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PubMed2001

Just before the Beagle: Charles Darwin's geological fieldwork in Wales, summer 1831.

Darwin returned to Shrewsbury in mid-June 1831 and spent that summer learning geology. He made geological maps of Shropshire and visited Llanymynech and other localities. From 3-20th August he joined Sedgwick on his tour of North Wales; they geologised west of Shrewsbury before travelling through Llangollen, Ruthin, Conwy to Bangor finally reaching Anglesey. Darwin left Sedgwick at Menai and walked to Barmouth making a special visit of Cwm Idwal. He returned to Shrewsbury on 29th August to open the letter from Fitzroy inviting him to join the Beagle. During this summer Darwin gained skills in all aspects of geology, including chemical analysis, which were to prove vital in the development of his ideas on natural selection.

Biology↗
PubMed1985

The epidemiology of meningococcal infections in England and Wales, 1912-1983.

The epidemiology of meningococcal infections that arose in England and Wales during the period 1912-1983 has been reviewed. The outcome of meningococcal disease was dramatically improved when treatment with sulphonamides was introduced. With the emergence of sulphonamide-resistant strains, penicillin has become the drug of choice. Despite modern treatment, however, the mortality ratio during the last 30 years has remained about the same. Prompt diagnosis as well as immediate and effective treatment are cardinal needs. Even so, when infection is overwhelming there is little chance of saving the patient. Immunisation is probably the only effective answer but as yet there is not an effective vaccine to prevent group B infections which predominate in this country.

Age Factors↗
PubMed1997

Outbreaks of infectious intestinal disease in residential institutions in England and Wales 1992-1994.

Data from the surveillance scheme of all general outbreaks of infectious intestinal disease in England and Wales reported to or otherwise identified, by the Public Health Laboratory Service Communicable Disease Surveillance Centre (CDSC) in 1992 and 1994 were used to describe the epidemiology of outbreaks of infectious intestinal disease in residential institutions. Outbreaks in residential institutions accounted for 22% (282/1275) of all outbreaks with most, 95% (268/282), occurring in homes for the elderly. The commonest pathogens in these 282 outbreaks were small round structured viruses 48% (132), salmonellas 17% (49). Clostridium perfringens 8% (23), rotavirus 5% (15) and Shigella sonnei 2% (6). The mode of transmission was described as mainly person to person in 71% (200 outbreaks) and mainly foodborne in 21% (58 outbreaks). The mean duration of outbreaks was 9 days. Duration of outbreaks varied with both the mode of transmission and the pathogen involved. The mean attack rate was 37%. Illness was reported in 5872 people. One or more individuals were admitted to hospital in 22% of outbreaks. Twenty-six deaths were reported, of which 18 were attributed to salmonellosis. Outbreaks in residential institutions are common. Attack rates are high and outbreaks are often prolonged, with high morbidity and mortality. There is a need for effective infection control policies which include appropriate training of staff, simple surveillance systems and readily available expert advice to ensure outbreaks are rapidly controlled.

Aged↗
PubMed1997

Cardiac rehabilitation services in England and Wales: a national survey.

We sent a short postal questionnaire to 244 centres in England and Wales that admitted patients with cardiac conditions. In total, 199 (81%) of the centres claimed to provide a cardiac rehabilitation service. Of these, 25 were randomly selected as a representative sample and visited in order to obtain detailed information concerning the provision of services. Most (18 (72%)) of the centres had commenced their rehabilitation programme within the previous 5 years, usually at the instigation of interested staff. Patient entry to cardiac rehabilitation programmes was restricted; women (who represented only 15% of attenders), elderly people (excluded in 10 (40%) centres), and those with more complex problems, such as angina or heart failure, were under-represented. The central components of all programmes were education and exercise training but there was a wide range in the quantity and quality of service provision. Most (22 (88%)) programmes were hospital out-patient based, one (4%) was hospital in-patient based, one (4%) was community-based and one (4%) was home-based. The staffing and funding of programmes was variable, with 7 (28%) having no identified funding. There are wide variations in the resources currently available for the rehabilitation of patients with coronary heart disease. There is a need for clearer direction of these services, in particular to determine minimum service provision. Guidelines are necessary to give a framework for this relatively new and rapidly expanding service.

Aged↗
PubMed2000

Disease incidence in dairy herds in the southern highlands district of New South Wales, Australia.

The purpose of this study was to determine clinical disease incidence in eight non-seasonally calving, pasture-fed dairy herds in the southern highlands district of New South Wales. This was a longitudinal population study. The study included all cows that calved between January 1994 and December 1995 and consisted of 2111 lactation records from 1430 cows. The incidence of the more common diseases were: calving-associated disorders, 18.0 cases per 100 calvings (95% CI 16.4-19.8 cases per 100 calvings); metabolic disorders, 5.5 cases per 100 cow-yr at risk (95% CI 4.5-6.6 cases per 100 cow-yr at risk); reproductive-tract disorders, 22.3 cases per 100 cow-yr at risk (95% CI 19.2-25.8 cases per 100 cow-yr at risk); udder disorders, 17.6 cases per 100 cow-yr at risk (95% CI 15.9-19.5 cow-yr at risk) and lameness, 3.7 cases per 100 cow-yr at risk (95% CI 2.9-4.7 cow-yr at risk). In agreement with dairy-cow disease-incidence studies conducted elsewhere, disorders of the reproductive-tract and udder were the most frequent clinical conditions encountered. These findings confirm that dairy herd-health programs should emphasise the control of these two groups of disorders.

Animals↗
PubMed2000

Cognitive dysfunction in older subjects with diabetes mellitus: impact on diabetes self-management and use of care services. All Wales Research into Elderly (AWARE) Study.

OBJECTIVE: To determine whether cognitive impairment is associated with changes in self-care behaviour and use of health and social services in older subjects with diabetes mellitus. RESEARCH DESIGN AND METHODS: This was a community based, case-control study of subjects registered with general practices participating in the All Wales Research into Elderly (AWARE) Diabetes Study. The 396 patients aged 65 years or older with known diabetes mellitus were compared with 393 age- and sex-matched, non-diabetic controls. Adjusted odds ratio estimates of normal performance on Mini-Mental State Examination (MMSE) and Clock Drawing Test (numbers and hands) were determined. Information on self-care behaviours and use of services was obtained. RESULTS: A total of 283 (71%) diabetic subjects scored 24 or more on MMSE, compared with 323 (88%) of controls (OR 0.54, P<0.0005). The mean (S.D.) scores were 24.5 (5.1) and 25.7 (4.3), respectively (difference between means 1.22; 95% CI 0.56, 1.88; P<0. 001). Clock testing demonstrated that 257 (65%) and 286 (72%) diabetic subjects correctly placed the numbers and hands, respectively, compared with 299 (76%) and 329 (84%) of controls (OR 0.59, P<0.001 and P<0.52, P<0.0005, respectively). Both test scores declined with increasing age, earlier school leaving age and deteriorating visual acuity. Of other variables examined, only need for oral hypoglycaemic drugs or insulin, history of stroke, dementia or Parkinson's disease and symptoms of autonomic neuropathy significantly impaired one or more cognitive test scores. The odds ratios (95% CI) for normal cognitive test results in subjects with diabetes after adjusting for all significant variables was 0.74 (0. 56, 0.97), P=0.029 for MMSE scores and 0.63 (0.44, 0.93), P=0.019, and 0.58 (0.38, 0.89), P=0.013, for the numbers and hands parts of the clock test, respectively. In comparison with diabetic subjects with no evidence of cognitive impairment, diabetic subjects with an MMSE score <23 were significantly less likely to be involved in diabetes self-care (P<0.001) and diabetes monitoring (P<0.001). A low MMSE score was also significantly associated with higher hospitalisation in the previous year (P=0.001), reduced ADL (activities of daily living) ability (P<0.001) and increased need for assistance in personal care (P=0.001). CONCLUSIONS: Elderly subjects with predominantly Type 2 diabetes mellitus display significant excess of cognitive dysfunction, associated with poorer ability in diabetes self-care and greater dependency. Routine screening of cognition in older subjects with diabetes is recommended.

Activities of Daily Living↗
PubMed2000

Intervention times series analysis of pertussis vaccination in England and Wales.

We use the ARIMA model with intervention in order to analyse the epidemiological situation of whooping-cough in England and Wales for the period of 1940-1990. The ARIMA modelling of this illness contains intervention variables, such as the introduction of widespread vaccination in 1957 and the fall in the level of vaccination down to 30% in 1978. The results of this analysis confirm the role of the intervention variables on the evolution of the morbidity due to whooping-cough, by quantifying their impact on the level of the morbidity, as well as the delay needed before they have an influence on the increase of recorded cases of whooping-cough.

England↗
PubMed2003

Clinical and lay preferences for the explicit prioritisation of elective waiting lists: survey evidence from Wales.

Waiting lists are a persistent feature of public health care systems. The United Kingdom National Health Service (NHS) is considering priority scoring systems as a means of ensuring that patients are treated according to clinical need rather than maximum waiting time targets. Our objective was to elicit the preferences of those involved in the finance, delivery and receipt of elective health care regarding the clinical and social factors that should and should not determine waiting time. We conducted a postal survey of 750 general practitioners, 500 consultants, 29 health authority commissioners and 1000 members of the general public across Wales. We found both professional and lay support for a more explicit system of rationing access to elective health care by waiting list. The majority of each of the survey groups believe that level of pain, rate of deterioration of disease, level of distress and level of disability should play the most influential role in determining waiting times. They agree that age, ability to pay, cost of treatment, evidence of cost-effectiveness, existence of dependants, and self-inflicted ill health should have little or no influence on patient priority. In conclusion, were the NHS to widen its use of waiting list priority scoring systems, our study suggests that there may be some degree of consensus as to the criteria to be used.

Attitude of Health Personnel↗
PubMed1996

Outbreaks of salmonellosis in hospitals in England and Wales: 1992-1994.

Data from the surveillance scheme of general outbreaks of infectious intestinal disease in England and Wales were used to describe the epidemiology of outbreaks of salmonellosis in hospitals from 1992-1994. Outbreaks of infectious intestinal disease in hospitals accounted for 15% (189/1275) of all outbreaks. A salmonella was the implicated pathogen in 12% (22/189). The mode of transmission was described as mainly person to person in 12 outbreaks, mainly foodborne in eight and equal or unknown proportions of foodborne and person to person in two. The most common strain involved was Salmonella enteritidis PT4 (11 outbreaks). The mean duration of outbreaks was 16 days. The mean attack rate in patients was 25% but varied from 2-67%. Illness was reported in 260 patients, of whom 130 had a laboratory confirmed infection. Eight hundred and twenty-six asymptomatic patients were tested, 31 of whom were positive. The salmonella infection was believed to have contributed to the deaths of five patients. Ill staff (115) were tested and 68 were positive; 1508 well staff were tested and 33 were positive. Outbreaks of salmonellosis in hospitals are preventable. Attack rates can be high and outbreaks are often prolonged, with high morbidity and associated disruption of hospital services. There is need for effective infection control policies, appropriate training of staff, simple surveillance systems and readily available expert advice to ensure outbreaks are rapidly controlled.

Cross Infection↗
PubMed1999

Clostridium difficile: an update on its epidemiology and role in hospital outbreaks in England and Wales.

Data from the surveillance system of general outbreaks of infectious intestinal disease and from laboratory reports collated by the Communicable Disease Surveillance Centre (CDSC) and requests for outbreak investigation by the PHLS Anaerobe Reference Unit were used to evaluate the current epidemiology of Clostridium difficile infection in England and Wales. Between January 1992 and December 1996, CDSC received 10,220 laboratory reports of C difficile isolation from patient's faeces and 26,873 of toxin in faeces. Over 75% of all reports were of people aged 64 years and over. The surveillance system captured a minimum data set on 694 hospital outbreaks of infectious intestinal disease. C. difficile was responsible for 109 (15%) outbreaks affecting 1625 people, of whom 1152 were found to have a C. difficile toxin producing strain. The median duration of outbreaks was 11 days. Fingerprinting by Pyrolysis Mass Spectrometry (PMS) was performed by the PHLS Anaerobe Reference Unit in 60 outbreaks, and typing by Polymerase Chain Reaction ribotyping (PCR) in 14.

Adolescent↗
PubMed2002

The role of the nurse lecturer in the supervision of students' essays, projects and assignments: results of an all Wales questionnaire survey.

This study explores the role of the lecturer in nursing and midwifery education in the supervision of students' essays, projects and assignments. Three methods were used within the study; semi-structured interviews, questionnaires and focus groups. The results from the semi-structured interviews were used to develop a questionnaire which was distributed to the population of lecturers in nursing and midwifery education (n=285) within Wales. This article reports some of the key findings of the questionnaire survey. Lecturers report a directive style of supervision with a considerable amount of time being invested in the supervision process. The production of guidelines for good supervision practice is recommended as a way of providing consistent and fair supervision for students.

Adult↗
PubMed2001

The epidemiology of herpes zoster and potential cost-effectiveness of vaccination in England and Wales.

The epidemiology of herpes zoster and post-herpetic neuralgia (PHN) was quantified from a variety of data sources and the potential cost-effectiveness of vaccination assessed. The annual incidence and severity of zoster increases sharply with age, as measured by physician consultation and hospitalisation rates, average length of stay, average proportion of cases developing PHN and the age-specific case-fatality ratio. Combining these data with information on health related quality of life results in an estimated loss of 20000 quality adjusted life years (QALYs) annually in England and Wales from herpes zoster (17400 due to PHN). The current cost of treating herpes zoster associated disease is estimated to be 47.6m pounds annually. Since both the health and economic burden are high, vaccination of the elderly is expected to be cost-effective under most scenarios, the attractiveness of immunisation increasing with age due to the increased burden of disease in the very elderly.

Adolescent↗
PubMed2002

The potential cost-effectiveness of acellular pertussis booster vaccination in England and Wales.

A cost-effectiveness analysis of the introduction of acellular pertussis booster doses at either 4 or 15 years of age was performed. A transmission dynamic model was used to predict the level of indirect protection in those too young to be vaccinated. Multivariate sensitivity analyses were performed. In England and Wales there are an estimated 35,000 general practitioner (GP) consultations, 5500 inpatient days, and nine deaths annually attributable to pertussis, despite high levels of coverage for the primary course (approximately 95%). Around 80% of the bed-days and 90% of the deaths occur in those too young to be immunised (< 3 months of age). The introduction of acellular booster doses at 4 years is expected to reduce morbidity and mortality in the younger age groups by 40-100%, and at 15 years by 0-100%. From the perspective of the health care provider, roughly 50% of the simulations result in a cost per life-year gained of less than 10,000 pounds for vaccination at 4 years, the corresponding proportion for vaccination at 15 years being only 35%. Apart from the degree of indirect protection the model was most sensitive to the discount rate, the price of the vaccine, and the mortality rate. Significant uncertainty remains regarding the epidemiology of pertussis and the impact of booster doses. Nevertheless, the introduction of acellular boosters, particularly at 4 years, has the potential to be cost-effective in the UK.

Adolescent↗
PubMed2002

Variations in the concentration of radon in parts of the Ogof Ffynnon Ddu system, Penwyllt, South Wales and estimates of doses to recreational cavers.

A new winter and summer investigation of radon concentrations in parts of the Ogof Ffynnon Ddu system at Penwyllt, South Wales, has been carried out using 100 environmental National Radiological Protection Board track etch detectors. Fifty detectors were installed in the system in December 1998 and again in August 1999 for a period of a month. The data obtained confirm that the system has moderately high radon concentrations with a system mean of 2318 Bq m(-3) in winter and 2844 Bq m(-3) in summer. Traverse means have a summer high of 3094 Bq m(-3) for OFDI to Cwm Dwr and a winter low of 1946 Bq m(-3). The extremely high concentrations approaching 20,000 Bq m(-3), reported previously from the system (Hyland, 1995), have not been reproduced. The data show that the airflow directions at the entrances are not what might have been predicted. Air appears to be largely continuously emerging from the lowest entrance but, at the higher entrances, conversely to the predictions, in winter air enters and in summer appears to be coming out or is variable. Internally, there are sites that in winter have very low radon concentrations that can only be explained by the ingress of fresh air. These are not matched in the summer experiment, again indicating that ingress of fresh air to some parts of the system is very variable. The data illustrate the complexity of airflow within a multi-entrance system but behind these variations several mean concentrations can be obtained from which an approximation of the dose likely to be received can be calculated. Using the maximum mean concentration obtained, 3094 Bq m(-3), and using the latest dose conversion, a 10 h underground trip in the Ogof Ffynnon Ddu system yields a calculated dose of 0.12 mSv. Given that the recommended limit for a member of the public is 1 mSv, this dose would be reached after about 80 h of caving in the system.

Air Pollutants, Radioactive↗
PubMed2001

Exposure to heavy metals and infectious disease mortality in harbour porpoises from England and Wales.

We investigate whether long-term exposure to heavy metals, including immunosuppressive metals like mercury (Hg), is associated with infectious disease in a wild cetacean. Post-mortem investigations on 86 harbour porpoises, Phocoena phocoena, found dead along the coasts of England and Wales revealed that 49 of the porpoises were healthy when they died as a consequence of physical trauma (most frequently entrapment in fishing gear). In contrast, 37 porpoises died of infectious diseases caused by parasitic, bacterial, fungal and viral pathogens (most frequently pneumonia caused by lungworm and bacterial infections). We found that mean liver concentrations of Hg, selenium (Se), the Hg:Se molar ratio, and zinc (Zn) were significantly higher in the propoises that died of infectious disease compared to healthy porpoises that died from physical trauma. Liver concentrations of lead (Pb), cadmium (Cd), copper (Cu) and chromium (Cr) did not differ between the two groups. Hg, Se, and the Hg:Se molar ratio were also positively correlated with age. The association between Zn concentration and disease status may result from Zn redistribution in response to infection. Further work is required to evaluate whether chronic exposure to Hg may have presented a toxic challenge to the porpoises that succumbed to infectious disease.

Animals↗
PubMed2003

The solid-solution partitioning of heavy metals (Cu, Zn, Cd, Pb) in upland soils of England and Wales.

Ninety-eight surface soils were sampled from the uplands of England and Wales, and analysed for loss-on-ignition (LOI), and total and dissolved base cations, Al, Fe, and trace heavy metals (Cu, Zn, Cd, Pb). The samples covered wide ranges of pH (3.4-8.3) and LOI (9-98%). Soil metal contents measured by extraction with 0.43 mol l-1 HNO3 and 0.1 mol l-1 EDTA were very similar, and generally lower than values obtained by extraction with a mixture of concentrated nitric and perchloric acids. Total heavy metal concentrations in soil solution depend positively upon soil metal content and [DOC], and negatively upon pH and LOI, values of r2 ranging from 0.39 (Cu) to 0.81 (Pb). Stronger correlations (r2=0.76-0.95) were obtained by multiple regression analysis involving free metal ion (Cu2+, Zn2+, Cd2+, Pb2+) concentrations calculated with the equilibrium speciation model WHAM/Model VI. The free metal ion concentrations depend positively upon MHNO3 and negatively upon pH and LOI. The data were also analysed by using WHAM/Model VI to describe solid-solution interactions as well as solution speciation; this involved calibrating each soil sample by adjusting the content of "active" humic matter to match the observed soil pH. The calibrated model provided fair predictions of total heavy metal concentrations in soil solution, and predicted free metal ion concentrations were in reasonable agreement with the values obtained from solution-only speciation calculations.

Cadmium↗
PubMed2002

Changing local geographies of private residential care for older people 1983-1999: lessons for social policy in England and Wales.

The population structures of many developed countries are changing and shifts towards much older age distributions are common. One way of meeting the resulting increasing demand for long-term care is through small business private sector provision allocated through market systems. However, the private residential care sector in England and Wales demonstrates some of the potential problems of leaving long-term care to the market. During the 1980s, the private residential sector for older persons enjoyed substantial state financed support. Since the 1990 National Health Service and Care in the Community Act introduced markets in social care in 1993, homes have had to compete amongst each other for a much smaller number of clients funded by limited local authority budgets. This impacted on their business and caring operations. Based on a three-stage quasi-longitudinal survey of over 100 residential care homes in one county, this paper considers changes in the overall size and structure of a local sector, discusses the specific management strategies that have been adopted by proprietors and the development of a purchasing and providing market culture. The paper also highlights the importance of interdisciplinary perspectives on the topic by illustrating how changes in social policy can influence local and national geographies of long-term care provision and how, in turn, an understanding of these geographies can inform the sensitive implementation of future social policy initiatives.

Aged↗
PubMed2002

Catching waves: the historical geography of the general practice fundholding initiative in England and Wales.

General practitioner fundholding is often represented as one of the more successful elements of the 1989/90 Conservative reforms of the UK National Health Service (NHS). Successive annual 'waves' of fundholding practices were approved from 1990 through to 1997 and, over time, the initiative came to involve some 50% of UK general practitioners. Fundholding is known to have had a strong regional geography that changed with evolving fundholding eligibility criteria. Further, there have been persistent allegations that fundholding tended to occur disproportionately in areas of higher social status. Past studies of fundholding have tended to consider single waves or the overall impact of the initiative rather than its development over time. They have also tended to work at a single geographic scale or through single-region case studies when exploring the statistical regularities underlying the uptake of fundholding. Using multilevel analysis, this paper seeks to enhance understanding of fundholding through an examination of the interaction of district health authority and practice characteristics across all implemented waves for all general medical practices in England and Wales. We conclude that wave mattered on a national scale, that deprivation was relatively unimportant and that there were certain types of area that exhibited persistent but unexpected high uptake.

Capitation Fee↗