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PubMed2005

Evaluation of the National Congenital Anomaly System in England and Wales.

OBJECTIVE: To evaluate the National Congenital Anomaly System (NCAS). METHODS: The NCAS in England and Wales based at the Office for National Statistics and the various regional registers that exchange data with it were examined, based on guidelines for evaluating public health surveillance systems, published by the Centres for Disease Control (CDC). Data relating to congenital anomaly notifications received from 1991 to 2002 were analysed. MAIN OUTCOME MEASURES: The main outcome measures were based on CDC standards and included the level of usefulness of the system, simplicity, flexibility, data quality, acceptability, sensitivity, representativeness, timeliness, and stability of the system. RESULTS: The NCAS has two main tiers: the "passive" system of voluntary notifications and the anomaly registers, but many reporting sources within these. It receives about 7000 notifications a year. It is inflexible and has variable data quality. The voluntary nature of reporting affects the system's acceptability. The sensitivity as compared with two regional registers (Trent and Wales) is about 33%. The congenital anomaly registers reporting to the NCAS achieve high levels of coverage and completeness. From 2003, they cover 42% of all births and account for the major proportion of the notifications. CONCLUSIONS: The NCAS serves the important function of monitoring birth defects in England and Wales, but is not currently operating in a timely or effective way. It should be adapted to meet its main objectives more effectively. More regional anomaly registers should be instituted and existing registers supported through central funds.

Congenital Abnormalities↗
PubMed1998

Management of tuberculosis in Wales: 1986-92.

OBJECTIVES: To describe the epidemiology of childhood tuberculosis in Wales and to assess the standard of management of patients with tuberculosis. DESIGN: Retrospective study of data retrieved from case notes and review of radiographs of all identified patients. SUBJECTS: Forty eight cases of tuberculosis and 10 of tuberculosis chemoprophylaxis in children under 15 years of age, in Wales, between January 1986 and December 1992. MAIN OUTCOME MEASURES: Management of childhood tuberculosis in Wales compared with the published recommendations of the Joint Tuberculosis Committee of the British Thoracic Society. RESULTS: Documentation was poor in most of the 48 cases of tuberculosis and only 31 (65%) were formally notified. One third of patients were asymptomatic and were detected by contact tracing; only eight (17%) were culture positive. Only 20% of patients from ethnic minorities had previously been immunised with BCG. Management and chemotherapy varied widely. Few patients were managed jointly by paediatricians and chest doctors. Only 10% completed treatment with a recommended chemotherapy regimen. In 37% of patients treatment was inadequate, and in the remainder either the choice of drugs or the duration of treatment was inappropriate. No patient died, nor had any relapsed by June 1995. CONCLUSIONS: Very few cases of childhood tuberculosis were managed according to the recommendations of the British Thoracic Society.

Adolescent↗
PubMed1979

Incidence of malignant melanoma of the skin in England and Wales and its relationship to sunshine.

In most of England and Wales the incidence of malignant melanoma of the skin has risen rapidly in recent years, especially in women. Mean incidences in the 14 English health regions and Wales correlated negatively with latitude and positively with hours of sunshine, suggesting that exposure to sunshine was an important causal factor. Male and female incidences within a region tended to show similar yearly fluctuations, implying a common factor affecting the incidence in both men and women with a short latent period of action. This factor may be exposure to sunshine, which may cause melanoma after an induction period of about two years; for women the incidence of melanoma in the regions of England and Wales correlated positively with hours of sunshine two years earlier.

England↗
PubMed1980

National survey of tuberculosis notifications in England and Wales 1978--9. Report from the Medical Research Council Tuberculosis and Chest Diseases Unit.

A survey of all tuberculosis notifications in England and Wales for a six-month period showed that 70% of 3732 newly notified, previously untreated patients had respiratory disease only, 23% had non-respiratory disease only, and 7% had both. Fifty-seven per cent of patients were of white and 35% were of Indian subcontinent (Indian, Pakistani, or Bangladeshi) ethnic origin, the latter group contributing over half the cases of non-respiratory disease. The estimated overall annual notification rate per 100 000 population for 1978--9 was 16.4 for England and 13.5 for Wales. The rates differed considerably between the different ethnic groups in England, the highest rates occurring in the Indian and in the Pakistani and Bangladeshi groups and the lowest in the white group; the differences in the non-respiratory rates were the more striking. Nearly a quarter of patients with respiratory disease had large pulmonary lesions, the proportion being higher for the white group than for the Indian subcontinent group. Over half the patients had positive cultures for tubercle bacilli and over a third had positive smears; both proportions were higher for the white group. This survey has identified many of the problems which tuberculosis presents in England and Wales today. These include the substantial number of patients with sputum-positive disease, the considerable variation in the rates in the different ethnic groups, and the not uncommon occurrence of childhood tuberculosis.

Adolescent↗
PubMed1988

Epidemiology of chickenpox in England and Wales, 1967-85.

Routine sources of data on chickenpox morbidity and mortality in England and Wales were reviewed for 1967-85. Only two epidemics occurred, one in 1967 and one in 1980, both of which were immediately followed by two to three years of low incidence. The age distribution of the disease appears to be changing, with more cases now being reported in children aged 0-4 years. The number of deaths in adults have, however, increased, particularly those deaths that are associated with pneumonia and immunosuppression. At present in England and Wales more deaths are attributed to chickenpox than to whooping cough and mumps. Widespread use of selective immunisation against chickenpox might be justified in England and Wales, but before routine immunisation of the child population can be considered special surveys to determine the incidence and severity of chickenpox and the effect of the vaccine on the subsequent development of herpes zoster are needed as well as cost-benefit studies of immunisation.

Adolescent↗
PubMed1989

Role of the private sector in elective surgery in England and Wales, 1986.

From a sample of 19,000 treatment episodes at 183 of the 193 independent hospitals with operating facilities in England and Wales that were open in 1986 it is estimated that 287,000 residents of England and Wales had elective surgery as inpatients in 1986 (an increase of 77% since 1981) and 72,000 as day cases. From 1985 Hospital In-Patient Enquiry data it was estimated that a further 36,000 similar elective inpatient treatments were undertaken in NHS pay beds (a decrease of 38%) and 21,000 as day cases. Overall, an estimated 16.7% of all residents of England and Wales who had non-abortion elective surgery as inpatients were treated in the private sector, as were 10.5% of all day cases. An estimated 28% of all total hip joint replacements were done privately, and in both the North West and South West Thames regions the proportion of inpatients treated privately for elective surgery was 31%. It is concluded that mainly for reasons of available manpower private sector activity may not be able to grow much more without arresting or reversing the growth of the NHS, in which case some method of calculating NHS resource allocation which takes account of the local strength of the private sector will be needed.

Adolescent↗
PubMed1989

Role of community pharmacies in prevention of AIDS among injecting drug misusers: findings of a survey in England and Wales.

OBJECTIVE: To determine the current and potential roles of community pharmacists in the prevention of AIDS among misusers of injected drugs. DESIGN: Cross sectional postal survey of a one in four random sample of registered pharmacies in England and Wales. SETTING: Project conducted in the addiction research unit of the Institute of Psychiatry, London. SUBJECTS: 2469 Community pharmacies in the 15 regional health authorities in England and Wales. MAIN OUTCOME MEASURES: Willingness of pharmacists to sell injecting equipment to known or suspected misusers of drugs; pharmacists' attitudes to syringe exchange schemes, keeping a "sharps" box for use by misusers of drugs, and offering face to face advice and leaflets; and opinions of community pharmacists on their role in AIDS prevention and drug misuse. RESULTS: 1946 Questionnaires were returned, representing a response rate of 79%. This fell short of the target of one in four pharmacies in each family practitioner committee area in England and Wales, and total numbers of respondents were therefore weighted in inverse proportion to the response rate in each area. The findings disclosed a substantial demand for injecting equipment by drug misusers. After weighting of numbers of respondents an estimated 676 of 2434 pharmacies were currently selling injecting equipment and 65 of 2415 (3%) were participating in local syringe exchange schemes; only 94 of 2410 pharmacies (4%) had a sharps box for used equipment. There was a high degree of concern among pharmacists about particular consequences of drug misusers visiting their premises, along with a widespread acceptance that the community pharmacist had an important part to play. CONCLUSIONS: Promoting the participation of community pharmacists in the prevention of AIDS among misusers of injected drugs is a viable policy, but several problems would need to be overcome before it was implemented.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Paralytic poliomyelitis in England and Wales, 1985-91.

OBJECTIVES: To ascertain all cases of paralytic poliomyelitis in England and Wales during 1985-91 and to determine the source of infection in each case. DESIGN: Descriptive study of cases reported between 1985 and 1991. SETTING: All health districts in England and Wales. SUBJECTS: Patients normally resident in England and Wales whose clinical features were consistent with paralytic poliomyelitis or with laboratory evidence of recent poliovirus infection and compatible symptoms. MAIN OUTCOME MEASURES: Clinical, epidemiological, and laboratory features in identified cases. RESULTS: Of 54 suspected cases of poliomyelitis, 33 were excluded, leaving 21 cases, of which 13 were vaccine associated (nine recipient and four contact) cases, five were imported cases, and three were cases whose source of infection was unknown. No cases due to indigenous wild polioviruses were identified; two were imported cases due to wild viruses. One patient died during the acute phase of the illness, and two children with previously unrecognised severe congenital immune deficiency died between one and two months after the onset of paralysis after the first or second dose of oral polio vaccine. The estimated risk of vaccine associated paralysis is 1.46 per million for the first dose, 0.49 for the second, zero for the third and fourth doses, and 0.33 for the fifth. CONCLUSIONS: Indigenous wild poliovirus seems to have been eradicated, although wild virus may be imported; improved surveillance of suspected cases including immediate notification and characterisation of the virus to ensure that eradication is maintained is essential.

Adolescent↗
PubMed1994

Serum screening for Down's syndrome: experiences of obstetricians in England and Wales.

OBJECTIVES: To assess the experiences of obstetricians in England and Wales of serum screening for Down's syndrome. DESIGN: Postal questionnaire survey. SUBJECTS: Questionnaires were sent to all practising obstetricians in England and Wales with nonacademic appointments who had not participated in an earlier (randomly sampled) survey of obstetricians' attitudes (n = 555). Responses were received from 393 (71%), of which 351 were analysed. The data represent about one third of obstetric consultants in England and Wales. MAIN OUTCOME MEASURES: The extent of use of serum screening for Down's syndrome, and the problems encountered. RESULTS: Serum screening for Down's syndrome was being offered on some basis by virtually all obstetricians in the survey. Nearly half the sample said that they did not have adequate resources for counselling all the women to whom screening was offered. Many problems were reported, which in all cases were more common than equivalent problems encountered with serum screening for neural tube defects. Over 80% (289) said that women not understanding the test was a problem. CONCLUSIONS: There is considerable confusion associated with serum screening for Down's syndrome. The precedent of serum screening for neural tube defects does not seem to have lessened the problems experienced, rather the contrary. Many obstetricians report inadequate resources for counselling, which is consistent with the high prevalence of problems associated with women not understanding the test. There is an urgent need to consider what counselling should consist of and who should undertake it and to ensure that necessary resources are available.

Anxiety↗
PubMed1994

Wartime evacuation and mortality from childhood leukaemia in England and Wales in 1945-9.

OBJECTIVE: To discover whether the wartime government evacuation of children from London and other population centres to rural districts was associated with any increase in childhood leukaemia. DESIGN: Observational study of mortality from leukaemia among the childhood population of England and Wales in relation to the unique population movements during the second world war. The 476 rural districts of England and Wales were ranked according to the ratio of government evacuees (two thirds of them children) to local children in September 1941. The districts were divided into three categories, each with similar numbers of children in 1947 but with different ratios of evacuees to local children ("low," "intermediate," "high"). Mortality from childhood leukaemia was examined in these three rural categories in 1945-9. Urban areas were also examined according to their exposure to evacuees. SETTING: Local authority areas of England and Wales. SUBJECTS: Children aged under 15. RESULTS: 47% excess of leukaemia at ages 0-14 years occurred in 1945-9 in the rural "high" category for evacuees relative to the "low" category, with a significant trend across the three categories. There were increases in both the 0-4 and 5-14 year age groups, but these were larger in the older age group. Rates 25% lower than average occurred in rural areas with few evacuees. CONCLUSION: These findings suggest that wartime evacuation increased the incidence of childhood leukaemia in rural areas and that other forms of population mixing may have contributed to the increases in past decades. Overall, they add to the appreciable evidence for an infective basis in childhood leukaemia.

Adolescent↗
PubMed1996

Association between incidence of non-Hodgkin's lymphoma and solar ultraviolet radiation in England and Wales.

OBJECTIVES: To examine whether the incidence of non-Hodgkin's lymphoma in different areas of England and Wales is associated with levels of solar ultraviolet radiation. DESIGN: Geographically based study examining the association between incidence of non-Hodgkin's lymphoma and estimated levels of solar ultraviolet radiation, controlling for social class and employment in agriculture. SETTING: 59 counties in England and Wales. SUBJECTS: All registered cases of non-Hodgkin's lymphoma during the period 1968-85. MAIN OUTCOME MEASURE: Age and sex adjusted odds ratio for non-Hodgkin's lymphoma in each county. RESULTS: Incidence of non-Hodgkin's lymphoma was significantly associated with solar ultraviolet radiation levels (P < 0.001), even after social class and employment in agriculture were controlled for (P = 0.004). In a comparison of counties in the highest and lowest quarters of solar ultraviolet radiation, the relative risk of non-Hodgkin's lymphoma was 1.27 (95% confidence interval 1.24 to 1.29), rising to 1.34 (1.32 to 1.37) after adjustment for social class and employment in agriculture. CONCLUSIONS: The incidence of non-Hodgkin's lymphoma in different areas of England and Wales is positively associated with levels of solar ultraviolet radiation. These results are consistent with the hypothesis that exposure to solar ultraviolet radiation increases the risk of non-Hodgkin's lymphoma.

Agricultural Workers' Diseases↗
PubMed1973

Area differences in spontaneous abortion rates in South Wales and their relation to neural tube defect incidence.

Data are presented from the South Wales Congenital Malformation Survey (92,982 births 1964-6 inclusive) showing that within areas in South Wales there exists an inverse relation between previous spontaneous abortion rate and the prevalence at birth of neural tube defect (anencephaly or spina bifida cystica or both). This relation is independent of social class, parity, and maternal age, and is not likely to be explained by area differences in accuracy of reporting previous spontaneous abortions.On the basis of these findings a hypothesis is advanced which proposes that the incidence of neural tube defects is uniform throughout South Wales and that the present substantial and relatively stable differences in area prevalence are controlled by small area differences in mortality of malformed embryos. This would seem to suggest that factors initiating the malformation are genetic and that any related environmental factors exert their effect on already abnormal fetuses by influencing, in one way or another, their capacity to survive.

Abortion, Spontaneous↗
PubMed2005

Urban legend versus rural reality: patients' experience of attendance at accident and emergency departments in west Wales.

OBJECTIVES: To investigate why and how patients decide to attend accident and emergency (A&E) departments, and to assess their satisfaction with the experience, in a predominantly rural west Wales population. METHODS: This was a semi-structured follow up telephone interview of patients who walked in to A&E in one of four general hospitals in west Wales and were triaged as Manchester Triage score 4 or 5. Patients were recruited by nurses during the period July-November 2002. The study sample consisted of 176 male and 145 female patients, mean (SD) age 36.6 (20.0) years. The main outcome measure was a quantitative and qualitative description of the recalled experiences of A&E attenders, the circumstances of their attendance, and their satisfaction with the experience. RESULTS: Of the study sample, 78% attended with injury or illnesses of recent origin, and 50% with actual or presumed musculoskeletal injury, 73% of which were sustained within 10 miles of home. Travel to hospital was by private transport for 86%, average distance 7.4 miles. The majority (90%) were registered with a local GP, but 32% felt A&E was the obvious choice, and a further 44% considered their GP inaccessible to their needs. Patients' reasons for seeking health care at A&E were similar to those described in an English urban study. Waiting times were rarely excessive; 80% left within 2 hours, and patient satisfaction was generally high. Among the 87 patients (27%) who reported a less satisfactory experience, 48 (55%) of these complained of dismissive attitudes of doctors. CONCLUSIONS: Anecdotal accounts of abuse of A&E services and unreasonable patient expectations gain the status of "urban legends" within the medical profession. Among the predominantly settled rural population in west Wales, there is little evidence of unreasonable patient expectations, and most patients report high satisfaction levels. Patients' bad experiences most frequently arise from a dismissive attitude on the part of medical staff. These attitudes are often consequent on an A&E culture that views some patients' attendances as less appropriate than others.

Adolescent↗
PubMed1996

Recent trends in the incidence of multiple births and associated mortality in England and Wales.

AIM: To review trends in multiple births and associated mortality in England and Wales since 1975, in the light of trends for earlier years; to assess, within the limitations of the available data, the extent of any association between multiple birth rates and assisted conception and drugs used for subfertility. METHODS: Data collected routinely in England and Wales, between 1975 and 1994, were retrospectively reviewed. These comprised Office of Population Censuses and Surveys (OPCS) data collected at the registration of live and stillbirths and deaths occurring under the age of 1 year in England and Wales from 1975 onwards. Department of Health data about NHS prescriptions dispensed outside hospitals within England for drugs which could be used in the medical management of subfertility were also included. RESULTS: The proportion of pregnancies that resulted in a registered multiple birth increased from a low of 9.9 per thousand in 1975 to 13.6 per thousand in 1994. Up to 1992, the increase was seen in all age groups except for women under 20, with the most substantial increase being in women aged 35 to 39. The rise in the rate of triplet and other higher order births was much steeper than that for all multiple births, increasing from 0.13 sets of triplets per thousand maternities in 1975, to 0.41 in 1994. Prescriptions dispensed for selected drugs that may be used for the medical management of subfertility and assisted conception became more common over this period. The fragmented nature of the data precluded direct comparison with changes in multiple birth rates, however. CONCLUSIONS: Although the causes of the rise since 1980 in multiple birth rates in general, and the dramatic rise in the triplet rate in particular, cannot be ascertained or quantified directly from routinely collected data, drugs used for subfertility and more recently, assisted conception, probably had a major role.

Adult↗
PubMed2001

Neonatal meningitis in England and Wales: 10 years on.

OBJECTIVES: To determine the incidence of neonatal meningitis in England and Wales. DESIGN: A national postal survey using the British Paediatric Surveillance Unit (BPSU) card scheme supplemented by information from other sources. SETTING: England and Wales 1996-1997. SUBJECTS: A total of 274 babies less than 28 days of age who were treated for meningitis. RESULTS: The incidence of neonatal meningitis in England and Wales has not changed since our previous study in 1985-1987. However, the acute phase mortality has fallen from 19.8% in 1985-1987 to 6.6% in this study. Group B streptococci (42%) and Escherichia coli (16%) remain the most common infecting microorganisms. Eight of 69 (12%) babies with group B streptococci and 4/26 (15%) with E coli died. Antibiotic regimens based on the third generation cephalosporins, notably cefotaxime, were most commonly used (84%). The BPSU scheme identified 72% of cases during the study period. Most cases of viral meningitis were not reported through the BPSU. Less than a third of samples from aseptic meningitis were examined for viruses; 56% of these were positive. CONCLUSIONS: Although the incidence of neonatal meningitis remains unchanged, mortality from this infection has fallen significantly. If this improvement is maintained as reflected in the level of sequelae at 5 years of age, then the fear surrounding meningitis during the neonatal period will have been dramatically reduced.

Anti-Infective Agents↗
PubMed2001

Increase in mortality rates from intrahepatic cholangiocarcinoma in England and Wales 1968-1998.

BACKGROUND: The age standardised mortality rate per 100 000 population for all causes of liver tumours (International Classification of Disease 9 (ICD-9) 155) has almost doubled in England and Wales during the period 1979-1996. We further analysed the mortality statistics to determine which anatomical subcategories were involved. METHODS: Mortality statistics for liver tumours of ICD-9 155, 156, and subcategories, and for tumours of the pancreas (ICD-9 157), in England and Wales were investigated from the Office for National Statistics, London, from 1968 to 1996 inclusive. Data for 1997 and 1998 were also available on intrahepatic cholangiocarcinomas. RESULTS: There has been a marked rise in age standardised mortality rates for intrahepatic cholangiocarcinoma. Since 1993, it represents the commonest recorded cause of liver tumour related death in England and Wales. This is evident in age groups older than 45 years. In contrast, mortality trends from other primary liver tumours, including hepatocellular carcinoma, were unremarkable. CONCLUSIONS: The observed increase in mortality from intrahepatic cholangiocarcinoma may represent better case ascertainment and diagnosis due to improved diagnostic imaging, use of image guided biopsies, or increased use of ERCP. However, the trend started before ERCP was introduced nationally, mortality rates have continued to increase steadily thereafter, and there is no clear evidence that diagnostic transfers easily explains the findings. Alternatively, these observations may represent a true increase in intrahepatic bile duct tumours. Epidemiological studies are required to determine whether there is any geographical clustering of cases around the UK.

Adult↗
PubMed2001

Trends in the prevalence and management of atrial fibrillation in general practice in England and Wales, 1994-1998: analysis of data from the general practice research database.

OBJECTIVE: To determine the prevalence of atrial fibrillation in England and Wales, and examine trends in its treatment with warfarin and aspirin between 1994 and 1998. DESIGN: Analysis of data from the general practice research database. SETTING: England and Wales. PATIENTS: 1.4 million patients registered with 211 general practices. MAIN OUTCOME MEASURES: Age and sex specific prevalence rates of atrial fibrillation; percentage of patients with atrial fibrillation treated with oral anticoagulants or aspirin. RESULTS: The prevalence of atrial fibrillation in 1998 was 12.1/1000 in men and 12.7/1000 in women. Prevalence increased from less than 1/1000 in under 35 year olds to over 100/1000 in those aged 85 years and over. There was a 22% increase in the age standardised prevalence of atrial fibrillation in men and a 14% increase in women between 1994 and 1998. The percentage of patients prescribed oral anticoagulants increased from 20% to 34% in men and from 17% to 25% in women. The percentage of men with atrial fibrillation prescribed aspirin increased from 26% to 36%, and the percentage of women increased from 24% to 36%. Applying the age and sex specific prevalence and treatment rates to the population gives an estimate of around 650 000 cases of atrial fibrillation in England and Wales. The greatest number of cases occurs in the 75-84 year old age group. CONCLUSIONS: The number of patients in the community with identified atrial fibrillation is increasing. There has also been a pronounced increase in the percentage of patients with atrial fibrillation prescribed oral anticoagulants or aspirin.

Administration, Oral↗
PubMed2006

Changes in socioeconomic inequalities in census measures of health in England and Wales, 1991-2001.

STUDY OBJECTIVES: To investigate changes in socioeconomic inequalities in census measures of health in England and Wales between 1991 and 2001. DESIGN: Indirect standardisation was used to calculate age standardised rates of limiting long term illness and permanent sickness in men and women in all residential wards in England and Wales in 1991 and 2001. The socioeconomic position of each ward was determined using Townsend deprivation scores. SETTING: All residential wards in England and Wales in 1991 and 2001. PARTICIPANTS: All people aged 16-65 who provided census information in the 1991 or 2001 censuses. MAIN RESULTS: There was strong evidence that Townsend deprivation score quintile could predict both logged standardised permanent sickness rate and logged standardised limiting long term illness rate. There was evidence that socioeconomic inequalities in standardised limiting long term illness rates decreased between 1991 and 2001 in both men and women and that socioeconomic inequalities in standardised permanent sickness rates decreased in women but increased in men between 1991 and 2001. CONCLUSIONS: As permanent sickness rates seem to reflect labour market accessibility, this study may have found evidence that socioeconomic inequalities in self reported morbidity decreased but inequalities in labour market participation in men increased between 1991 and 2001.

Adolescent↗