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PubMed2005

Investigations of cattle herd breakdowns with bovine tuberculosis in four counties of England and Wales using VETNET data.

Cattle herd breakdown (HBR) with bovine tuberculosis (BTB) was investigated for farms in four counties of England and Wales outside southwest England from 1986 to early 2000. Data from the national database of TB testing history (VETNET) were used. Factors that influenced HBR included calendar time, herd size, number of cattle tested, the test type, the inter-test interval and spatial grouping of farms. Herd tests other than routine herd tests had an increased risk of HBR in all four counties. In all counties, the risk of HBR increased with calendar time and in Shropshire a test interval of 3 years was associated with an increased risk of HBR compared with a 1-year test interval. In Staffordshire and Sussex, a 4-year test interval was associated with a lower risk of HBR compared with a 1-year test interval. There was no evidence of spatial clustering of HBR in West Glamorgan (equal spatial risk in a 15-30 km radius) and weak evidence of spatial clustering in Shropshire (7-15 km) and Sussex (5-10 km). In Staffordshire, there was evidence of spatial (2-4 km) and time (3-4 years) clustering of HBR. The locally increased rate of testing following a confirmed HBR increased the detection of infected herds but did not prevent local spread in two of the four counties (Shropshire and Staffordshire) since the rate of HBR increased linearly from 1988 to 2000. The main conclusion is that there were both local and distant components of spread.

Animals↗
PubMed2005

Trends in survival from muscular dystrophy in England and Wales and impact on respiratory services.

Respiratory failure is an important terminal event in muscular dystrophy, but increasingly is effectively treated by non-invasive ventilation. This study was designed to assess mortality statistics in this patient group in order to get an indication of future demand. Mortality data for all deaths from muscular dystrophy registered by death certification in England and Wales between 1993 and 1999 were analysed. In total, 817 deaths from muscular dystrophy were registered between 1993 and 1999. Annual number of deaths was unchanged over this period. Median age at death (interquartile range) for all cause muscular dystrophy increased from 20 (17-42.5) years in 1993, to 26 (17.5-63) years in 1999. Respiratory failure was the primary or contributory cause of death in 82% of cases. Two thirds of these deaths were during acute infection. We can expect 100 patients with muscular dystrophy to develop respiratory failure in England and Wales each year, so non-invasive ventilation services probably need to be able to provide for 0.2 new patients per 100,000 population annually. Respiratory services also need to provide adequate monitoring and early treatment of infection in these patients.

Adolescent↗
PubMed2005

The relative contribution of sewage and diffuse phosphorus sources in the River Avon catchment, southern England: implications for nutrient management.

In order to effectively manage nutrient river load reductions and target remediation strategies, it is important to determine the relative contributions of diffuse and point sources across the river catchment. This study used a geographical information system (GIS) to apply phosphorus (P) export coefficients (obtained from the literature) to 58 water quality monitoring sites across a large, urbanised, mixed land use catchment, typical of southern lowland England (the River Avon, Warwickshire, UK). These coefficients were used to estimate the annual P load at each monitoring site, and also the relative contribution of point source (from sewage treatment works (STW)) and diffuse input (from both livestock and agricultural land use). The estimated annual P loads showed very close agreement (r2=0.98) with the measured total phosphorus (TP) loads. Sites with the highest proportion of P derived from STW had the highest TP concentrations and loads, and also had greater variations between seasons, with elevated P concentrations occurring during the summer months. The GIS model was re-run to determine the effect of an 80% reduction in P output from STW serving over 10,000 people, thereby assessing the effect of implementing the European Union's Urban Waste Water Treatment Directive (UWWTD). The exported TP load was reduced by 52%, but the sites with the highest TP concentrations were still those with the highest proportion of P derived from STW. The GIS model was re-run to estimate the impact of 80% P reductions at a further 11 STW of varying sizes. This reduced the total TP load by only 29 tonnes year-1, but greatly reduced the P concentrations in many highly nutrient contaminated tributaries. The number of sites with P concentrations greater than 1 mg l-1 was cut from 15 (before UWWTD implementation) to 2. These findings suggest that after UWWTD implementation, resources should focus on introducing tertiary sewage treatment at the remaining large STW, before targeting diffuse inputs. This conclusion is also likely to apply to other lowland river catchments in southern England, most of which have similar population densities to the River Avon.

Diffusion↗
PubMed2006

Bioaccessible arsenic in the home environment in southwest England.

Samples of household dust and garden soil were collected from twenty households in the vicinity of an ex-mining site in southwest England and from nine households in a control village. All samples were analysed by ICP-MS for pseudo-total arsenic (As) concentrations and the results show clearly elevated levels, with maximum As concentrations of 486 microg g(-1) in housedusts and 471 microg g(-1) in garden soils (and mean concentrations of 149 microg g(-1) and 262 microg g(-1), respectively). Arsenic concentrations in all samples from the mining area exceeded the UK Soil Guideline Value (SGV) of 20 microg g(-1). No significant correlation was observed between garden soil and housedust As concentrations. Bioaccessible As concentrations were determined in a small subset of samples using the Physiologically Based Extraction Test (PBET). For the stomach phase of the PBET, bioaccessibility percentages of 10-20% were generally recorded. Higher percentages (generally 30-45%) were recorded in the intestine phases with a maximum value (for one of the housedusts) of 59%. Data from the mining area were used, together with default values for soil ingestion rates and infant body weights from the Contaminated Land Exposure Assessment (CLEA) model, to derive estimates of As intake for infants and small children (0-6 years old). Dose estimates of up to 3.53 microg kg(-1) bw day(-1) for housedusts and 2.43 microg kg(-1) bw day(-1) for garden soils were calculated, compared to the index dose used for the derivation of the SGV of 0.3 microg kg(-1) bw day(-1) (based on health risk assessments). The index dose was exceeded by 75% (18 out of 24) of the estimated As doses that were calculated for children aged 0-6 years, a group which is particularly at risk from exposure via soil and dust ingestion. The results of the present study support the concerns expressed by previous authors about the significant As contamination in southwest England and the potential implications for human health.

Air Pollution, Indoor↗
PubMed2004

Gender and age inequity in the provision of coronary revascularisation in England in the 1990s: is it getting better?

Although the mortality and incidence of coronary heart disease (CHD) in England and Wales has declined in recent years, an ageing population has contributed to keeping the prevalence of CHD largely unchanged. Evidence suggests that revascularisation procedures have contributed not only to this decline in mortality, but also to the decline in morbidity from heart disease, and to improvements in quality of life, even in old age. Despite clinical evidence of benefit, revascularisation is less often provided for older people and for women. This paper considers the equity of the provision of revascularisation according to need by gender and age using the Hospital Episodes Statistics (HES) database which includes all NHS hospital admissions in England. Trends from 1991 to 1999 were examined comparing admissions for acute myocardial infarction (as a proxy indicator of need in the absence of direct measures) and the procedures coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA). The rates of CABG and PTCA have increased dramatically by 72% and 48%, respectively, between 1991/3 and 1997/9. Making allowance for differences in need, to achieve equitable provision with men, over 12,000 extra CABG and over 5000 PTCA procedures would be required for women, amounting to 19% and 10% increases in the total volume of each procedure, respectively. Similarly, attempting to meet need up to the age of 79 years would require over 13,000 extra CABG and over 13,000 PTCA procedures for men, and an additional 14,300 CABG and almost 10,000 extra PTCA procedures for women, representing 42% and 40% increases in CABG and PTCA, respectively. As women tend to present with CHD at older ages this indicates that they may be the victims of a 'double whammy' of inequity. Moreover, these inequities have remained constant through the study period. Possible explanations for this shortfall of provision are proposed.

Adult↗
PubMed2006

Effects of socioeconomic and geographic variations on survival for adult glioma in England and Wales.

BACKGROUND: To investigate the effects of SES and geographic variations on survival for adult patients with glioma, we analyzed data from 30489 patients from the Cancer Registry in England and Wales. METHODS: Median survival and CSRs for 8 variables (age, sex, morphology, World Health Organization [WHO] grade, tumor site, SES, geographic regions, and periods of diagnosis) are calculated using the Kaplan-Meier method. Distributions among different variables are compared using chi(2) test. Cox regressions are performed for estimating HRs to death. RESULTS: The median survival and the 1-, 5-, and 10-year CSR in this population are 0.42 years, 29.1%, 12.0%, and 7.7%, respectively. There is a gradient in SES from the south to the north (chi(2) test, P < .001) and a gradual increment in higher SES from the early to the recent period (chi(2) test, P < .001). Mono- and multivariate analyses reveal that all the 8 variables influenced the survival (P < .05). Age (HR, 1.04 per year from 15 years, P < .001), WHO grade (1.21 per grade from grade I, P < .001), and morphology (HR from 1.23 to 1.89, compared with ependymoma, P < .05) are the most influential factors. However, there are also independent effects from SES (HR, 1.03 per quintile of deprivation, P < .001) and geographic regions (HR, 1.10 for outside southern England; P < .001) on the survival. CONCLUSIONS: Although age and tumor characteristics (morphology, WHO grade, tumor site) are well-known prognostic factors, SES and geographic variations also play a slight but significant role, and for more cost-effective allocation of health resources, alleviation on these 2 modifiable factors should be considered.

Adult↗
PubMed2006

Survival analysis of 459 adult patients with primary spinal cancer in England and Wales: a population-based study.

BACKGROUND: Primary spinal gliomas are rare. Because data from the Cancer Registry of England and Wales covered larger numbers of patients and longer durations of follow-up, our objective was to define prognostic factors for survival at a national population level. METHODS: From 1971 to 1995, data on 459 adult patients (age, >15 years) with primary spinal cancer from the Cancer Registry of England and Wales were analyzed. Median survival and CSRs with respect to 7 variables (age, sex, morphology, WHO grade, socioeconomic status, geographic region, and period of diagnosis) were calculated using the Kaplan-Meier method. Cox regression was performed for estimating HRs for death. RESULTS: The median survival and the 1-, 5-, and 10-year CSRs for the population were 10.2 years, 78.7%, 59.7%, and 50.5%, respectively. Univariate analysis revealed that age at diagnosis, morphology, WHO grade, and period of diagnosis affected the CSR. Multivariate analysis demonstrated 3 factors influencing survival: older age (ie, >60 years; HR = 2.67; P < .001), non-ependymomas (HR = 3.51; P < .001), and high-grade tumors (HR = 3.01; P < .001). The improved survival in recent periods was associated with an increased number of diagnosed ependymomas. CONCLUSION: This study identifies old age, non-ependymomas, and high-grade tumors as negative prognostic factors for patient survival. The results from this population-based study are very helpful for comparison with those of other hospital-based studies and for public health purposes.

Adolescent↗
PubMed2004

Waning immunity and subclinical measles infections in England.

Following the introduction of vaccination against measles, levels of clinical infection have dropped markedly. As we move further into the vaccine era, increasingly many individuals owe their measles immunity to vaccination and have had few (if any) exposures to wild virus. A number of recent reports suggest that vaccinated individuals with low levels of immunity may be at risk of subclinical measles infection. We explore the interplay between levels of infection and immunity over time using a mathematical model that simulates infection, waning and boosting of immunity. We focus particularly on the situation in England, where vaccination has been in place since 1966. Simulations of our model demonstrate a rise in the levels of subclinical measles infection over time, and a corresponding rise in clinical measles infections if vaccination levels are too low. We compare the impact of intervention strategies, and find that the rise in cases is most effectively reduced by 'catch-up' vaccination of children. In recent years, vaccination levels in England have dropped from above 90% in the 1990s to 84% in 2001/2002. We discuss the impact of declining vaccination levels on clinical and subclinical infections.

Antibodies, Viral↗
PubMed2005

Influenza vaccine uptake in adults aged 50-64 years: policy and practice in England 2003/2004.

A small national study was carried out in England in 2003/2004 to ascertain the views of primary care trusts (PCTs) and general practitioners (GPs) on whether influenza immunisation should be extended to all people aged 50-64 years from the current recommendation of 65 years or more. Results showed that as many primary care trusts would be in favour, as would not be in favour. A similarly divided view was expressed by general practitioners. Vaccine uptake rates for high-risk (HR) and low-risk (LR) adults aged 50-64 years in the study population were higher in those practices where the GP was in favour of a more inclusive policy of offering flu vaccine to all persons aged 50 years or more, compared with those that did not favour this policy (60% versus 54% HR (p=0.02) and 16% versus 11% LR (p=0.02)). Higher rates of vaccine uptake for low-risk patients aged 50-64 years were also reported from practices where GPs perceived a greater health benefit of immunisation for this age group. Although policy for recommending vaccine to all patients aged 50 years or more is established elsewhere, opinion on whether such a policy should be adopted in England is currently divided amongst those providing local health services.

England↗
PubMed2005

Modelling the impact of prison vaccination on hepatitis B transmission within the injecting drug user population of England and Wales.

A vaccination programme offering hepatitis B (HBV) vaccine at reception into prison has been introduced into selected prisons in England and Wales. The work here considers the impact of prison vaccination on the incidence and prevalence of hepatitis B virus (HBV) in the injecting drug user (IDU) population of England and Wales. A dynamic model of the transmission of HBV in IDUs is developed with key model assumptions and parameters being subject to sensitivity analyses. The base case model (that assumes that the vaccination coverage on prison reception is 5% in 2002, 10% in 2003 and then increases linearly up to 50% of prison receptions being vaccinated by 2006) predicts that the incidence of HBV in IDUs might be reduced by almost 80% in 12 years, and the HBV prevalence (IDUs ever infected by HBV) may be reduced from approximately 18% in 2002 to 7% in 2015. The model presented here demonstrates that HBV vaccination on prison reception can have a significant impact on the prevalence and incidence of HBV in the IDU population over time.

Adolescent↗
PubMed1999

Trends in rates of reexploration for hemorrhage after coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group.

BACKGROUND: While mortality rates associated with coronary artery bypass grafting (CABG) have been declining, it is unknown whether similar improvements in the rates of morbidity have been occurring. This study examines trends in reexploration rates for hemorrhage, one of the serious complications of CABG surgery. It also explores changes in patient characteristics and several surgeon practice patterns potentially related to bleeding risks that may explain variations in these rates. METHODS: We performed a regional observational study of all of the 12,555 consecutive patients undergoing isolated CABG surgery in northern New England between 1992 and 1997. The rates of reexploration and patient characteristics were examined between two time intervals: period I (January 1, 1992 to June 1, 1994) and period II (June 1, 1995 to March 31, 1997). All of the region's 23 practicing surgeons responsible for these patients were surveyed to assess changes in practice patterns potentially related to bleeding risks. RESULTS: The adjusted rates of reexploration for bleeding declined 46% between periods I and II (3.6% versus 2.0%, p < 0.001). All of the five cardiac centers in northern New England showed similar trends with adjusted risk reductions ranging from 32% to 48% between the two time periods. This decline occurred despite the patients in period II having higher percentages of risk factors for reexploration for bleeding compared to patients in period I. From the surgeon survey, the number of surgeons using antifibrinolytics markedly increased from period I to period II. More surgeons were also using preoperative aspirin and heparin up until the time of surgery in period II. CONCLUSIONS: Similar to the rates of mortality, the rates of reexploration for bleeding following CABG surgery are substantially declining. This decrease in the reexploration rates occurred despite higher patient risks.

Aged↗
PubMed2003

Changes in summer temperature and heat-related mortality since 1971 in North Carolina, South Finland, and Southeast England.

Three climatically diverse regions were studied to determine the impact of temperature change on heat-related mortality from 1971 to 1997. Median regressions showed that May-August temperatures in North Carolina rose by 1.0 degrees C (95% CL 0.0-2.0 degrees C) from 23.5 degrees C (74.3 degrees F), were unchanged in South Finland at 13.5 degrees C (56.3 degrees F), and rose in Southeast England 2.1 degrees C (0.3-4.0 degrees C) from 14.9 degrees C (58.8 degrees F). After determining for each region the daily temperature (as a 3 degrees C band) at which the mortality was the lowest, annual heat-related mortality was obtained as excess mortality per million at temperatures above this. Annual heat-related mortality per million (among the population at risk, aged 55+) fell in North Carolina by 212 (59-365) from 228 (140-317) to only 16 (not significant, NS); fell in South Finland by 282 (66-500) from 382 (257-507) to 99 (NS); and fell in Southeast England by 2.4 (NS) from 111 (41-180) to 108 (41-176). The falls in North Carolina and South Finland remained significant after allowances were made for changes in age, sex, and baseline mortality. Increased air conditioning probably explains the virtual disappearance of heat-related mortality in the hottest region, North Carolina, despite warmer summers. Other lifestyle changes associated with increasing prosperity probably explain the favorable trends in the cooler regions.

Aged↗
PubMed2003

An audit of the management of induced abortion in England and Wales.

OBJECTIVES: To assess the quality of care provided to women undergoing induced abortion. METHODS: The design was a single round audit questionnaire aimed at the providers of abortion services throughout England and Wales (NHS hospitals, clinics under NHS, agency agreements and private units. The levels of care were assessed against agreed audit criteria. RESULTS: Responses were received from 240 (74%) of the 324 units providing abortion care in England and Wales. These units undertook 80% of the 176,000 termination procedures. Generally standards of care were appropriate, but there were clear areas for improvement including choice of method, infection screening, and delays in referral. A number of unnecessary investigations were still evident, including cross-matching, while lower doses and alternative drug regimens might reduce costs. Only half of the units audited procedures and complications. CONCLUSIONS: This audit was carried out prior to the publication of the RCOG evidence-based guideline and a further round of audit to assess the impact of the guideline should now be considered.

Abortion Applicants↗
PubMed2006

Incidence of primary and recurrent acute urinary retention between 1998 and 2003 in England.

PURPOSE: We report how the incidence of primary and recurrent acute urinary retention changed in England between 1998 and 2003. In addition, we present data on changes with time in the use of prostatectomy after acute urinary retention and recurrent acute urinary retention. MATERIALS AND METHODS: Data were extracted from the Hospital Episode Statistics database of the Department of Health in England. Patients were included in the study if an International Classification of Diseases, Tenth Revision code for acute urinary retention or an operative procedure code for transurethral prostate resection was present in any diagnosis or procedure fields of the Hospital Episode Statistics database. A total of 165,527 men were identified to have been hospitalized with acute urinary retention in the study period. RESULTS: The incidence of primary acute urinary retention was 3.06/1,000 men yearly. Acute urinary retention was spontaneous in 65.3% of cases. The incidence of acute urinary retention decreased from 3.17/1,000 men yearly in 1998 to 2.96/1,000 yearly in 2003. Surgical treatment following spontaneous acute urinary retention decreased 20% from 32% in 1998 to 26% in 2003. This trend coincided with a 20% increase in the rate of recurrent acute urinary retention. CONCLUSIONS: The slight decrease in the incidence of primary acute urinary retention suggests that the shift away from surgical treatment for benign prostatic hyperplasia has not resulted in an increase in acute urinary retention. The increase in recurrent acute urinary retention suggests that the observed decrease in surgery after acute urinary retention may have put more men at risk for acute urinary retention recurrence.

Acute Disease↗
PubMed1990

Geographical and social variations in mortality due to childhood accidents in England and Wales 1975-1984.

An analysis was made of the death rates from accidents in children aged 0-14 by health districts in England and Wales during the five year periods 1974-79 and 1980-84. Death rates were generally higher in the north and west of England and lower in the south and east. Rates were higher in urban areas than in rural areas. There was a more than five-fold difference between the highest and lowest rates by districts during both periods. There was a very strong correlation with social deprivation. Greater efforts are required to reduce unnecessary deaths and disability from childhood accidents. The lessons already learned in many parts of the world must now be put into much wider use and practice in the United Kingdom.

Accident Prevention↗
PubMed1986

The geographical distribution of tuberculosis notifications in a national survey of England and Wales in 1983. Report from the Medical Research Council Tuberculosis and Chest Diseases Unit.

A survey of all tuberculosis notifications in England and Wales for the first 6 months of 1983 has made it possible to estimate the annual notification rates for that year for the White and the Indian subcontinent (Indian, Pakistani and Bangladeshi) ethnic groups for the nine regions of England and Wales and for the 33 boroughs of Greater London. The rates have been compared with those estimated from an earlier 6-month survey in 1978/79. However, for the 53 counties and the 370 local authority areas outside Greater London only the overall rates could be calculated because population data by ethnic group were not available. There was considerable variation between the 9 regions in the notification rates for all ethnic groups combined (range 28.1 per 100,000 in Greater London to 4.5 per 100,000 in Anglia) and for the White ethnic group (range 13.1 per 100,000 in Greater London to 3.1 per 100,000 in Anglia). The rates for the Indian subcontinent (ISC) ethnic group were high in all the regions and were 15-60 times higher than the corresponding rates for the White ethnic group. Between 1978/79 and 1983 there was a decline in all of the regions in the notification rates for all ethnic groups combined and the White group. For the ISC ethnic group there was a decline in all regions apart from Anglia (where the number of cases was small). The difference in rates for the London boroughs, from 92.3 per 100,000 for Brent to 5.7 per 100,000 for Havering, were associated not only with the proportion of the population who were of ISC ethnic origin but also with indices of socio-economic class for the borough. There was, however, no evidence to suggest that high rates in the White population were a consequence of the presence of a large number of infectious patients of ISC ethnic origin. Notification rates for the 53 counties apart from Greater London ranged from 23.7 per 100,000 for the West Midlands to 3.1 per 100,000 for Surrey and with few exceptions there was a decline in rates between the surveys. Considering the 370 local authorities outside Greater London, the number with a notification rate of less than 5 per 100,000 increased from 73 in 1978/79 to 105 in the 1983 survey and the number of local authorities in which no cases were notified in the 6-month survey period increased from 32 to 41.

Bangladesh↗
PubMed2002

Polybrominated diphenyl ethers in two species of marine top predators from England and Wales.

During an earlier study, polybrominated diphenyl ethers were detected at high concentrations in fish and sediments downstream of a manufacturing site in NE England. We have now undertaken analysis of 14 tri- to heptabromodiphenyl ether congeners in tissues of two species of marine top predators exposed to these compounds through their consumption of fish. In this paper we report data for 47 cormorants and 60 harbour porpoises from England and Wales, sampled during the period 1996-2000. Concentrations of the summed congeners ranged from 1.8 to 140 microg kg(-1) wet weight in cormorant livers, and from not detected to 6900 microg kg(-1) wet weight in porpoise blubber. The major congeners present were generally BDE47, BDE99 and BDE100. There was little correlation between concentrations of chlorobiphenyls (as the sum of 25 individual congeners) and the sum of the 14 BDE congeners determined, particularly for the porpoises.

Adipose Tissue↗
PubMed2004

Human lead exposure in England from approximately 5500 BP to the 16th century AD.

Lead concentration and isotope ratio data are presented for the tooth enamel of 77 individuals buried in England and spanning approximately 5000 years from the Neolithic until the 16th century AD. Whereas other tissues may be affected by diagenesis in the burial environment, the Pb concentration of tooth enamel is directly related to childhood exposure. This record is preserved post-mortem and over archaeological time. Tooth enamel Pb concentrations in the prehistoric period appear to be variable within the range 0.04 to approximately 0.4 ppm, with occasional higher levels. The Romano-British and medieval periods show a marked increase in Pb exposures with enamel concentrations reaching up to approximately 40 ppm. These exposures would today be associated with industrial pollution. Exposures appear to be highly variable compared with modern people, however, with many medieval individuals having very low enamel Pb concentrations comparable with prehistoric people. Lead isotope data refine this picture. We distinguish between the diverse isotopic ratios we believe to be characteristic of 'natural' exposure to Pb-from geological sources via the diet-and the much narrower isotopic range characteristic of exposure to technological Pb from ore sources. Taken together the data suggest that the maximum concentrations associated with 'non-technological' exposure at any period are approximately 0.5-1.0 ppm, similar to that reported for modern people in England.

Adult↗