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PubMed2001

Medical specialists servicing the New England Health Area of New South Wales.

There is increasing emphasis on research, policy and program activity to recruit and retain rural general practitioners in Australia. In contrast, until recently, there has been less attention paid to specific policies and programs relating to rural medical specialists. The New England Area Health Service experiences a shortage of general practitioners and specialists. This study surveyed this region's specialist workforce in 1998 and aimed to identify recruitment and retention issues affecting specialist rural workforce planning in north-west New South Wales. All 91 medical specialists practising in this rural area were surveyed. Seventy-one completed survey forms were received, representing a response rate of 78%. Positive features of rural specialist practice included the rural lifestyle, professional autonomy and available medical infrastructure. Negative features included professional isolation, long working hours, lack of locum relief and inadequate remuneration. Almost all surveyed specialists believe that there is a shortage of specialists servicing the New England Health Area. The major deficits in specialty areas identified relate to: dermatology; ear, nose and throat; obstetrics and gynaecology; orthopaedics; paediatrics; and urology. Recruiting and retaining medical specialists would be facilitated by improvements in the following areas: specialist resources and facilities, specialist locum scheme, remuneration and professional support. Effective strategies need to take account of local circumstances and be based on discussions involving all local key stakeholders.

Female↗
PubMed1996

Fertility in England and Wales: a fifty-year perspective.

This paper provides a detailed account of fertility levels and trends in England and Wales since 1938, with a briefer coverage of a much longer time-span. The paper is concerned both with the measurement of fertility and with understanding the observed fertility behaviour. We lament and correct the failure of demographers to apply measurement tools available since the 1950s to the analysis of fertility in England and Wales, with a particular emphasis on adjustment of period measures and period parity progression ratios and show how some of the grosser errors of analysis and interpretation might have been avoided by earlier use of these approaches. We also relate these estimates to more recent ones. Once a clearer account of trends has been established, the paper goes on to reinterpret and explain the baby boom and baby bust. The conclusion looks at future prospects for fertility.

Fertility↗
PubMed1998

Survey of amphetamine prescribing in England and Wales.

A survey was undertaken of senior medical specialists in drug dependence in England and Wales, enquiring about their attitudes and practices concerning the prescription of amphetamines to dependent users. Of the 149 who replied, 60% saw a role for amphetamine prescribing, with 46% currently doing so. Of those who did not prescribe, 32% would like to have done so. Respondents often did not know if general practitioners in their area were prescribing amphetamines. Many could not estimate the percentage of injecting amphetamine users in their area. There was a wide range in the dosage of amphetamine prescribed with a mean maximum of 66 mg. There was agreement about entry criteria for prescribing programmes and also on ways of monitoring those receiving amphetamine. Our results indicate that amphetamine prescribing is widespread in England and Wales although there is little scientific evidence for its efficacy. We have developed some guidelines for good practice, drawing on our own and others' experience.

Journal Article↗
PubMedDate not supplied

Cancer incidence among first generation Scottish, Irish, West Indian and South Asian migrants living in England and Wales.

OBJECTIVES: To examine the incidence of cancers among persons born in Scotland, Northern Ireland, the Irish Republic, Caribbean Commonwealth and Indian subcontinent and living in England and Wales. METHODS: Longitudinal Study of 1% of population of England and Wales followed from 1971 to 1989. Standardised incidence ratios (SIRs) were derived for commonly occurring cancers and all cancers using the age-sex-specific rates for all females and all males in the Longitudinal Study. RESULTS: The incidence of all malignant neoplasms among West Indians (females SIR = 67, male SIR = 70) and Indians (female SIR = 32, male SIR = 52) was low. Among South Asians, this pattern was consistent for Hindus, Sikhs and Moslems. Scottish females showed raised incidence of lung cancer (SIR = 149) and those from the Irish Republic of oral cavity and pharynx (SIR = 321), oesophageal (SIR = 219) and liver (SIR = 373) cancers. Among Northern Irish females, incidence of lung cancer (SIR = 193) was raised. West Indian and South Asian females showed low incidence of breast cancer (SIR = 55 and 45, respectively). High incidence of laryngeal (SIR = 229) and renal (SIR = 203) cancers was observed for Scottish males and of oral cancer (SIR = 259) for males from the Irish Republic. At ages 15-64, raised incidence of prostate cancer (SIR = 129) and of leukaemia (SIR = 252) was also observed for men from the Irish Republic. Northern Irish males showed raised incidence of stomach cancer (SIR = 200). CONCLUSION: This study describes patterns of cancer incidence among migrant groups, most of which reflect environmental influences. This has challenging implications for sensitive targeting of primary interventions. It is important not to be complacent about lower risks of main cancers among West Indians and South Asians. In all Longitudinal Study members, breast cancer was the most common malignancy among females and lung cancer among males. This was also true for all migrant groups with the exception of Northern Irish women for whom lung cancer was the most common.

Adolescent↗
PubMed1982

Measles in England and Wales--I: An analysis of factors underlying seasonal patterns.

Examination of the weekly measles notifications for England and Wales, 1950-1979, reveals a regular biennial pattern of major and minor epidemics before the national immunization programme began in 1968, followed by an annual cycle of minor epidemics. Each year the reported incidence reaches its annual low between weeks 36 and 39, very close to the opening of primary schools. Analysis of these data with a simple mass action model reveals that the underlying transmission parameter has had a similar annual pattern in years of major and minor epidemics. The transmission parameter rises three times each year, coinciding with opening of school terms, and falls with school term and mid-term holidays. This pattern of the transmission parameter has been maintained in the decade since national vaccination began, indicating that the importance of schools in the annual dynamics of measles has not changed. The analysis further suggests that the national measles vaccination programme has not lowered the total number of individuals susceptible to measles in England and Wales.

Disease Outbreaks↗
PubMed1992

Antimicrobial resistance in Haemophilus influenzae from England and Scotland in 1991.

Twenty-two laboratories in England and Scotland sent 2212 clinical isolates of Haemophilus influenzae to The London Hospital Medical College (LHMC) between 1 January and 31 March 1991. After confirmation of identity, the prevalence of resistance was determined and compared with results from previous similar surveys. beta-Lactamase was produced by 8.3% of non-capsulate isolates and 21% of 52 type b isolates; both figures were higher than the 6% and 18% figures recorded, respectively, in 1986. There was an increase in the prevalence of non-beta-lactamase-mediated diminished susceptibility to ampicillin (5.8%) and co-amoxiclav (6.1%) compared with 1986 (4%). Whereas fewer H. influenzae isolates were resistant to tetracycline (1.4%) or chloramphenicol (0.8%), there was an increase in resistance to trimethoprim (6.8%) and to sulphamethoxazole (16.9%) compared with 1986 (4.2% and 3.5% respectively). In addition, 95 isolates (4.3%) were resistant to both of these anti-folate antimicrobials. Six isolates (one type b from CSF) were resistant to all drugs tested, except for co-amoxiclav. Overall, the results demonstrated that changes have occurred in the last decade in England and Scotland, such that H. influenzae isolates are increasingly likely to be resistant to ampicillin, co-amoxiclav and co-trimoxazole.

Chloramphenicol Resistance↗
PubMed1998

Accessibility and health service utilization for asthma in Norfolk, England.

BACKGROUND: Good access to health services may be important for effective asthma management amongst patients. Previously, we found elevated asthma mortality in parts of England with poor access to acute hospitals. A possible explanation is that barriers of access to care may lead to residents of more remote areas having a lower propensity to utilize health services, with the result that their asthma is poorly controlled. Here, we examine the relationship between utilization and the geographical accessibility of health services amongst self-reported asthmatics in a rural county of England. METHODS: The study involved analysis by logistic regression of questionnaire responses from a 10 per cent population sample of 9764 adults aged between 20 and 44 years, and resident within the catchment area of Norwich Health Authority. RESULTS: Utilization behaviour was associated with the smoking status of respondents, and levels of car ownership in their ward of residence. After controlling for these factors, respondents reporting asthma were less likely to have ever visited a general practitioner if they lived outside a settlement containing a surgery (odds ratio (OR) 3.07, 95 per cent confidence interval (CI) 1.11-8.48, p = 0.03), and the likelihood of consultation declined with distance from a surgery (OR for a 1 minute increase in travel time 0.79, 95 per cent CI 0.66-0.94, p < 0.01). Those living further from an acute hospital unit were also less likely to have consulted a hospital doctor in the previous 12 months (OR for a 1 minute increase in travel time 0.95, 95 per cent CI 0.9-0.99, p = 0.01). CONCLUSIONS: Our finding of lower levels of health service utilization amongst some self-reported asthmatics living further from health facilities suggests that the condition of some individuals might be poorly treated, which could increase the risk of fatality.

Adult↗
PubMed1994

Mortality in England in the eighteenth and the nineteenth centuries: a reply to Sumit Guha.

In the last issue of Social History of Medicine, Sumit Guha published a critique of the thesis presented in Szreter (1988), which argued that an increasing weight and diversity of social interventions were primarily responsible for the reduction in Britain's mortality achieved from the 1870s. Previoiusly neglected and harmful urban, factory, and eventually even home environments were improved, as both political and social as well as scientific approaches gradually changed, albeit in a locally diversified manner. Guha's critique is shown to be fundamentally misguided because it is premissed on the assumption that the disease ecologies of eighteenth- and of nineteenth-century England were essentially comparable. This ignores important recent research in the historical epidemiology and demography of seventeenth- and eighteenth-century England. In conclusion, it is suggested that some of the information presented by Guha in fact further supports the plausibility of the interpretation in Szreter (1988), rather than the McKeown thesis.

History, 18th Century↗
PubMed2006

Evidence for an apartheid-like social structure in early Anglo-Saxon England.

The role of migration in the Anglo-Saxon transition in England remains controversial. Archaeological and historical evidence is inconclusive, but current estimates of the contribution of migrants to the English population range from less than 10000 to as many as 200000. In contrast, recent studies based on Y-chromosome variation posit a considerably higher contribution to the modern English gene pool (50-100%). Historical evidence suggests that following the Anglo-Saxon transition, people of indigenous ethnicity were at an economic and legal disadvantage compared to those having Anglo-Saxon ethnicity. It is likely that such a disadvantage would lead to differential reproductive success. We examine the effect of differential reproductive success, coupled with limited intermarriage between distinct ethnic groups, on the spread of genetic variants. Computer simulations indicate that a social structure limiting intermarriage between indigenous Britons and an initially small Anglo-Saxon immigrant population provide a plausible explanation of the high degree of Continental male-line ancestry in England.

Computer Simulation↗
PubMed1976

Goitre survey in Armidale and the New England region.

The results of a goitre survey in school children in the New England Region are presented and compared with previous studies. Goitre incidence has fallen significantly in Tamworth but has remained unchanged in Armidale. Analyses of blood and urine showed no differnces in thyroid hormone levels, TSH, and urinary iodide in goitre and non-goitre subjects. In one group of goitre subjects prolactin levels were found to be significantly higher than those in a non-goitre group matched for sex, age and years in the district. The estimated iodine intake was well above normal requirements in all age groups studied. Sources of dietary iodine in the New England Region are outlined with special reference to milk and water. A brief review of clinical thyroid disease in Armidale is presented and reveals an unusually high incidence of both hyper- and hypo-thyroidism.

Adolescent↗
PubMed1999

Resistance to ciprofloxacin in non-typhoidal salmonellas from humans in England and Wales-the current situation.

OBJECTIVE: To report on the prevalence of isolates with ciprofloxacin resistance in non-typhoidal salmonellas from humans in England and Wales in 1997. METHODS: All non-typhoidal salmonellas referred to the Laboratory of Enteric Pathogens in 1997 were screened for resistance to ciprofloxacin at 0.125 and 1.0 mg/L and nalidixic acid at 16 mg/L, and results were compared to those for 1994. Full minimal inhibitory concentrations (MICs) of these antimicrobials were also determined for a selection of isolates resistant to ciprofloxacin at 0.125 mg/L but sensitive at 1.0 mg/L, and for all isolates resistant at 1.0 mg/L. RESULTS: Since 1994 there have been increases in the occurrence of resistance to ciprofloxacin (MICs: 0.25-1.0 mg/L) in Salmonella enterica serotypes Enteritidis, Typhimurium, Virchow and Hadar. Of particular importance have been increases in the occurrence of resistance in multiresistant S. Typhimurium DT 104, and also in S. virchow, a serotype with a propensity for causing extraintestinal infections in humans. High-level resistance (MIC >/=2.0 mg/L) was uncommon and was identified in only a few strains, all from patients with a history of recent foreign travel. CONCLUSIONS: There is a strong temporal association between increases in the occurrence of ciprofloxacin resistance in Salmonella serotypes Typhimurium, Virchow and Hadar from humans in England and Wales and with the licensing for use in food animals in the UK of the related fluoroquinolone antibiotic enrofloxacin; in contrast, for S. enteritidis ciprofloxacin resistance was most common in a phage type associated with foreign travel. It is hoped that recent recommendations for the use of fluoroquinolone antimicrobials in food animals in the UK will result in a reduction in the occurrence of resistance to ciprofloxacin in zoonotic salmonellas causing infections in humans.

Journal Article↗
PubMedDate not supplied

Guidelines for gynecological cancer-an audit of current network documents in England and Wales.

The objective of this study was to assess the adequacy of network cancer guidelines paying particular attention to referral criteria, referral routes, tumor diagnosis, staging, and suggested management and care pathways for ovarian and endometrial cancer. Guidelines from 15 regions in England and Wales were analyzed quantitatively and qualitatively as a prospective audit of predefined data items and subsequently agreed management recommendations. Details of unit and center clinicians were included in a minority of documents (2 to 5/15). Multidisciplinary team membership was not usually offered (6/15). Among the least reported data items were histopathology minimum dataset for endometrial cancer and an algorithm for management or summary and clinical symptoms and signs for both cancers. Among the most reported data items were hysteroscopy and ultrasound scanning for endometrial cancer and CA125 and chemotherapy for ovarian cancer. Qualitative analysis revealed differing criteria for the use of endometrial biopsy and radiotherapy in endometrial cancer, for lymphadenectomy and management of recurrent disease in ovarian cancer, and for referral pathways and the use of computed tomography/magnetic resonance (MR) scanning in the assessment of either disease. This study concludes that consideration should be given to the development of national guidelines or templates to ensure consistency of management for gynecological malignancy in England and Wales.

Female↗
PubMed1972

Atmospheric sulfur: its effect on the chemical weathering of New England.

The present acidity and sulfur content of the upland streams of New England can be accounted for on the basis of the rainout and washout of sulfuric acid from the atmosphere. In spite of this excess acid flux over the New England landscape, the rate of cationic denudation of upland watersheds is relatively low.

Atmosphere↗
PubMed1992

National survey of current arrangements for diversion from custody in England and Wales.

OBJECTIVES: To assess the extent and nature of psychiatric assessment schemes based at magistrates' courts in England and Wales for the early diversion of mentally disordered offenders from custody and to determine the response of the NHS to new initiatives concerning alternatives to custody for this group. DESIGN: Postal survey of the probation service, petty sessional divisions, mental health provider units, and district purchasing authorities in England and Wales. SUBJECTS: All chief probation officers (n = 55), clerks to the justices (n = 284), managers of mental health provider units (n = 190), and purchasers of mental health services (n = 190) in each of the district health authorities. MAIN OUTCOME MEASURES: Number of psychiatric assessment schemes, practical difficulties in their operation, extent of regular liaison with health and social services; current and future intentions to purchase or provide services for diversion from custody. RESULTS: Data were obtained from every magistrates' court. Forty eight psychiatric assessment schemes were identified with another 34 under development. Particular problems were lack of adequate transport arrangements, difficulties with hospital admissions, and overdependence on key people. There was little liaison between health, social services, and members of the criminal justice system. Twenty five of the 106 purchasers who responded had a policy dealing with diversion, and 39 had a scheme under development; 56 purchasers had no current or future plans about diversion. Sixty nine of the 150 providers who responded reported that diversion was included in their current or next business plan. CONCLUSION: Schemes to divert mentally disordered offenders from the criminal justice system are often hampered by lack of adequate transport arrangements, difficulties in hospital admissions, and overdependence on key people.

Commitment of Persons with Psychiatric Disorders↗
PubMed2000

Demand for and supply of out of hours care from general practitioners in England and Scotland: observational study based on routinely collected data.

OBJECTIVES: To determine the level of demand and supply of out of hours care from a nationally representative sample of general practice cooperatives. DESIGN: Observational study based on routinely collected data on telephone calls, patient population data from general practices, and information about cooperatives from interviews with managers. SETTING: 20 cooperatives in England and Scotland selected after stratification by region and by size. SUBJECTS: 899 657 out of hours telephone calls over 12 months. MAIN OUTCOME MEASURES: Numbers and age and sex specific rates of calls; variation in demand and activity in relation to characteristics of the population; timing of calls; proportion of patients consulting at home, at a primary care centre, or on the telephone; response times; hospital admission rates. RESULTS: The out of hours call rate (excluding bank holidays) was 159 calls per 1000 patients/year, with rates in children aged under 5 years four times higher than for adults. Little variation occurred by day of the week or seasonally. Cooperatives in Scotland experienced higher demand than those in England. Patients living in deprived areas made 70% more calls than those in non-deprived areas, but this had little effect on the overall variation in demand. 45.4% (408 407) of calls were handled by telephone advice, 23.6% (212 550) by a home visit, and 29.8% (267 663) at a centre. Cooperatives responded to 60% of calls within 30 minutes and to 83% within one hour. Hospital admission followed 5.5% (30 743/554 179) of out of hours calls (8 admissions per 1000 patients/year). CONCLUSIONS: This project provides national baseline data for the planning of services and the analysis of future changes.

Adult↗
PubMed2001

Meningitis in infancy in England and Wales: follow up at age 5 years.

OBJECTIVE: To describe important sequelae occurring among a cohort of children aged 5 years who had had meningitis during the first year of life and who had been identified by a prospective national study of meningitis in infancy in England and Wales between 1985 and 1987. DESIGN: Follow up questionnaires asking about the children's health and development were sent to general practitioners and parents of the children and to parents of matched controls. The organism that caused the infection and age at infection were also recorded. SETTING: England and Wales. PARTICIPANTS: General practitioners and parents of children who had had meningitis before the age of 1 year and of matched controls. MAIN OUTCOME MEASURES: The prevalence of health and developmental problems and overall disability among children who had had meningitis compared with controls. RESULTS: Altogether, 1584 of 1717 (92.2%) children who had had meningitis and 1391 of 1485 (93.6%) controls were successfully followed up. Among children who survived to age 5 years 247 of 1584 (15.6%) had a disability; there was a 10-fold increase in the risk of severe or moderate disability at 5 years of age among children who had had meningitis (relative risk 10.3, 95% confidence interval 6.7 to 16.0, P<0.001). There was considerable variation in the rates of severe or moderate disability in children infected with different organisms. CONCLUSION: The long term consequences of having meningitis during the first year of life are significant: 32 of 1717 (1.8%) children died within five years. Not only did almost a fifth of children with meningitis have a permanent, severe or moderately severe disability, but subtle deficits were also more prevalent.

Age Factors↗
PubMed2006

Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study.

OBJECTIVE: To provide perinatal mortality and congenital anomaly rates for babies born to women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland. DESIGN: National population based pregnancy cohort. SETTING: 231 maternity units in England, Wales, and Northern Ireland. PARTICIPANTS: 2359 pregnancies to women with type 1 or type 2 diabetes who delivered between 1 March 2002 and 28 February 2003. MAIN OUTCOME MEASURES: Stillbirth rates; perinatal and neonatal mortality; prevalence of congenital anomalies. RESULTS: Of 2359 women with diabetes, 652 had type 2 diabetes and 1707 had type 1 diabetes. Women with type 2 diabetes were more likely to come from a Black, Asian, or other ethnic minority group (type 2, 48.8%; type 1, 9.1%) and from a deprived area (type 2, 46.3% in most deprived fifth; type 1, 22.8%). Perinatal mortality in babies of women with diabetes was 31.8/1000 births. Perinatal mortality was comparable in babies of women with type 1 (31.7/1000 births) and type 2 diabetes (32.3/1000) and was nearly four times higher than that in the general maternity population. 141 major congenital anomalies were confirmed in 109 offspring. The prevalence of major congenital anomaly was 46/1000 births in women with diabetes (48/1000 births for type 1 diabetes; 43/1000 for type 2 diabetes), more than double that expected. This increase was driven by anomalies of the nervous system, notably neural tube defects (4.2-fold), and congenital heart disease (3.4-fold). Anomalies in 71/109 (65%) offspring were diagnosed antenatally. Congenital heart disease was diagnosed antenatally in 23/42 (54.8%) offspring; anomalies other than congenital heart disease were diagnosed antenatally in 48/67 (71.6%) offspring. CONCLUSION: Perinatal mortality and prevalence of congenital anomalies are high in the babies of women with type 1 or type 2 diabetes. The rates do not seem to differ between the two types of diabetes.

Adolescent↗
PubMed1995

Indications, methods, and outcomes of percutaneous liver biopsy in England and Wales: an audit by the British Society of Gastroenterology and the Royal College of Physicians of London.

The liver section of the British Society of Gastroenterology and the research unit of the Royal College of Physicians collaborated to set up a nationwide audit to investigate the practice of percutaneous liver biopsy in England and Wales. Each of 189 health districts in England and Wales was approached to provide a list of 10 consecutive percutaneous biopsies performed during 1991, and details of demographic data, indications, suspected diagnosis, investigations, biopsy technique, outcome, and influence on patient management were collected. Data were retrieved on 1500 (79%). The age distribution showed 6% of biopsies were done in those over 80 years of age and as many over 90 as under 10 years of age. Suspected malignancy and chronic liver disease each contributed one third of the indications. In 34% the procedure was carried out by radiologists under ultrasound image control. The remainder were done by general physicians and gastroenterologists, with the operator in the second group being more senior and experienced. The Trucut biopsy needle accounted for two thirds of biopsies, the remainder being the Menghini type. For both needles the samples were recorded as excellent or satisfactory in 83% and inadequate in only 5%. Bleeding complicated 26 procedures (1.7%), requiring transfusion in 11, and was commoner when clotting was impaired or serum bilirubin raised. There were two definite and three possible procedure related, given an overall mortality of 0.13-0.33%. The diagnosis made before biopsy was confirmed in 63% of patients, and the clinician found the biopsy helpful in treatment in 75%. Day case biopsy and techniques to reduce the risk of bleeding were surprisingly rare in this series, which has given a unique opportunity to examine everyday practice across a wide range of hospitals.

Adolescent↗