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PubMed1995

Mortality from cardiovascular disease among interregional migrants in England and Wales.

OBJECTIVE: To investigate the extent to which geographical variations in mortality from ischaemic heart disease and stroke in Britain are influenced by factors in early life or in adulthood. DESIGN: Longitudinal study of migrants. SUBJECTS: 1% sample of residents in England and Wales born before October 1939 and enumerated at the 1971 census (the Office of Population Censuses and Surveys' longitudinal study). MAIN OUTCOME MEASURE: 18,221 deaths from ischaemic heart disease and 9899 deaths from stroke during 1971-88 were analysed by areas of residence in 1939 and 1971. These included 2928 deaths from ischaemic heart disease and 1608 deaths from stroke among individuals moving between 14 areas defined by the major conurbations and nine standard administrative regions of England and Wales. RESULTS: The southeast to northwest gradient in mortality from ischaemic heart disease was related significantly to both the 1939 area (chi 2 = 6.09, df = 1) and area in 1971 (chi 2 = 5.05, df = 1). Geographical variations in mortality from stroke were related significantly to the 1939 area (chi 2 = 4.09, df = 1) but the effect of area in 1971 was greater (chi 2 = 8.07, df = 1). The effect of 1971 area on mortality from stroke was largely due to a lower risk of death from stroke among individuals moving into Greater London compared with migrants to the rest of the South East region (chi 2 = 4.54, df = 1). CONCLUSIONS: Geographical variations in mortality from cardiovascular disease in Britain may be partly determined by genetic factors, environmental exposures, or lifestyle acquired early in life, but the risk of fatal ischaemic heart disease and stroke changes on migration between areas with differing mortality. The low risk of death from stroke associated with residence in Greater London is acquired by individuals who move there.

Adult↗
PubMed1996

Patterns of mortality in second generation Irish living in England and Wales: longitudinal study.

OBJECTIVE: To examine the mortality of second generation Irish living in England and Wales. DESIGN: Longitudinal study of 1% of the population of England and Wales (longitudinal study by the Office of Population Censuses and Surveys (now the Office for National Statistics)) followed up from 1971 to 1989. SUBJECTS: 3075 men and 3233 women aged 15 and over in 1971. MAIN OUTCOME MEASURES: Age and sex specific standardised mortality ratios for all causes, cancers, coronary heart disease, cerebrovascular diseases, respiratory diseases, and injuries and poisonings. Deaths were also analysed by socioeconomic indicators. RESULTS: 786 deaths were traced to men and 762 to women. At working ages (men, aged 15-64; women, 15-59) the mortality of men (standardised mortality ratio 126) and women (129) was significantly higher than that of all men and all women. At ages 15-44, relative disadvantages were even greater both for men (145) and for women (164). Mortality was raised for most major causes of death. Significant excess mortality from cancers was seen for men of working age (132) and for women aged 60 and over (122). At working ages mortality of the second generation Irish in every social class and in the categories of car access and housing tenure was higher than that of all men and all women in the corresponding categories. Adjusting for these socioeconomic indicators did not explain the excess mortality. CONCLUSION: Mortality of second generation Irish men and women was higher than that of all men and all women and for most major causes of death. While socioeconomic factors remain important, cultural and lifestyle factors are likely to contribute to this adverse mortality.

Adolescent↗
PubMed1996

Congenital anterior abdominal wall defects in England and Wales 1987-93: retrospective analysis of OPCS data.

OBJECTIVES: Analysis of incidence and characteristics of congenital abdominal wall defects, with special reference to the differences between the incidence of gastroschisis and exomphalos (omphalocele). DESIGN: Retrospective analysis using data from the Office of Population Censuses and Surveys (recoded to differentiate exomphalos and gastroschisis) and the National Congenital Malformation Notification Scheme. SETTING: England and Wales, 1987 to 1993. RESULTS: 1043 congenital anterior abdominal wall defects were notified within the seven year study period. Of these, 539 were classified as gastroschisis, 448 as exomphalos, 19 as "prune belly syndrome," and 37 as "unclassified." Gastroschisis doubled in incidence from 0.65 in 1987 to 1.35 per 10,000 total births in 1991, with little further change; the incidence of exomphalos decreased from 1.13 to 0.77 per 10000 births. The overall incidence of notified congenital abdominal wall defects was 2.15 per 10000 total births. Gastroschisis was associated with a lower overall maternal age than exomphalos and with a significantly lower proportion of additional reported congenital malformations (5.0%) than in the cohort with exomphalos (27.4%) (odds ratio 0.14, 95% confidence interval 0.09 to 0.22; P < 0.001). The sex ratio of the two cohorts was the same. The incidence of gastroschisis and exomphalos was higher in the northern regions of England than in the south east of the country. CONCLUSIONS: The national congenital malformation notification system showed an increasing trend in the incidence of fetuses born with gastroschisis and a progressive decreasing incidence of exomphalos in England and Wales between 1987 and 1993. Although the reasons for this are likely to be multifactorial, a true differential change seems likely. The observed increase in incidence of gastroschisis relative to exomphalos and the differentiation in maternal age have implications for resource management within the NHS and warrant further epidemiological monitoring. Regional differences may be due to a dietary or environmental factor, which requires further study.

Abdominal Muscles↗
PubMedDate not supplied

"I'm all right, John": voting patterns and mortality in England and Wales, 1981-92.

OBJECTIVE: To investigate the association between voting patterns, deprivation, and mortality across England and Wales. DESIGN: Ecological study. SETTING: All the electoral constituencies of England and Wales. MAIN OUTCOME MEASURES: Combined and sex specific standardised mortality ratios. RESULTS: For the years surrounding the three elections of 1983, 1987, and 1992 overall standardised mortality ratios showed substantial negative correlations of -0.74 to -0.76 with Conservative voting and substantial positive correlations of 0.73 to 0.77 with Labour voting (all P < 0.0001). Correlations were higher for male than female mortality. Conservative voting was strongly negatively correlated (r = -0.84) with the Townsend deprivation score, while Labour voting was positively correlated (r = 0.74) with this. Labour and Conservative voting explained more of the variance in mortality than did the Townsend score. In multiple regression analyses for the 1992 election Labour voting (P < 0.0001), Conservative voting (P < 0.0001), the Townsend score (P = 0.016), and abstentions (P = 0.032) were all associated with mortality. Labour and conservative voting explained 61% of the variance in mortality between constituencies; when Townsend score and abstentions were added this increased to 63%. CONCLUSIONS: Conservative and Labour voting are at least as strongly associated with mortality as is a standard deprivation index. Voting patterns may add information above that provided by indicators of material deprivation. People living in better circumstances and who have better health, who are least likely to require unemployment benefit and free school meals or to rely on a state pension in old age, and who are most able to opt out of state subsidised provision of transport, education, and the NHS, vote for the party that is most likely to dismantle the welfare state.

England↗
PubMed1997

Age specific trends in asthma mortality in England and Wales, 1983-95: results of an observational study.

OBJECTIVE: To determine trends in asthma mortality by age group in England and Wales during 1983-95. DESIGN: Observational study. SETTING: England and Wales. SUBJECTS: All deaths classified as having an underlying cause of asthma registered from 1 January 1983 to 31 December 1995. MAIN OUTCOME MEASURE: Time trends for age specific asthma deaths. RESULTS: Deaths in the age group 5-14 years showed an irregular downward trend during 1983-95; deaths in the age groups 15-44, 45-64, and 65-74 years peaked before 1989 and then showed a downward trend; and deaths in the age group 75-84 years peaked between 1988 and 1993 and subsequently dropped. Trends were: age group 5-14 years, 6% (95% confidence interval 3% to 9%); 15-44 years, 6% (5% to 7%); 45-64 years, 5% (4% to 6%); 65-74 years, 2% (1% to 3%). Deaths in the 75-84 and 85 and over categories plateaued. CONCLUSIONS: There are downward trends in asthma mortality in Britain, which may be due to increased use of prophylactic treatment.

Adolescent↗
PubMed1999

Bullying behaviour and psychosocial health among school students in New South Wales, Australia: cross sectional survey.

OBJECTIVES: To examine the prevalence of bullying behaviours in schoolchildren and the association of bullying with psychological and psychosomatic health. DESIGN: Cross sectional survey. SETTING: Government and non-government schools in New South Wales, Australia. PARTICIPANTS: 3918 schoolchildren attending year 6 (mean age 11.88 years), year 8 (13.96), and year 10 (15.97) classes from 115 schools. MAIN OUTCOME MEASURES: Self reported bullying behaviours and psychological and psychosomatic symptoms. RESULTS: Almost a quarter of students (23.7%) bullied other students, 12.7% were bullied, 21.5% were both bullied and bullied others on one or more occasions in the last term of school, and 42.4% were neither bullied nor bullied others. More boys than girls reported bullying others and being victims of bullying. Bullying behaviour was associated with increased psychosomatic symptoms. Bullies tended to be unhappy with school; students who were bullied tended to like school and to feel alone. Students who both bullied and were bullied had the greatest number of psychological and psychosomatic symptoms. CONCLUSIONS: Being bullied seems to be widespread in schools in New South Wales and is associated with increased psychosomatic symptoms and poor mental health. Health practitioners evaluating students with common psychological and psychosomatic symptoms should consider bullying and the student's school environment as potential causes.

Adolescent↗
PubMed2001

Deaths from chickenpox in England and Wales 1995-7: analysis of routine mortality data.

OBJECTIVE: To evaluate the epidemiology and impact of mortality from chickenpox in England and Wales. DESIGN: Review of death certificates from the Office for National Statistics on which codes for "chickenpox" or "varicella" were mentioned. Further information ascertained from certifying physician. PARTICIPANTS: Those certified as having died from chickenpox in England and Wales, 1995-7. MAIN OUTCOME MEASURES: Diagnosis and age and sex distributions of deaths from chickenpox. RESULTS: On average, 25 people a year die from chickenpox. Overall case fatality was 9.22 per 100 000 consultations for chickenpox. Adults accounted for 81% of deaths and 19% of consultations. Deaths were twice as common in men as in women. More of those who died were born outside United Kingdom than expected (12% v 4%). CONCLUSIONS: Chickenpox is not a mild disease. Deaths in adults are increasing, both in number and proportion.

Adolescent↗
PubMed2004

Trends in Haemophilus influenzae type b infections in adults in England and Wales: surveillance study.

OBJECTIVE: To describe invasive Haemophilus influenzae type b (Hib) infections in individuals aged 15 years or older in England and Wales between 1991 and 2003. DESIGN: Prospective, laboratory based surveillance of invasive Hib infections and cross sectional seroprevalence study. SETTING: England and Wales. PARTICIPANTS: Cases were confirmed by isolation of H influenzae from a normally sterile site, or from a non-sterile site in cases with a diagnosis of epiglottitis. Excess serum samples collected from English 30-39 year olds as part of a national serosurvey were identified for the years 1990, 1994, 1997, 2000, and 2002. MAIN OUTCOME MEASURES: The number of invasive Hib infections from 1991 to 2003. Population immunity to H influenzae type b in English adults was also measured. RESULTS: After routine infant immunisation was introduced in October 1992, adult Hib infections decreased initially but then rose from a low in 1998 to reach prevaccine levels in 2003. An associated fall in median Hib antibody concentrations occurred, from 1.29 microg/ml (95% confidence interval 0.90 to 1.64) in 1991 to 0.70 microg/ml (0.57 to 0.89) in 1994 (P = 0.006), with no significant change observed thereafter. CONCLUSIONS: Although immunisation of infants resulted in an initial decline in Hib infections in adults, a resurgence in reported cases occurred in 2002-3. This rise was associated with an increase in cases in children and evidence of reduced immunity in older unimmunised cohorts. Childhood immunisation programmes may have unanticipated effects on the epidemiology of disease in older age groups, and surveillance strategies must be targeted at entire populations.

Adolescent↗
PubMed2004

Improved access and targeting of musculoskeletal services in northwest Wales: targeted early access to musculoskeletal services (TEAMS) programme.

PROBLEM: The hospital based musculoskeletal service in northwest Wales was unable to cope with the demand for referrals from general practitioners. Waiting times were long, duplicate referrals to other departments were common, and general practitioners were reluctant to refer patients with common problems because of the perceived lack of service. Many referrals were made to the inappropriate specialty, especially orthopaedics. At least part of this problem was due to a lack of coordination between the four hospital departments providing musculoskeletal services and the emphasis on district general hospital based rather than community provision. DESIGN: Review over 18 months of impact of the targeted early access to musculoskeletal services (TEAMS) programme on accessibility to musculoskeletal services. SETTING: Northwest Wales. KEY MEASURES FOR IMPROVEMENT: Number of patients referred and seen with musculoskeletal problems, waiting times, number of duplicate referrals, and surgery conversion rates in orthopaedic clinics. STRATEGIES FOR CHANGE: Establishing with central clinical triage a common pathway for all musculoskeletal referrals so that patients attend the appropriate department. A back pain pathway led by extended scope physiotherapists was developed, and general practitioners with special interests and extended scope physiotherapists were trained to provide services for patients with uncomplicated musculoskeletal problems in the community. EFFECTS OF CHANGE: Over 18 months the number of referrals more than doubled. Despite this, waiting times for musculoskeletal services fell; this was noticeable for rheumatology and pain management. Duplicate referrals were abolished. Surgery conversion rates did not, however, change. Questionnaires from the clinics showed a high level of patient satisfaction. LESSONS LEARNT: Integration of hospital services that traditionally have worked in isolation can result in greatly improved access to musculoskeletal services. Community based multidisciplinary clinics run by specially trained general practitioners with special interests and extended scope physiotherapists are an effective way of managing patients with uncomplicated musculoskeletal problems and have been well received by patients and general practitioners. The huge unmet burden of need was reflected by the great increase in musculoskeletal referrals. Other approaches are needed to meet this, including better education of general practitioners and methods for identifying and modifying psychosocial risk factors for chronic pain at an early stage.

Health Services Accessibility↗
PubMed2006

Impact of specialty of admitting physician and type of hospital on care and outcome for myocardial infarction in England and Wales during 2004-5: observational study.

OBJECTIVE: To examine process of care and outcome for patients admitted with acute myocardial infarction to hospitals in England and Wales in relation to type of consultant care and type of hospital. DESIGN: Observational study of 88,782 patients admitted with myocardial infarction during 2004-5, using records from the national audit of myocardial infarction project (MINAP) database. OUTCOME MEASURES: Use of reperfusion treatment and secondary prevention drugs, use of angiography, and 90 day mortality of patients admitted under the care of cardiologists and non-cardiologists in hospitals with and without facilities for coronary intervention. FINDINGS: 36% of patients were admitted under the care of a cardiologist and 20% to a hospital with coronary interventional facilities. Patients admitted under cardiologists had fewer comorbidities than other patients and were more likely to have reperfusion treatment (12,266/14,433 (85%) v 13,682/17,064 (80%)) and appropriate secondary prevention drugs. Overall, 27,431/79,374 (35%) of patients had angiography. Relatively more patients admitted to interventional hospitals (8167/14,661; 56%) than to other hospitals had angiography (19,264/64,713; 30%). The adjusted risk of death by 90 days for patients treated in interventional compared with non-interventional hospitals was 0.93 (95% confidence interval 0.82 to 1.06). The adjusted risk of death at 90 days for patients admitted under cardiologists compared with non-cardiologists was 0.86 (0.81 to 0.91). CONCLUSIONS: Patients cared for by cardiologists had less comorbidity than other patients. They were more likely to receive proved treatments and angiography, and they had a lower adjusted 90 day mortality. Large differences existed in the use of angiography between interventional and non-interventional hospitals. These findings show wide variations in the management and outcome of patients with myocardial infarction in England and Wales.

Aged↗
PubMed1985

Changing digoxin potency and cardiac mortality in England and Wales 1968-76.

Data on monthly totals of cardiac deaths in England and Wales were examined in different ways to see whether there were any unexplained fluctuations in rates both at the time of an unplanned increase in the bioavailability and therefore the potency of the Lanoxin brand of digoxin in May 1972 and also when there was a coordinated increase in the bioavailability of other brands in October 1975. Despite advice to prescribers, dosages were not proportionately reduced in the 600 000 patients who were on treatment. Monthly totals of deaths from cardiac causes were high through the summer of 1972 but not at the end of 1975 and the excess in 1972 seems to be related to a cold summer. There was no evidence of a consistent or specific effect of changes in digoxin potency, either beneficial or harmful, on deaths from all cardiac causes or in specific subgroups in which digoxin treatment was likely to be most common. Although major changes in digoxin potency in England and Wales did not seem to produce a repeatable effect on death rates, data from other countries should also be examined for evidence of such an effect.

Biological Availability↗
PubMed1990

Multiple drug resistance in salmonellae in England and Wales: a comparison between 1981 and 1988.

Each year from 1981 through to 1988 the most common serotypes isolated from man in England and Wales and identified at the Division of Enteric Pathogens were S typhimurium, S enteritidis, and S virchow. In 1981 these three serotypes accounted for 45%, 12%, and 7% of isolations. The remaining 35% comprised strains belonging to a further 188 different serotypes, none of which accounted for more than 1% of the total. In 1988 S typhimurium accounted for 24% of isolations, S enteritidis 57%, and S virchow 4%. The remaining 15% comprised strains of a further 184 serotypes. The resistances to the common antimicrobial drugs in non-typhoidal salmonellas isolated in England and Wales in 1981 and 1988 were reported with particular reference to resistance to four or more antimicrobial drugs (multiple resistance). For S typhimurium the overall percentage of resistant strains varied little, but multiple resistance more than doubled from 5% to 12%; in S enteritidis the incidence remained the same. In S virchow the percentages of strains resistant to all the antimicrobial drugs and in particular, to chloramphenicol, streptomycin, trimethoprim and furazolidone, rose from 0.2% to 10.4%. Salmonella enteritis in man is usually a self limiting disease and antimicrobial treatment is seldom required; but should spread beyond the intestine occur, effective antimicrobial treatment is essential. Under these circumstances a knowledge of the likelihood of resistances to commonly available drugs could be of considerable value to the clinician.

Anti-Bacterial Agents↗
PubMed1992

Salmonella bacteraemia in England and Wales, 1981-1990.

AIMS: To report the incidence of nontyphoidal salmonellas in England and Wales and identified in the Division of Enteric Pathogens, London between 1981 and 1990. METHODS: Strains were serotyped and phage typed for Salmonella typhimurium, S enteritidis, and S virchow, using established methods. RESULTS: Overall, less than 2% of nontyphoidal salmonellas isolated from humans were from blood culture. The highest numbers of bloodstream isolates were from infections caused by S enteritidis and S typhimurium, but the highest incidence of septicaemias was attributable to infections with S cholerae-suis, S dublin, and S virchow. 2.2% of S typhimurium isolates phage type 204C were from blood culture; likewise, 5.5% of S virchow phage type 19. This could be a cause for concern as most isolates of both these phage types are multiresistant to antimicrobial drugs. CONCLUSIONS: Salmonella septicaemia is rare in England and Wales in other than a few serotypes of limited epidemiological importance.

Bacteremia↗
PubMed2000

What is a natural cause of death? A survey of how coroners in England and Wales approach borderline cases.

AIM: Many deaths fall in the "grey" area between those that are clearly natural and those that are unnatural. There are no guidelines to help doctors in dealing with such cases and death certification is often arbitrary and inconsistent. In an attempt to initiate debate on these difficult areas, and with the ultimate aim of achieving national consensus, the views of coroners in England and Wales were sought. METHODS: Sixteen clinical scenarios, with causes of death, were circulated to all coroners in England and Wales. For each case they were asked to provide a verdict, with explanation. The deaths fell into three groups: (1) postoperative, (2) a combination of trauma and natural disease, and (3) infectious disease. RESULTS: Sixty four questionnaires were returned. There was near consensus (> 80% concordance) in only two of the 16 cases. In five, there was no significant agreement between coroners in the verdicts returned ("natural causes" versus "misadventure/accidental"). These included all three cases in which death resulted from a combination of trauma and natural disease (a fall after a grand mal fit; falls resulting in fractures of bones affected by metastatic carcinoma and osteoporosis), bronchopneumonia after hip replacement for osteoarthritis, and new variant Creutzfeldt-Jakob disease. The comments made for each case indicate that the variation between coroners in whether or not to hold an inquest, and the verdict arrived at, reflect the lack of a definition for natural causes, together with differences in the personal attitudes of each coroner. CONCLUSIONS: There is considerable variation in the way in which coroners approach these borderline cases, many of which are common in clinical practice. This study indicates a need for discussion, working towards a national consensus on such issues. It highlights the importance of good communication between coroners and medical staff at a local level.

Adolescent↗
PubMed2004

Prevalence of comorbid psychiatric illness and substance misuse in primary care in England and Wales.

STUDY OBJECTIVE: To estimate the annual period prevalence of co-occurring psychiatric illness and substance misuse among patients in primary care. DESIGN: Analysis of the general practice research database. SETTING: England and Wales, 1993-1998. PARTICIPANTS: Registered patients at 230 general practices representing 3.1% of the population. A comorbid case was defined as one with both a psychiatric diagnosis and substance misuse diagnosis (not including alcohol or tobacco) within a calendar year. A potentially chronic comorbid case was one that met this definition and, in addition, was treated in subsequent years for either a psychiatric condition or substance misuse. MAIN RESULTS: The annual period prevalence of comorbidity increased from 50/100 000 patient years of exposure (PYE) to 80/100 000 PYE, an increase of 62% during the study period. Rates of comorbid psychoses, comorbid schizophrenia, and comorbid paranoia increased by 147%, 128%, and 144%. The average age of comorbid cases decreased from 38 years to 34 years. Over 80% of comorbid cases were newly diagnosed in each study year, although many are treated in subsequent years for either psychiatric illness or substance misuse. CONCLUSIONS: This study provides data on the nature and extent of comorbidity in primary care in England and Wales. As the comorbidity rate is increasing by about 10% each year, and as comorbid cases are becoming younger, it is probable that the comorbidity rate will have increased beyond the study end point.

Adolescent↗
PubMed1980

Drug prescribing by GPs in Wales and in England.

There is a large excess in prescribing costs by GPs in Wales compared with England. This excess amounts to about 30%, equivalent at present to over pounds 11 m a year. The pattern of drug prescribing by GPs and of patient consultation was studied in random samples of electors in Cardiff and Bristol. Overall, more subjects in Cardiff had received prescriptions, and the average number of scripts for each person was higher than in England in the same period. The pattern for consultations was similar. For both prescriptions and consultations the rates were higher in Wales and the difference from those in England seemed to be greater for women than for men. There was no consistent difference between the two cities in the proportions of those who had consulted who received a script, nor was there any evidence that subjects in Cardiff received more prescriptions without a consultation. In both cities similar proportions of subjects bought drugs from chemists without a prescription.

Adult↗
PubMed1981

THe changing seasonality of infant deaths in England and Wales 1912-78 and its relation to seasonal temperature.

Seasonal variation in the rates of stillbirth, and of deaths under the age of one year, were studied for England and Wales in order to examine (a) changes in the seasonal variation over the years and (b) the correlation between seasonal rates and seasonal temperatures. The quarterly rates of stillbirths were studied for the period 1928-78; and of deaths under the age of one year, in six different age groups, for the period 1912-78. A disappearance of seasonal variation in rates ('deseasonality') occurrred from stillbirths in about 1950, and for neonatal deaths in about 1965. For deaths at 1-2 months a trend towards deseasonality has been apparent since 1955, but there has been no such trends for deaths at 3-11 months of age. In the period before deseasonality, and for the first quarter of the year, there was a high negative correlation between the neonatal death rate and the mean temperature in England and Wales but this correlation fell as the seasonal variation in rates fell. The findings suggest that seasonal variation in the neonatal death rate was closely related to winter temperatures during the period 1921-60. For deaths at 1-11 months old, there has been and still is a relation between temperature and seasonal variation in rates, but the relation was less close than for the neonatal death rate.

England↗