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PubMed2004

Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000.

BACKGROUND: Coronary heart disease mortality rates have been decreasing in the United Kingdom since the 1970s. Our study aimed to examine how much of the decrease in England and Wales between 1981 and 2000 could be attributed to medical and surgical treatments and how much to changes in cardiovascular risk factors. METHODS AND RESULTS: The IMPACT mortality model was used to combine and analyze data on uptake and effectiveness of cardiological treatments and risk factor trends in England and Wales. The main data sources were published trials and meta-analyses, official statistics, clinical audits, and national surveys. Between 1981 and 2000, coronary heart disease mortality rates in England and Wales decreased by 62% in men and 45% in women 25 to 84 years old. This resulted in 68 230 fewer deaths in 2000. Some 42% of this decrease was attributed to treatments in individuals (including 11% to secondary prevention, 13% to heart failure treatments, 8% to initial treatments of acute myocardial infarction, and 3% to hypertension treatments) and 58% to population risk factor reductions (principally smoking, 48%; blood pressure, 9.5%; and cholesterol, 9.5%). Adverse trends were seen for physical activity, obesity and diabetes. CONCLUSIONS: More than half the coronary heart disease mortality decrease in Britain between 1981 and 2000 was attributable to reductions in major risk factors, principally smoking. This emphasizes the importance of a comprehensive strategy that promotes primary prevention, particularly for tobacco and diet, and that maximizes population coverage of effective treatments, especially for secondary prevention and heart failure. These findings may be cautiously generalizable to the United States and other developed countries.

Adult↗
PubMed2004

Stroke unit care and outcome: results from the 2001 National Sentinel Audit of Stroke (England, Wales, and Northern Ireland).

BACKGROUND AND PURPOSE: Stroke unit care is one of the most powerful interventions available to help stroke patients. There are limited data available to assess the impact of stroke units in routine clinical practice outside randomized clinical trials. This article uses data from the 2001 to 2002 National Stroke Audit to assess the effectiveness of stroke unit care in England, Wales, and Northern Ireland in delivering effective processes of care and in reducing case fatality and disability. METHODS: An observational study of the organization, structure, process of care, and outcomes for stroke in 2001. Case fatality after stroke in England was compared using data from the audit and routinely collected data from the Department of Health. 240 hospitals (196 Trusts) from England, Wales, and Northern Ireland took part in the 2001 to 2002 National Stroke Audit, a response rate of >95%. These sites assessed a total of 8200 patients using the Royal College of Physicians Intercollegiate Working Party Stroke Audit Tool. RESULTS: The availability of stroke unit care varies hugely across the country. Case fatality after stroke was higher in Trusts with least availability of stroke unit care. These differences persisted after control for case mix. The process of care was better for patients managed on stroke units compared with other settings. Overall, the risk of death for patients who received stroke unit care was estimated to be approximately 75% that of the risk for those having no stroke unit care (95% CI, 60 to 90). CONCLUSIONS: Stroke unit care as provided in routine clinical practice in England, Wales, and Northern Ireland reduces case fatality by approximately 25%, which is in line with the figures obtained from systematic analysis of stroke unit trial data.

Aged↗
PubMed1997

Gender-based differences in the treatment of young offenders by the police and the children's court in New South Wales, Australia.

It has been consistently reported that young males commit crimes with an average frequency five times greater than their female peers. Most data supporting this view are derived from juvenile court and police statistics. Studies using data derived from self-reported behaviour suggest that the true relative frequency may be closer to 2:1. Police and juvenile justice data for the year 1994-5 in New South Wales, Australia, were analysed in an attempt to determine whether court and police statistics might reflect a form of selection bias, where the likelihood of arrest, trial and/or sentence is a function of gender, rather than frequency and nature of offence. The results suggest that the 5:1 gender ratio reflects a strong component of gender bias in the workings of the juvenile justice system in New South Wales. If suspected of a given crime, young males are more likely to be denied bail and (if found guilty) to be given a harsher sentence than young females suspected (or found guilty) of the same crime. Overall, if found guilty of an offence, boys were four times more likely than girls to receive a custodial sentence. Therefore, boys are selectively denied access to alternate rehabilitation resources which are made available to girls who are in trouble with the law. The juvenile justice system in New South Wales requires careful examination and reform if such apparently deeply entrenched biases are to be eliminated.

Adolescent↗
PubMed2007

The effect of gender, age, and geographical location on the incidence and prevalence of renal replacement therapy in Wales.

BACKGROUND: This study used a cross sectional survey to examine the effect of gender, age, and geographical location on the population prevalence of renal replacement therapy (RRT) provision in Wales. METHODS: Physicians in renal centres in Wales and in adjacent areas of England were asked to undertake a census of patients on renal replacement therapy on 30 June 2004 using an agreed protocol. Data were collated and analysed in anonymous form. RESULTS: 2434 patients were on RRT in Wales at the census date. Median age of patients on RRT was 56 years, peritoneal dialysis 58 years, haemodialysis 66 years and transplantation 50 years. The three treatment modalities had significantly different age-specific peak prevalence rates and distributions. RRT age-specific prevalence rates peaked at around 70 years (1790 pmp), transplantation at around 60 years (924 pmp), haemodialysis at around 80 years (1080 pmp) and peritoneal dialysis did not have a clear peak prevalence rate. Age-specific incidence of RRT peaked at a rate of 488 pmp at 79 years, as did incidence rates for haemodialysis, which peaked at the same age. Age had less effect on the initiation of peritoneal dialysis, which had a broad plateau between the early fifties and late seventies. Kidney transplantation rates were highest in the early fifties but were markedly absent in old age. CONCLUSION: Differences in the provision of RRT are evident, particularly in the very elderly, where the gender difference for haemodialysis is particularly marked. The study illustrates that grouping patients over 75 years into a single age-band may mask significant diversity within this age group. Significant numbers of very elderly patients who are currently not receiving RRT may wish to receive RRT as the elderly population increases, and as technology improves survival and quality of life on RRT. The study suggests that if technologies that are more effective were developed, and which had a lower impact on quality of life, there might be up to a 17% increase in demand for RRT in those aged over 75 years; around 90% of this increased demand would be for haemodialysis.

Age Distribution↗
PubMed2003

Caring for the dying: how well prepared are general practitioners? A questionnaire study in Wales.

CONTEXT: General practitioners (GPs) and generalist hospital doctors provide the majority of palliative and terminal care in the UK. Studies have revealed problems with symptom control and communication in these settings and inadequate training for clinical students and junior doctors. OBJECTIVES: To investigate the training of GPs in Wales in palliative medicine throughout their careers, with a focus on the Welsh Valleys, an area of social deprivation and high levels of chronic ill health. To compare these data with those previously obtained from a survey of GPs in East Anglia. To develop regression models that enable the prediction of less well trained medical students and GPs. METHODS: A postal questionnaire survey of a random sample of GPs, stratified by practice location (Valleys or elsewhere in Wales). Responders were invited to recall their training in five topics of palliative care (pain control, other symptom control, use of syringe drivers, communication skills and bereavement care) during four career stages (clinical students, junior doctors, GP registrars and GP principals). RESULTS: The response rate was 67.6%. Available data enabled evaluation of generalizability and response bias. Contrary to an initial hypothesis, no significant differences were found between Valleys and non-Valleys responders' reported training, although the study was adequately powered. As medical students, 27% reported receiving no training in any topic, 75% no training in bereavement care and 50% no training in communication skills. Training varied across medical schools and was more common for more recent graduates. As junior doctors, 25% reported no training in any topic, 75% no training in bereavement care and 77% no training in communication skills. The GP registrar year provided significantly more coverage of communication, bereavement and syringe drivers than the combined preceding 6 years of general professional training. As GP principals, a high level of training is reported in all topics. The training experience of GPs in Wales is very similar to that previously reported by GPs in East Anglia: this lends support to the generalizability of these data. Logistic regression analysis indicated that the only predictor of less common training as medical students was having qualified less recently. The main predictors of less common training as GP principals was having become a GP more recently and not being a GP trainer. CONCLUSIONS: There is still some way to go in ensuring that medical students, junior hospital doctors and GPs are all adequately trained for their important role in caring for dying patients.

Adult↗
PubMed2005

Palliative care in children in Wales: a study of provision and need.

AIM: To establish incidence and prevalence of children needing palliative care in Wales. PATIENTS AND METHODS: Children were identified in three ways: (1) from paediatricians using the Welsh Paediatric Surveillance Unit (WPSU); (2) referrals to the specialist palliative medicine service based in Cardiff; and (3) children under the care of the two principal children's hospices serving Wales. All children referred or reported between January 2001 and December 2002 were included. RESULTS: A total of 226 children were identified. Fifty (22%) were identified by paediatricians, 58 (26%) were referred to the specialist paediatric palliative medicine service, 158 (70%) had been under the care of a children's hospice, and 34 (15%) were identified by more than one source. This study identified approximately 3.75 per 10000 children. This is about half the prevalence figures quoted in the ACT/ RCPCH document in 1997. CONCLUSIONS: The study may underestimate prevalence. Children needing palliative medicine are still under-recognized in Wales. The overlap between children's hospice care and specialist paediatric palliative medicine is relatively small.

Child↗
PubMed2000

Seasonal variation in suicides: diminished or vanished. Experience from England and Wales, 1982-1996.

BACKGROUND: Seasonal variation in suicidal death has been observed in many countries. In particular, a cyclic variation was found for both men and women in England and Wales in the 1960s and 1970s. Men showed a single 12-month cycle whereas women showed two cycles. AIMS: To re-examine the seasonal variation in suicides in England and Wales for the period 1982-1996. METHOD: A harmonic analysis was used to detect the seasonality of the suicide data. RESULTS: The seasonal effect on suicide is greatly diminished in England and Wales. This is shown by the reduced amplitude and smaller proportion of variance accounted for by the season. CONCLUSIONS: The seasonal effect on suicide has either diminished or vanished.

Adolescent↗
PubMed2003

Effect of 11 September 2001 on suicide and homicide in England and Wales.

BACKGROUND: The tragic events of 11 September 2001 and televised scenes of the terrorists' homicidal and suicidal acts could have had an impact on the behaviour of some people, who harbour suicidal ideation or homicidal tendencies. AIMS: To assess the effect of 11 September 2001 on the rate of suicide and homicide in England and Wales. METHOD: Analysis of the number of suicides (ICD-9 codes: E950-E959), undetermined injury deaths (E980-E989) and homicides (E960-E969) in England and Wales in the 12 weeks before and after 11 September 2001 and during a similar period in the previous two years. RESULTS: The number of suicides reported in the month of September 2001 was significantly lower than other months in the same year and any September of the previous 22 years in England and Wales. A suicide reduction in men, regardless of age, occurred in the week starting Tuesday 11 September 2001. A reduction in female suicide occurred during the four weeks following the attack. There was no evidence of a similar effect on homicide. CONCLUSIONS: The tragic events of 11 September 2001 appear to have had a brief but significant inverse effect on suicide.The finding of this study supports Durkheim's theory that periods of external threat create group integration within society and lower the suicide rate through the impact on social cohesion.

England↗
PubMed1981

Occupational life tables for cerebrovascular disease and ischemic heart disease in Japan compared with England and Wales.

Life tables have been calculated for cerebrovascular disease and ischemic heart disease in various occupational groups in Japan, and England and Wales. For cerebrovascular disease there are large occupational differences in both countries, and the experience of the lowest-ranking Japanese group (administrators and managers) is better than that of the highest-ranking group in England and Wales (miners). For ischemic heart disease the occupational variations within each country are less, and all Japanese groups fare better than any groups in England and Wales. Within each country mortality from cerebrovascular disease in different occupations has many positive and significant correlation coefficients with rates for stillbirth, and mortality from infections, cancers, etc. However, mortality from ischemic heart disease shows relatively less correlation coefficients with other diseases.

Actuarial Analysis↗
PubMed2005

Recommended standards for biochemical markers of myocardial damage: All Wales Clinical Biochemistry Audit Group.

The effective use of cardiac-specific troponin estimations in the diagnosis of acute myocardial infarction (AMI) is clouded by the imprecise definition surrounding the decision limits. This has led to a wide variation of criteria for the diagnosis of myocardial infarction. A survey of troponin measurements in Welsh laboratories, undertaken in 2003 under the auspices of the All Wales Clinical Biochemistry Audit Group, revealed significant variations in laboratory and clinical practice. Extensive discussion and consultation led by a working group of clinical biochemists and cardiologists in Wales culminated in recommendations concerning the use of troponin assays to establish myocardial damage. The key recommendations are: Cardiac troponin (T or I) should be the first-line test for myocardial damage; Two samples should be collected, at admission and 12-24 h later. The first sample is used for 'rule in' purposes, but not to 'rule out' myocardial damage; Only one threshold (cut-off) value for troponin should be quoted on laboratory reports, values above which are indicative of myocardial damage. A study by the Wales External Quality Assurance Scheme (WEQAS) enabled the derivation of the recommended cut-off concentrations of troponin for defining myocardial damage, defined for each assay as the concentration that can be reliably distinguished, with a confidence interval of 99%, from the 99th percentile reference limit. These recommended standards provide a rationale for a uniform approach for troponin assays for patients with chest pain, working towards a standardized approach to the diagnosis and management of patients presenting with acute coronary syndromes.

Biomarkers↗
PubMed1999

A survey of contact tracing practice for sexually transmitted diseases in GUM clinics in England and Wales.

We set out to determine current policy and practice in relation to contact tracing (partner notification) for sexually transmitted diseases (STDs) within genitourinary medicine (GUM) clinics in England and Wales. A confidential postal questionnaire survey of all GUM clinics in England and Wales was undertaken. Completed questionnaires were returned by 105 GUM clinics (a response rate of 65%). All respondents undertook routine contact tracing for gonorrhoea and chlamydia. The most popular method of contact tracing used was patient referral. The majority of contact tracing was undertaken by health advisers. Information on the time period over which contact tracing was undertaken showed wide variation. Audit data on the effectiveness of contact tracing in terms of the proportion of sexual contacts seen were available from only a minority of GUM clinics (33/79, 42%). Only chlamydia (24/79, 30%) and gonorrhoea (22/79, 28%) were the subject of any appreciable audit activity. There is wide variation in contact tracing policy and practice in GUM clinics in England and Wales. Audit of contact tracing effectiveness appears to be a minority activity. Further research is needed before an evidence-based approach to contact tracing can be implemented.

Contact Tracing↗
PubMed2005

Fingerprint evidence in England and Wales--the revised standard.

Evidence of personal identity, often based solely on the comparison of a single finger impression, or fragment of an impression, has been accepted by courts of law at all levels in England and Wales since 1901, when the fingerprint system of identification was first adopted by police forces. Fingerprint identification is used by police forces world-wide, not only for the identification of latent fingermarks left at crime scenes, but also as the basis for ensuring accuracy in the criminal record system. For more than a century fingerprint evidence has been shown without doubt to be the best form of personal identification yet devised and millions of comparisons and subsequent identifications have been effected world-wide without any flaw in the system having been detected. From 1953-2001 it was the usual practice in England and Wales for the police to proffer fingerprint evidence showing 16 common matching characteristics, or features in agreement, between the two impressions being compared. In 1996 the Association of Chief Police Officers (ACPO) commissioned a review of the existing methods of presenting fingerprint evidence before the courts and on 11 June 2001 a new standard of fingerprint evidence was adopted by the police forces of England and Wales. This paper describes how the new standard was developed and implemented and why it was considered necessary to move away from the existing 16-point standard.

Criminal Law↗
PubMed2005

Factors associated with the recent decline in suicide rates in the elderly in England and Wales, 1985-1998.

Elderly suicide rates have declined in recent years in several countries including England and Wales. This study examined the association between a trend of decline in age-specific suicide rates in the elderly in England and Wales and changes in various health and social factors for the period 1985 to 1998. Data on age-specific suicide rates was ascertained from the annual mortality statistics for the years 1985 to 1998. Data on the various health and social variables was ascertained from both the Statistics Division at the Department of Health and the Health and Personal Social Services Statistics, the yearly publications of the Department of Health from 1985 to 1998. The main findings of this study were (i) a significant negative correlation between the number of general practitioners and all categories of whole-time-equivalent (WTE) hospital medical staff and suicide rates for each of the four five-year age bands for males and females after the age of 65; (ii) a significant negative correlation between the number of new outpatient appointments for mental illness and suicide rates in males and females for each of the four five-year age bands between the ages 65-85 years; (iii) a significant positive correlation between the average daily number of available beds for mental illness and elderly suicide rates, for all five-year age bands between the ages 65-85 years; (iv) a significant negative correlation between the number of field social work staff and day centre staff and elderly suicide rates for each of the four five-year age bands after the age of 65 for males and females; and, (v) a significant positive correlation between the total number of elderly in all residential homes and the number of elderly in local authority residential homes and elderly suicide rates for each of the four five-year age bands between the ages 65-85 years for males and females. A trend of decline in age-specific suicide rates in the elderly in England and Wales from 1985 to 1998 was significantly associated with changes in various health and social variables. These included the number of general practitioners and hospital medical staff, the hospital psychiatric services, the number of local authority staff and the number of elderly residents in accommodation supported by a local authority. The results of this study suggest that changes in these variables may be important factors contributing to the recent decline in suicide rates but this effect should be viewed in the context of other health and social factors.

Age Factors↗
PubMed2005

The incidence of dementia in England and Wales: findings from the five identical sites of the MRC CFA Study.

BACKGROUND: Although incidence of dementia is known to vary between nations, variation within country has not been explored because most incidence studies are single site or have insufficient numbers to compare sites. Few countries have conducted multisite incidence studies in order to facilitate national comparisons. This study aims to provide robust measures of the variation of the incidence of dementia across sites within England and Wales and produce overall estimates by age and sex. METHODS AND FINDINGS: The Medical Research Council Cognitive Function and Ageing Study used identical methodology in five diverse sites across the United Kingdom, each with different risk patterns and mortality rates. Incidence has been estimated using likelihood-based methods between the first two waves of interviews. Incidence rates rise with age, particularly above the age of 75 y, from 6.7 [corrected] (95% confidence interval, 3.8 [corrected]-12.4 [corrected]) per 1,000 person years at age 65-69 y to 68.5 [corrected] (95% confidence interval, 52.5 [corrected]-88.1 [corrected]) per 1,000 person years at age 85 y and above. The rate of increase for both sexes is marked, and continues into the oldest age groups. Hence, it is estimated that approximately 163,000 [corrected] new cases of dementia occur in England and Wales each year. There is no convincing evidence of variation across sites, and incidence rates do not reflect the variations in the prevalence of possible risk factors in these sites. CONCLUSION: There is no evidence, within England and Wales, of variation in dementia incidence across sites. Dementia incidence rates do not tail off at the oldest ages.

Aged↗
PubMed2006

Twins and their health cost: consequences of multiple births on parental health and mortality in Denmark and England and Wales.

The rapid increase in twinning rates in developed countries has increased interest in the question as to whether twin mothers have higher mortality and more health problems than mothers of singletons. Here we use a national survey, the Office for National Statistics Longitudinal Study of England & Wales, and a linkage between the Danish Twin Registry and the Danish population register to examine mortality patterns after age 45 (50 for fathers) for twin parents and the whole population born from 1911 to 1950. For England and Wales, presence of limiting long-term illnesses and self-rated health status was also investigated. Overall similar health and mortality was found for twin parents and the whole population although both life table methods and survival analysis suggested a slight excess mortality among older cohorts of twin mothers in England and Wales.

Adolescent↗
PubMed2004

Baseline rates of Campylobacter and Salmonella in raw chicken in Wales, United Kingdom, in 2002.

The Public Health Laboratory Service in Wales, in cooperation with local authorities and the Food Standards Agency Wales, carried out a survey to establish baseline figures for the contamination of raw retail chicken with Salmonella and Campylobacter available within Wales, a devolved part of the United Kingdom with a population of approximately 3 million. Seven hundred thirty-nine samples were obtained between November 2001 and December 2002. Overall, 71% of samples were contaminated with Campylobacter, and 8% were contaminated with Salmonella. There were no significant differences between fresh and frozen carcasses and between samples taken from retailers or butchers. There was seasonal variation in the level of Campylobacter contamination of fresh chicken, with a peak in June and the lowest positive rates in January, March, and December. There was no similar peak observed in frozen samples or for Salmonella.

Animals↗
PubMed2005

Survey of Salmonella and Campylobacter contamination of whole, raw poultry on retail sale in Wales in 2003.

A survey of the Salmonella and Campylobacter contamination of raw, whole chickens available to consumers in Wales was performed between March and December 2003. In total, 736 samples were taken, and overall contamination rates of 73.1% for Campylobacter and 5.7% for Salmonella were found. This survey follows a survey performed during 2001 to 2002 by Welsh local authorities and the National Public Health Service for Wales that established updated baseline rates for both pathogens in raw, whole chicken available to consumers in Wales. This survey indicated no difference in Campylobacter rates between fresh and frozen samples or between samples taken from retailers and local butchers, but significant differences existed in Salmonella rates between fresh and frozen samples and between those sampled from retailers and butchers, with frozen chickens and samples taken from retailers having significantly higher rates. However, the difference in Salmonella isolation rate between retailers and butchers was found to be due to the differences in the proportions of fresh and frozen chickens sampled from these locations, with a significantly higher number of frozen chickens (with a higher Salmonella rate) being sampled from retailers.

Animals↗
PubMed1988

Meningococcal serogroups in New South Wales, 1977-1987.

Data are presented on serogroups of meningococci (Neisseria meningitidis) that were submitted to Westmead Hospital and The Children's Hospital, Camperdown, from patients in Sydney and in rural areas of New South Wales, from January 1, 1977 to December 31, 1987. One hundred and ten organisms that were isolated from cerebrospinal fluid or from blood were examined. All organisms were isolated from sporadic cases of meningococcal disease. Patients in the zero-to-two-years' age-group were affected most commonly, but 36.3% of isolates were from older children and adults. The distribution of serogroups was as follows: serogroup B, 43.6; serogroup A, 28.2%; serogroup C, 10.0%; serogroup W135, 8.2%; serogroup Y, 4.5%; and serogroup Z, 0.9%. The isolates that were serogrouped by us represented approximately half the cases of meningococcal meningitis that were notified in New South Wales during this period. Serogrouping of meningococcal isolates is very important in order to follow epidemiological trends in the disease and to monitor the serogroups that cause outbreaks, where vaccination of contacts may be indicated. Our laboratories are prepared to receive isolates for serogrouping and antibiotic sensitivity testing from across New South Wales.

Adolescent↗