greater universality would reduce inequity, but more stringent targeting and reduction of school-level variation would increase efficiency.

Body Height↗
PubMed2001

Utilisation of private care by public primary care clinic attenders with diabetes: relationship to health status and social factors.

Private health care provision is important in most middle-income countries but factors influencing the demand for private care have not been well defined. This paper evaluated the relationships of health status and socio-economic variables with utilisation of private care by public primary care clinic attenders. The sample included 2117 randomly selected subjects with clinical diabetes attending 35 government health centres in Trinidad and Tobago. Measures included attendance at a private doctor, the type 2 Diabetes Symptom Checklist, the SF36 questionnaire, and indicators of socio-economic status. Of the sample, 1256 (59%) reported attending a private doctor, 577 (27%) attended a private doctor for diabetes, and 378 (18%) attended a private doctor regularly. Attendance at a private doctor was associated with lower SF36 scores. The odds ratio for a 10 unit increase in SF36 physical component score was 0.81, 95% confidence interval 0.72-0.91. After adjusting for demographic and social factors the relative odds were 0.89, 0.80 to 1.00. After allowing for differences in health status, the relative odds of attending for private care for those without a pipe borne water supply in the home, compared with those with water in the home, were 0.77, 0.63-0.94. Those living alone were less likely to attend a private doctor than those living with their children and partner (odds ratio 0.60, 0.43-0.83). Among people attending public clinics, the decision to utilise private care is sensitive to health status. After adjusting for health status, there was evidence for horizontal inequity in access to private care in relation to household amenities and composition.

Adult↗
PubMed2001

Evaluating variations in medical practice between government primary care health centres.

We evaluated variations in medical care for diabetes among government health centres in Trinidad and Tobago. Data were analysed for 1579 subjects with clinical diabetes attending 23 health centres concerning 12 processes of care and six case-mix or outcome variables. Random effects models were used for analysis. Health centre level variation was appreciable. Intraclass correlations ranged from 0.025 to 0.316 for process of care variables and 0.000 to 0.056 for case-mix variables. Compared with health centres with only one nurse, patients attending those with three or more nurses received 1.18 (95% confidence interval 0.27 to 2.09) more processes of care. Delivery of medical care varied among the health centres and those with higher staffing levels provided more processes of care.

Adult↗
PubMed2001

Determinants of glycated haemoglobin in the general population: associations with diet, alcohol and cigarette smoking.

OBJECTIVE: We evaluated cigarette smoking, alcohol intake and consumption of different foods as determinants of glycated haemoglobin in a general population sample. DESIGN: Cross-sectional survey. SETTING: England. SUBJECTS: Representative sample of 15 809 adults aged 16 y and older. Data analysed for 9772 non-diabetic, white European subjects. MAIN OUTCOME MEASURES: Glycated haemoglobin (GHb). Analyses were adjusted for age, sex, body mass index (BMI), waist-hip circumference ratio, activity level, and educational attainment. RESULTS: After adjusting for confounding, GHb was 0.277% (95% confidence interval 0.218 to 0.336) higher in current smokers of 20 or more per day, compared with non-smokers. GHb was 0.189% (0.101 to 0.277) lower in those drinking 42 or more units of alcohol per week than in non-drinkers. GHb was not associated with frequency of consumption of pulses, fruit, vegetables and salads, cakes, bread or confectionery. GHb was higher in subjects who took sugar in tea (0.051%, 0.015 to 0.087%) or in coffee (0.069%, 0.034 to 0.105%). GHb was higher in subjects who used solid fat for cooking (0.082%, 0.022 to 0.142%), or who drank whole rather than reduced-fat milk (0.088%, 0.036 to 0.140%), or used butter or hard margarine rather than low-fat spreads (0.075%, 0.029 to 0.121%). CONCLUSIONS: In the general population, higher GHb may be associated with cigarette smoking, or frequent consumption of fat-containing foods. Consumption of alcohol may be associated with lower GHb. SPONSORSHIP: None.

Adolescent↗
PubMed2001

Low rates of detection and treatment of hypertension among current cigarette smokers.

This report analysed data from the Health Survey for England 1994 to evaluate blood pressure (BP) management in relation to cigarette smoking. Data were analysed for 12 013 adults aged > or = 16 years living in England in 1994. Among 2280 subjects with BP > or = 160/95 mm Hg or treated with BP-lowering medication, rates of awareness were 63% in never-smokers, 66% in ex-smokers and 51% in current smokers. After adjusting for age, sex, housing tenure, educational attainment, and systolic and diastolic BP, the relative odds of hypertension awareness for smokers, compared with never-smokers, were 0.63, 95% confidence interval 0.49 to 0.82, P < 0.001. In the same group, the rates of BP treatment were 50% in never-smokers, 53% in ex-smokers and 36% in current smokers (odds ratio 0.64, 0.49 to 0.84, P = 0.001). In 4500 subjects with BP > or = 140/90 mm Hg or treated, there was also strong evidence that current smokers were less likely to be aware of their high BP or treated. In this group, ex-smokers were more likely than never-smokers to be aware (odds ratio 1.23, 1.06 to 1.42, P = 0.006) or treated for high BP (odds ratio 1.25, 1.06 to 1.47, P = 0.009). Detection and treatment of high BP are particularly relevant in subjects who continue to smoke.

Adolescent↗
PubMed2001

Overweight, obesity and skinfold thicknesses of children of African or Indian descent in Trinidad and Tobago.

BACKGROUND: To evaluate distribution of body mass index (BMI) and subcutaneous fat in children of African or Indian subcontinent descent living in Trinidad and Tobago. METHODS: A cross-sectional survey was carried out in a nationally representative sample of 66 government schools. Measurements were made of children's heights, weights, triceps and subscapular skinfold thicknesses. Data were analysed by sex and ethnic group and comparison was made with international standards for overweight and obesity and with British (1990) reference curves for BMI. RESULTS: Data were analysed for 5688/6731 (85%) eligible children including 1934 Afro-Trinidadian, 1689 Indo-Trinidadian, and 1794 of mixed ethnicity. Afro-Trinidadian and mixed children were taller, but Indo-Trinidadian children were shorter than reference. Values for BMI were lower than reference: mean standard deviation score (SDS), (95% confidence interval) Afro-Trinidadian -0.34 (-0.39 to -0.28), Indo-Trinidadian -1.32 (-1.39 to -1.25), mixed -0.67 (-0.74 to -0.61). Overall 486 (8.5%, 7.8 to 9.3%) of children were overweight and 138 (2.4%, 2.0 to 2.9%) were obese. Triceps skinfold thickness values were lower than reference (-0.45, -0.48 to -0.42 SDS) but subscapular skinfold thicknesses were higher (0.45, 0.43 to 0.47 SDS). Higher BMI were associated with higher BMI in the child's parents, higher reported birthweight, older age of the child's mother, smaller family size, and with higher maternal educational attainment. CONCLUSIONS: Overweight was prevalent and distribution of subcutaneous fat was central. Work is needed to determine whether these findings are associated with adult patterns of fat distribution and metabolic abnormalities.

Africa↗
PubMed2001

Management of diabetes mellitus in three settings in Jamaica.

OBJECTIVES: To evaluate the quality of diabetic care in three clinics (one of them private and the other two public) in Jamaica, which is a middle-income country with a high prevalence (13%) of diabetes. METHODS: During a six-week census in 1995 at the three clinics we collected data retrospectively on a total of 437 diabetic patients. One of the clinics was a specialist public-hospital clinic ("SPMC"), one was a private group general practice ("PRMC"), and one was a public polyclinic ("PUBMC"). The patients' median age ranged from 56 years at SPMC and PRMC to 63 years at PUBMC. Median follow-up had been 6.0 years at SPMC, 9.2 years at PRMC, and 6.3 years at PUBMC. RESULTS: Fewer than 10% of the patients were controlled with diet alone. Insulin was the most commonly prescribed agent at SPMC (46%), compared to 7% each at the two other clinics. Sulfonylurea drugs alone or in combination with metformin were the most common agents at PUBMC and PRMC. Overall, 40% of the patients had satisfactory blood glucose control (< 8 mmol/L fasting or < 10 mmol/L postprandial). There was no significant difference among the clinics in the proportion of patients with satisfactory blood glucose control (P = 0.26). A blood glucose measurement had been recorded in the preceding year in 84% of the patients at SPMC, 79% at PRMC, and 67% at PUBMC. Glycosylated hemoglobin was infrequently measured: 16% at SPMC, 10% at PRMC, and 0% at PUBMC. Overall, 96% of patients had had surveillance for hypertension, and 81% had had surveillance for proteinuria. Surveillance for foot and retinal complications was generally infrequent and had been noted in patients' clinic records most commonly at SPMC (14% for foot complications, and 13% for retinal complications). The staff at the three clinics seldom advised the diabetic patients on diet, exercise, and other nonpharmacological measures, according to the clinics' records. CONCLUSIONS: The management of diabetes in Jamaica fell short of international guidelines. Our results also indicate the need to better sensitize health care professionals to these standards in order to reduce the burden of diabetes.

Adult↗
PubMed2000

Self-monitoring in Type 2 diabetes mellitus: a meta-analysis.

AIMS: Self-monitoring of blood or urine glucose is widely used by subjects with Type 2 diabetes mellitus. This study evaluated the effectiveness of the technique at improving blood glucose control through a systematic review and meta-analysis. METHODS: Randomized controlled trials were identified that compared the effects of blood or urine glucose monitoring with no self-monitoring, or blood glucose self-monitoring with urine glucose self-monitoring, on glycated haemoglobin as primary outcome in Type 2 diabetes. RESULTS: Eight reports were identified. These were rated for quality and data were abstracted. The mean (SD) quality score was 15.0 (1.69) on a scale ranging from 0 to 28. No study had sufficient power to detect differences in glycated haemoglobin (GHb) of less than 0.5%. One study was excluded because it was a cluster randomized trial of a complex intervention and one because fructosamine was used as the outcome measure. A meta-analysis was performed using data from four studies that compared blood or urine monitoring with no regular monitoring. The estimated reduction in GHb from monitoring was -0.25% (95% confidence interval -0.61 to 0.10%). Three studies that compared blood glucose monitoring with urine glucose monitoring were also combined. The estimated reduction in GHb from monitoring blood glucose rather than urine glucose was -0.03% (-0.52 to 0.47%). CONCLUSIONS: The results do not provide evidence for clinical effectiveness of an item of care with appreciable costs. Further work is needed to evaluate self-monitoring so that resources for diabetes care can be used more efficiently.

Blood Glucose Self-Monitoring↗