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Background Achieving high human papillomavirus (HPV) vaccine coverage may reduce inequalities in cervical cancer prevention by mitigating the inequalities seen in the cervical screening programme. This paper assesses whether the same sociodemographic factors are associated with both cervical screening and HPV vaccination. Methods Girls' HPV vaccination records were linked by address to cervical screening records for their mothers in the North West of England. Index of Multiple Deprivation scores (2010) and census ethnicity data (2001) were used to investigate the association between deprivation and ethnic composition of area of residence with HPV vaccination and cervical screening uptake, along with potential differences between Primary Care Trusts (PCTs), which were responsible for vaccine delivery. Results Deprivation was not associated with routine (12-13-year-olds) vaccination initiation, but girls living in the most deprived quintile were significantly less likely to complete the three vaccine doses (OR 0.75; 95% CI 0.63 to 0.88). Mother-daughter pairs failing to engage in either screening or vaccination were also more likely to live in deprived areas (routine vaccination OR for most deprived quintile: 2.35; 95% CI 2.00 to 2.77). There were differences between PCTs after controlling for demographic effects (OR 1.35; 95% CI 1.23 to 1.52). Conclusions Ensuring completion of the vaccine schedule is critical for organisations responsible for vaccine delivery in order to reduce cancer risk among girls living in deprived areas. There remains a small minority of mothers and daughters from disadvantaged backgrounds who do not participate in either cervical screening or HPV vaccination. [ABSTRACT FROM AUTHOR]

Background Although long-term trends in local labour market conditions are likely to influence health, few studies have assessed whether this is so. This paper examines whether (1) trends in local employment rates have relevance for mortality and morbidity outcomes in England and (2) trends are stronger predictors of these outcomes than employment rates measured at one point in time. Methods Using latent class growth models, local areas were classified into eight groups following distinct trends in employment rates between 1981 and 2008. Areas were also categorised in 'octile' groups by rank of employment rates in 2001. These area groupings were linked to a sample of 207 959 individuals from the Office of National Statistics Longitudinal Study. Associations between area groupings and risk of all-cause mortality and of reporting a limiting long-term illness at the end of the period were measured using logistic regression. Models were adjusted for individuals' socio-demographic characteristics measured in 1981 and for their residential mobility between 1981 and 2001. Results Compared to areas with continuously high employment rates over the period, risk of mortality and morbidity was higher in areas with persistently low or declining employment rates. Findings suggest that longterm trends in local employment rates are useful as predictors of mortality and morbidity differences. These are not so clearly distinguished by only considering employment rates at one point in time. Conclusion Poor health outcomes are associated with long-term economic disadvantage in some areas of England, reflected in employment rates, underlining the importance of efforts to improve health in areas with especially 'deep-seated' deprivation. [ABSTRACT FROM AUTHOR]

Introduction Unintentional injuries to children in the outdoors have a significant impact on child mortality, development and healthcare costs. This paper presents the findings of a systematic review about the effectiveness of programs that provided information, advice or education about the prevention of unintentional injuries to children under 15 years during outdoor play and leisure. Methods A structured search strategy was conducted in a range of databases. All report titles and abstracts were screened using pre-defined criteria. Included reports were quality appraised using a modified Graphical Appraisal Tool for Epidemiological studies (GATE) tool. All quality appraisals and data extraction were checked by a second reviewer. If not provided in the original reports, ORs and mean differences were calculated, where sufficient data were available. Results Twenty-three studies met the inclusion criteria. There was a paucity of robust study designs. The majority of studies only reported a short-term follow-up of intermediate outcome measures. Only two studies measured injury rates; both reported a reduction, but both studies also had considerable methodological weaknesses. The five studies that measured the use of protective equipment reported mixed results, although there is some evidence that suggests that more extensive educational programs (such as health fairs and media campaigns) increase their use. The 20 studies that measured behaviour, attitude or knowledge outcomes reported highly mixed results. Discussion Methodological weaknesses of the included studies limit support for a particular course of action. To better inform policy and practice, future research should (1) use robust study designs and (2) not rely on short-term proxy outcome measures. [ABSTRACT FROM AUTHOR]

Objective: This study assessed the transfer of patients from paediatric cardiac to adult congenital heart disease (ACHD) services in England and the factors impacting on this process.Methods: This retrospective cohort study used a population-based linked data set (LAUNCHES QI data set: 'Linking Audit and National datasets in Congenital Heart Services for Quality Improvement') including all patients born between 1987 and 2000, recorded as having a congenital heart disease (CHD) procedure in childhood. Hospital Episode Statistics data identified transfer from paediatric to ACHD services between the ages of 16 and 22 years.Results: Overall, 63.8% of a cohort of 10 298 patients transferred by their 22nd birthday. The estimated probability of transfer by age 22 was 96.5% (95% CI 95.3 to 97.7), 86.7% (95% CI 85.6 to 87.9) and 41.0% (95% CI 39.4 to 42.6) for severe, moderate and mild CHD, respectively. 166 patients (1.6%) died between 16 and 22 years; 42 of these (0.4%) died after age 16 but prior to transfer. Multivariable ORs in the moderate and severe CHD groups up to age 20 showed significantly lower likelihood of transfer among female patients (0.87, 95% CI 0.78 to 0.97), those with missing ethnicity data (0.31, 95% CI 0.18 to 0.52), those from deprived areas (0.84, 95% CI 0.72 to 0.98) and those with moderate (compared with severe) CHD (0.30, 95% CI 0.26 to 0.35). The odds of transfer were lower for the horizontal compared with the vertical care model (0.44, 95% CI 0.27 to 0.72). Patients who did not transfer had a lower probability of a further National Congenital Heart Disease Audit procedure between ages 20 and 30 compared with those who did transfer: 12.3% (95% CI 5.1 to 19.6) vs 32.5% (95% CI 28.7 to 36.3).Conclusions: Majority of patients with moderate or severe CHD in England transfer to adult services. Patients who do not transfer undergo fewer elective CHD procedures over the following decade. [ABSTRACT FROM AUTHOR]

The article summarizes a study evaluating the relation between high ambient temperatures with the changes in the risk of myocardial infarction on an hourly timescale. Paper-adds including data at an hourly temporal resolution from 11 conurbations in England and Wales showed that higher temperatures were associated with increased risk of myocardial infarction, with reductions in risk at longer lags being consistent with heat, in the six hours after exposure, above a threshold of 20°C.

AimsIt is important to know how far smokers' attempts at using nicotine replacement therapy (NRT) for smoking ‘harm reduction’ (reducing harm from continued smoking) promote or undermine cessation. To contribute to that goal, this study aimed to assess whether smokers' reports of smoking reduction (SR) and the use of NRT for SR and temporary abstinence (TA) predicted subsequent attempts to quit smoking and smoking status in a population sample. It also examined whether use of NRT for SR or TA was associated with reduced cigarette consumption compared with SR without NRT and non-use of NRT for TA.MethodData were collected from 15 539 smokers involved in the Smoking Toolkit Study, a series of monthly household surveys of adults aged 16+; of whom 23% (n=3149) completed a 6-month follow-up questionnaire. At baseline, participants were asked whether they were currently using NRT for SR or TA. They were also asked for demographic information and daily cigarette consumption. At 6-month follow-up, data on attempts to quit smoking and smoking status were collected.ResultsNRT use for SR and TA prospectively predicted attempts to quit smoking (OR 1.61, 95% CI 1.30 to 2.01 and OR 1.94, 95% CI 1.56 to 2.38 for SR and TA respectively) and abstinence (OR 1.51, 95% CI 1.06 to 2.16 and OR 2.09, 95% CI 1.51 to 3.34 for SR and TA respectively) at 6-months follow-up. Use of NRT for SR or TA was associated with a small reduction in cigarette consumption (two cigarettes per day) compared with SR without NRT or non-use of NRT for TA.ConclusionsThe use of NRT for SR or TA appears to be positively associated with subsequent attempts to quit smoking and abstinence among smokers in England, despite very little apparent effect on daily cigarette consumption. With replication, these findings support the potential benefit of using NRT for harm reduction but primarily as a means of promoting cessation. [ABSTRACT FROM AUTHOR]

Background Disturbed sleep is common throughout the community and is associated with an increase in daytime sleepiness, both of which, in turn are associated with an increased risk of ischaemic vascular disease. The hypothesis that sleep disturbances are predictive of dementia, and in particular vascular dementia was tested in a large community-based cohort of older men. Methods A questionnaire on sleep disturbances was administered to 1986 men aged 55-69 years in the Caerphilly Cohort Study and 10 years later the men were examined clinically for evidence of dementia or cognitive impairment with no dementia (CIND). Findings Approximately 20% of the men reported disturbed sleep and 30% reported 'severe' daytime sleepiness. Ten years later 1225 men (75% of the surviving men in the cohort) were tested and 268 (22%) were found to be cognitively impaired with 93 (7.6%) showing clear evidence of dementia and the remaining 175 (14.3%) showing evidence of CIND. After adjustment for possible confounding, including cognitive function and the taking of sleeping tablets at baseline, sleep disturbances appeared to be predictive of dementia and CIND of vascular origin, while there was no suggestion of prediction of non-vascular cognitive impairment by sleep. Prediction of vascular dementia appeared to be particularly strong for daytime sleepiness, with an adjusted OR of 4.44 (95% CI 2.05 to 9.61). Further adjustments for psychological distress at baseline reduced the size of the relationships, but the ORs remain large, consistent with a direct positive effect of sleep disturbance on vascular dementia. Interpretation Sleep disturbances, and in particular severe daytime sleepiness, appear to be strongly predictive of vascular dementia, but have no predictive power for non vascular dementia. [ABSTRACT FROM AUTHOR]

Objectives To investigate parental smoking behaviours between England and Scotland after the smoke-free legislation in Scotland came into effect in 2006 and examine inequalities in maternal smoking behaviours between countries. Methods 5954 white mothers and 3757 fathers resident in England and 1522 white mothers and 904 fathers resident in Scotland who participated in the Millennium Cohort Study (a prospective nationally representative cohort study) when the cohort child was age 9 months (before legislation) and 5 years (after legislation in Scotland but not in England). The main outcome measures were smoking at 9 months and 5 years, quitting smoking by 5 years, starting smoking by 5 years. Results In England and Scotland approximately 30% of parents reported smoking at 9 months with only a slight decrease in smoking at 5 years. There were no differences between countries in parental smoking after the smoke-free legislation in Scotland came into effect, taking into account prior smoking levels. Light smokers (1-9 cigarettes/day) from Scotland were less likely to quit by 5 years than those from England, but there were no differences between countries among heavy smokers (10+ cigarettes/day). Non-smoking mothers from Scotland (6.2%) were less likely to start smoking by 5 years than mothers from England (7.3%). Mothers from more disadvantaged circumstances in both countries were more likely to report that they smoked or started smoking. In England quitting was also socially patterned, but in Scotland, after the legislation was introduced, the gradients in quitting smoking were flatter across social groups. Conclusions Smoking behaviours among parents with young children remained relatively stable, highlighting the need for additional tobacco control efforts to support smoking cessation. However, the smoke-free legislation does not appear to widen health inequalities and may even help reduce them by encouraging quitting across socioeconomic groups. [ABSTRACT FROM AUTHOR]

Objectives: To explore the reasons for the 40-fold variation in diagnostic testing for genital Chlamydia trachomatis by general practices.Methods: A qualitative study with focus groups. We randomly selected urban and rural high and low testing practices served by Bristol, Hereford, and Gloucester microbiology laboratories. Open questions were asked about the investigation of C trachomatis in men and women in different clinical contexts.Results: The high and low testing practices did not differ in their age/sex make-up or by deprivation indices. There were major differences between high and low chlamydia testing practices. Low testing practices knew very little about the epidemiology and presentation of genital chlamydia infection and did not consider it in their differential diagnosis of genitourinary symptoms until patients had consulted several times. Low testers were less aware that chlamydia was usually asymptomatic, thought it was an inner city problem, and had poor knowledge of how to take diagnostic specimens. High testing practices either had a general practitioner with an interest in sexual health or a practice nurse who had completed specialist training in family planning. High testing practices were more cognizant of the symptoms and signs of chlamydia and always considered it in their differential diagnosis of genitourinary symptoms, including patients attending family planning clinics.Conclusions: Any programme to increase chlamydia testing in primary care must be accompanied by an education and awareness programme especially targeted at low testing practices. This will need to include information about the benefits of testing and who, when, and how to test. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to quantify the incidence rates of common mental and physical health conditions in mothers of children with a life-limiting condition.Methods: Comparative national longitudinal cohort study using linked primary and secondary care data from the Clinical Practice Research Datalink in England. Maternal-child dyads were identified in these data. Maternal physical and mental health outcomes were identified in the primary and secondary care datasets using previously developed diagnostic coding frameworks. Incidence rates of the outcomes were modelled using Poisson regression, adjusting for deprivation, ethnicity and age and accounting for time at risk.Results: A total of 35 683 mothers; 8950 had a child with a life-limiting condition, 8868 had a child with a chronic condition and 17 865 had a child with no long-term condition.The adjusted incidence rates of all of the physical and mental health conditions were significantly higher in the mothers of children with a life-limiting condition when compared with those mothers with a child with no long-term condition (eg, depression: incidence rate ratio (IRR) 1.21, 95% CI 1.13 to 1.30; cardiovascular disease: IRR 1.73, 95% CI 1.27 to 2.36; death in mothers: IRR 1.59, 95% CI 1.16 to 2.18).Conclusion: This study clearly demonstrates the higher incidence rates of common and serious physical and mental health problems and death in mothers of children with a life-limiting condition. Further research is required to understand how best to support these mothers, but healthcare providers should consider how they can target this population to provide preventative and treatment services. [ABSTRACT FROM AUTHOR]

Aim: To investigate sex differences in acute myocardial infarction (AMI) guideline-indicated care as defined by the European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) quality indicators.Methods: Nationwide cohort study comprising 691 290 AMI hospitalisations in England and Wales (n=233 hospitals) from the Myocardial Ischaemia National Audit Project between 1 January 2003 and 30 June 2013.Results: There were 34.5% (n=238 489) women (median age 76.7 (IQR 66.3-84.0) years; 33.9% (n=80 884) ST-elevation myocardial infarction (STEMI)) and 65.5% (n=452 801) men (median age 67.1 (IQR 56.9-77.2) years; 42.5% (n=192 229) STEMI). Women less frequently received 13 of the 16 quality indicators compared with men, including timely reperfusion therapy for STEMI (76.8% vs 78.9%; p<0.001), timely coronary angiography for non-STEMI (24.2% vs 36.7%; p<0.001), dual antiplatelet therapy (75.4% vs 78.7%) and secondary prevention therapies (87.2% vs 89.6% for statins, 82.5% vs 85.6% for ACE inhibitor/angiotensin receptor blockers and 62.6% vs 67.6% for beta-blockers; all p<0.001). Median 30-day Global Registry of Acute Coronary Events risk score adjusted mortality was higher for women than men (median: 5.2% (IQR 1.8%-13.1%) vs 2.3% (IQR 0.8%-7.1%), p<0.001). An estimated 8243 (95% CI 8111 to 8375) deaths among women could have been prevented over the study period if their quality indicator attainment had been equal to that attained by men.Conclusion: According to the ESC ACCA AMI quality indicators, women in England and Wales less frequently received guideline-indicated care and had significantly higher mortality than men. Greater attention to the delivery of recommended AMI treatments for women has the potential to reduce the sex-AMI mortality gap. [ABSTRACT FROM AUTHOR]

Objective: To analyse survival trends and regional variation for very preterm infants admitted to neonatal care.Setting: All neonatal units in England.Patients: Infants born at 22+0-31+6 weeks+daysgestational age (GA) over 2008-2014 and admitted to neonatal care; published data for admitted infants 22+0-25+6 weeks+days GA in 1995 and 2006, and for live births at 22+0-31+6 weeks+days GA in 2013.Methods: We obtained data from the National Neonatal Research Database. We used logistic regression to model survival probability with birth weight, GA, sex, antenatal steroid exposure and multiple birth included in the risk adjustment model and calculated annualpercentage change (APC) for trends using joinpoint regression. We evaluated survival over a 20-year period for infants <26 weeks' GA using additional published data from the EPICure studies.Results: We identified 50 112 eligible infants. There was an increase in survival over 2008-2014 (2008: 88.0%; 2014: 91.3%; adjusted APC 0.46% (95% CI 0.30 to 0.62) p<0.001). The greatest improvement was at 22+0-23+6 weeks (APC 6.03% (95% CI 2.47 to 3.53) p=0.002). Improvement largely occurred in London and South of England (APC: London 1.26% (95% CI 0.60 to 1.96); South of England 1.09% (95% CI 0.36 to 1.82); Midlands and East of England 0.15% (95% CI -0.56 to 0.86); and North of England 0.26% (95% CI -0.54 to 1.07)). Survival at the earliest gestations improved at a similar rate over 1995-2014 (22+0-25+6 weeks, APC 2.73% (95% CI 2.35 to 3.12), p value for change=0.25).Conclusions: Continued national improvement in the survival of very preterm admissions masks important regional variation. Timely assessment of preterm survival is feasible using electronic records. [ABSTRACT FROM AUTHOR]

Objective: Little is known about persistence of or recovery from chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) in adolescents. Previous studies have small sample sizes, short follow-up or have focused on fatigue rather than CFS/ME or, equivalently, chronic fatigue, which is disabling. This work aimed to describe the epidemiology and natural course of CFS/ME in adolescents aged 13-18 years.Design: Longitudinal follow-up of adolescents enrolled in the Avon Longitudinal Study of Parents and Children.Setting: Avon, UK.Participants: We identified adolescents who had disabling fatigue of >6 months duration without a known cause at ages 13, 16 and 18 years. We use the term 'chronic disabling fatigue' (CDF) because CFS/ME was not verified by clinical diagnosis. We used multiple imputation to obtain unbiased estimates of prevalence and persistence.Results: The estimated prevalence of CDF was 1.47% (95% CI 1.05% to 1.89%) at age 13, 2.22% (1.67% to 2.78%) at age 16 and 2.99% (2.24% to 3.75%) at age 18. Among adolescents with CDF of 6 months duration at 13 years 75.3% (64.0% to 86.6%) were not classified as such at age 16. Similar change was observed between 16 and 18 years (75.0% (62.8% to 87.2%)). Of those with CDF at age 13, 8.02% (0.61% to 15.4%) presented with CDF throughout the duration of adolescence.Conclusions: The prevalence of CDF lasting 6 months or longer (a proxy for clinically diagnosed CFS/ME) increases from 13 to 18 years. However, persistent CDF is rare in adolescents, with approximately 75% recovering after 2-3 years. [ABSTRACT FROM AUTHOR]

Objective: To examine whether physical activity (PA) moderates the association between alcohol intake and all-cause mortality, cancer mortality and cardiovascular diseases (CVDs) mortality.Design: Prospective study using 8 British population-based surveys, each linked to cause-specific mortality: Health Survey for England (1994, 1998, 1999, 2003, 2004 and 2006) and Scottish Health Survey (1998 and 2003).Participants: 36 370 men and women aged 40 years and over were included with a corresponding 5735 deaths and a mean of 353 049 person-years of follow-up.Exposures: 6 sex-specific categories of alcohol intake (UK units/week) were defined: (1) never drunk; (2) ex-drinkers; (3) occasional drinkers; (4) within guidelines (<14 (women); <21 (men)); (5) hazardous (14-35 (women); 21-49 (men)) and (6) harmful (>35 (women) >49 (men)). PA was categorised as inactive (≤7 MET-hour/week), active at the lower (>7.5 MET-hour/week) and upper (>15 MET-hour/week) of recommended levels.Main Outcomes and Measures: Cox proportional-hazard models were used to examine associations between alcohol consumption and all-cause, cancer and CVD mortality risk after adjusting for several confounders. Stratified analyses were performed to evaluate mortality risks within each PA stratum.Results: We found a direct association between alcohol consumption and cancer mortality risk starting from drinking within guidelines (HR (95% CI) hazardous drinking: 1.40 (1.11 to 1.78)). Stratified analyses showed that the association between alcohol intake and mortality risk was attenuated (all-cause) or nearly nullified (cancer) among individuals who met the PA recommendations (HR (95% CI)).Conclusions: Meeting the current PA public health recommendations offsets some of the cancer and all-cause mortality risk associated with alcohol drinking. [ABSTRACT FROM AUTHOR]

Background: In England there are four national routinely collected data sets on births: Office for National Statistics (ONS) births based on birth registrations; Hospital Episode Statistics (HES) deliveries (mothers' information); HES births (babies' information); and NHS Numbers for Babies (NN4B) based on ONS births plus gestational age and ethnicity information. This study describes and compares these data, with the aim of recommending the most appropriate data set(s) for use in epidemiological research and surveillance.Methods: We assessed the completeness and quality of the data sets in relation to use in epidemiological research and surveillance and produced detailed descriptive statistics on common reproductive outcomes for each data set including temporal and spatial trends.Results: ONS births is a high quality complete data set but lacks interpretive and clinical information. HES deliveries showed good agreement with ONS births but HES births showed larger amounts of missing or unavailable data. Both HES data sets had improved quality from 2003 onwards, but showed some local spatial variability. NN4B showed excellent agreement with ONS and HES deliveries for the years available (2006-2010). Annual number of births increased by 17.6% comparing 2002 with 2010 (ONS births). Approximately 6% of births were of low birth weight (2.6% term low birth weight) and 0.5% were stillbirths.Conclusions: Routinely collected data on births provide a valuable resource for researchers. ONS and NN4B offer the most complete and accurate record of births. Where more detailed clinical information is required, HES deliveries offers a high quality data set that captures the majority of English births. [ABSTRACT FROM AUTHOR]

Background Structured diabetes care can improve outcomes and reduce risk of complications, but improving care in a deprived, ethnically diverse area can prove challenging. This report evaluates a system change to enhance diabetes care delivery in a primary care setting. Methods All 35 practices in one inner London Primary Care Trust were geographically grouped into eight networks of four to five practices, each supported by a network manager, clerical staff and an educational budget. A multidisciplinary team developed a 'care package' for type 2 diabetes management, with financial incentives based on network achievement of targets. Monthly electronic performance dashboards enabled networks to track and improve performance. Network multidisciplinary team meetings including the diabetic specialist team supported case management and education. Key measures for improvement included the number of diabetes care plans completed, proportion of patients attending for digital retinal screen and proportions of patients achieving a number of biomedical indices (blood pressure, cholesterol, glycated haemoglobin). Results Between 2009 and 2012, completed care plans rose from 10% to 88%. The proportion of patients attending for digital retinal screen rose from 72% to 82.8%. The proportion of patients achieving a combination of blood pressure ≤140/ 80 mm Hg and cholesterol ≤4mmol/Lrose from 35.3% to 46.1%. Mean glycated haemoglobin dropped from 7.80% to 7.66% (62-60 mmol/mol). Conclusions Investment of financial, organisational and education resources into primary care practice networks can achieve clinically important improvements in diabetes care in deprived, ethnically diverse communities. This success is predicated on collaborative working between practices, purposively designed high-quality information on network performance and engagement between primary and secondary care clinicians. [ABSTRACT FROM AUTHOR]

The article reports a study which examined the relations between the organization of stroke services, process measures of the quality of care, and mortality outcomes after ischaemic stroke. The result revealed that patients admitted to more organized stroke services are more likely to receive high quality care. Patients receiving the highest quality care had a reduced risk of mortality in the 30 days after stroke.

The article discusses the link between postoperative mortality and the day of the week on which the procedure is carried out. It states that the risk of death is higher for patients who undergo elective surgical procedures later in the working week and at the weekend compared with those who have their operations carried out on Mondays. It states that the study should be interpreted with caution due to selection bias. It discusses generalisability to other populations as well as funding sources.

The article discusses a study that is aimed to evaluate the risk of narcolepsy in children and adolescents in England targeted for vaccination with ASO3 adjuvanted pandemic A/H1N1 2009 influenza vaccine. It states that children and young people have a significantly increased risk of developing narcolepsy, after receiving vaccination with AS03 adjuvanted pandemic A/H1N1 vaccine. It mentions that the study was funded by Department of Health policy research programme and Health Protection Agency.

The article discusses a study by Eileen Kaner, Martin Bland and Paul Cassidy on the most effective intervention strategy to reduce primary care patients’ hazardous and harmful drinking which found that five minutes of brief advice or 20 minutes of brief lifestyle counselling provided no additional benefit. Pragmatic cluster randomised controlled trial of patients (n=3562) aged 18 showed that screening followed by simple feedback and written information was most effective.

Background: Various human and animal studies suggest that peak alcohol exposure during a binge episode, rather than total alcohol exposure, may determine fetal development. Research about the impact of binge drinking on birth outcomes is sparse and inconclusive. Data from the Born in Bradford cohort study were used to explore the impact of binge drinking on birth outcomes. Methods: Interview-administered questionnaire data about the lifestyle and social characteristics of 10 851 pregnancies were linked to maternity and birth data. The impact of self-reported binge drinking (5 units: 40 g of pure alcohol) on two birth outcomes (small for gestational age (SGA) and preterm birth (<37 weeks)) was assessed using multivariate logistic regression models, while adjusting for confounders. Results: The percentage of women classified as binge drinkers fell from 24.5% before pregnancy to 9% during the first trimester and 3.1% during the second trimester. There was a significant association between SGA birth and binge drinking (all categories combined; OR 1.68, 95% CI 1.15 to 2.47, p=0.01). No association was observed between moderate drinking and either birth outcome, or between binge drinking and preterm birth. Conclusions: Binge drinking during the second trimester of pregnancy was associated with an increased risk of SGA birth. No association was found between any level of alcohol consumption and premature birth. This work supports previous research showing no association between SGA and low-alcohol exposure but adds to evidence of a dose-response relationship with significant risks observed at binge drinking levels. [ABSTRACT FROM AUTHOR]

Background: Major behavioural risk factors, namely obesity, alcohol consumption, smoking, lack of fruit and vegetable intake and physical inactivity negatively impact on self-reported quality of life. However, little is known about their impact on preference-based measures of health-related quality of life commonly used to inform economic evaluations. Methods: Preference-based health-related quality of life outcomes associated with major behavioural risk factors were estimated using the EuroQol EQ-5D responses of 14 117 participants, aged ≥16 years, in the 2008 Health Survey for England. Multivariable linear regression was used to model the relationship between the five risk factors and EQ-5D utility scores. In addition, logistic regression was used to model their relationship to dichotomous reports of problems for each of the five EQ-5D dimensions. Results: Only one-third of participants had a body mass index within normal range, never drank alcohol, consumed at least five portions of fruit or vegetable/day or exercised regularly, while nearly half of participants were smokers or ex-smokers. In the fully adjusted multivariable analyses, reductions in EQ-5D utility scores (95% CI) of 0.105 (0.072 to 0.137), 0.062 (0.042 to 0.082) and 0.142 (0.129 to 0.155) were estimated for a body mass index ≥40 kg/m2, heavy smoking (≥20 cigarettes/day) and physical inactivity, respectively. Hazardous alcohol consumption (men >4 and ≤8 units/ day; women >3 and ≤6 units/day) and daily fruit and vegetable intake between three and less than five portions were associated with small positive effects on EQ-5D utility scores (p<0.05). Conclusions: The high prevalence and substantial utility loss associated with obesity, smoking and physical inactivity highlight the potential impact that interventions aimed at their prevention or alleviation may have on population health. [ABSTRACT FROM AUTHOR]

Objectives To explore patterns of repeat chlamydia testing among young people in England and factors associated with testing positive at repeat test. Methods We analysed chlamydia testing among 15 to 24-year-olds in England in a single calendar year (2010) using data from the genitourinary medicine clinic activity dataset (GUMCAD) and tests reported through the National Chlamydia Screening Programme (NCSP). Case records were linked using patient clinic numbers (GUMCAD), or by matching date of birth, gender and postcode (NCSP). Individuals could not be linked between datasets. The incidence of repeat testing was estimated using survival analysis. Risk factors for testing positive at repeat test were explored using multivariable logistic regression. Results 1 235 058 tests in the NCSP dataset and 502 095 in GUMCAD were included. The incidence of repeat testing was 18.4 and 26.1 per 100 person years in the NCSP dataset and GUMCAD respectively. Among NCSP repeat tests, the proportion testing positive was higher in those reporting recent change of sexual partner (adjusted OR males 1.44; females 1.52), and among those with a positive compared to a negative baseline test (adjusted OR males 2.57; females 1.95). Conclusions We observed moderate levels of repeat testing within a year. Considering the frequency of partner change among young people, more could be done to encourage re-testing upon change of sexual partner. Increasing re-testing following a positive test could probably identify unresolved or repeat infections that may otherwise go untreated. Work to establish the optimum approach to repeat testing in England is now warranted. [ABSTRACT FROM AUTHOR]

Background The source of infection for most sporadic cases of Legionnaires' disease remains unknown. This study aims quantify the relationship between cases and wet cooling systems (WCS), a potential source of aerosolised legionella bacteria. Methods The study analysed data on 1163 sporadic, community-acquired cases of Legionnaires' disease in England and Wales with onset between 1996 and 2006, and 11630 postcode controls randomly sampled in proportion to population size and matched on region, age group and sex. The relationship between risk of Legionnaires' disease and distance from a WCS was analysed by conditional logistic regression. Results Cases and controls had a mean age of 56.3 years; 79.3% were male. Cases lived appreciably closer to WCS than their controls (mean distance of cases=2.11 km, controls=2.58 km; mean difference 0.47 km (95% CI 0.28 to 0.65)). The OR for disease within 1 km of a WCS compared with over 6 km (a distance taken to reflect background rates of Legionnaires' disease) was 1.59 (95% CI 1.26 to 2.01) when adjusted for socio-economic deprivation, and 1.33 (95% CI 1.04 to 1.71) when additionally adjusted for population density. The results suggest that residential proximity to a WCS may account for 19.6% of sporadic community-acquired cases. Conclusions WCS may be an important source of sporadic, community-acquired cases of Legionnaires' disease, an observation that has important implications for health protection, especially given the likely increase in such systems as a component of strategies to improve energy efficiency in buildings. [ABSTRACT FROM AUTHOR]

Background All residents of England aged 60 years and older became entitled to free travel on local buses on 1 April 2006. This study examines the impact of this policy on public transport use, a mode of active transport and levels of obesity. Methods Logistic regression analyses using three waves of data (2004, 2006 and 2008) from the English Longitudinal Study of Ageing. Our main outcome measures were changes in self-reported public transport use, body mass index, waist circumference and obesity. Results Eligibility for free bus travel was associated with increased use (adjusted odds ratio (AOR) 1.51, 95% CI 1.14 to 2.00) of public transport among older people. Older people who used public transport had reduced odds of being obese in 2008 compared with those who did not (AOR 0.75, 95% CI 0.65 to 0.86), as did those who were eligible for free local bus travel (AOR 0.75, 95% CI 0.59 to 0.97). Older people who used public transport had reduced odds of becoming obese between 2004 and 2008 (AOR 0.79, 95% CI 0.63 to 0.98). Conclusion The introduction of free bus travel for older residents of England appears to have increased public transport use and may have conferred a protective effect against obesity. [ABSTRACT FROM AUTHOR]

Objective To derive and validate risk algorithms so that the risks of four clinical outcomes associated with statin use can be estimated for individual patients. Design Prospective open cohort study using routinely collected data from 368 QResearch general practices in England and Wales to develop the scores. The scores were validated using two separate sets of practices-188 separate QResearch practices and 364 practices contributing to the THIN database. Subjects In the QResearch derivation cohort 225 922 new users of statins and 1⇔778⇔770 non-users of statins were studied. In the QResearch validation cohort 118⇔372 statin users and 877⇔812 non-users of statins were studied. In the THIN validation cohort, we studied 282⇔056 statin users and 1⇔923⇔840 non-users of statins were studied. Methods Cox proportional hazards models in the derivation cohort to derive risk equations. Measures of calibration and discrimination in both validation cohorts. Outcomes 5-Year risk of moderate/serious myopathic events; moderate/serious liver dysfunction; acute renal failure and cataract. Results The performance of three of the risk prediction algorithms in the THIN cohort was very good. For example, in women, the algorithm for moderate/serious myopathy explained 42.15% of the variation. The corresponding D statistics was 1.75. The acute renal failure algorithm explained 59.62% of the variation (D statistic=2.49). The cataract algorithm explained 59.14% of the variation (D statistic=2.46). The algorithms to predict moderate/severe liver dysfunction only explained 15.55% of the variation (D statistics=0.89). The performance of each algorithm was similar for both sexes when tested on the QResearch validation cohort. Conclusions The algorithms to predict acute renal failure, moderate/serious myopathy and cataract could be used to identify patients at increased risk of these adverse effects enabling patients to be monitored more closely. Further research is needed to develop a better algorithm to predict liver dysfunction. [ABSTRACT FROM AUTHOR]

Background: Previous studies have estimated the prevalence of tuberculosis and HIV infection in population subgroups in the UK. This study was undertaken to describe recent trends in the proportion of individuals with HIV infection among reported cases of tuberculosis in England and Wales, and to review the implications for clinical and public health core. Methods: A population-based matching study using national surveillance databases was used to investigate all persons aged 15 years and over reported with a diagnosis of tuberculosis to the Health Protection Agency in England and Wales in 1999-2003. Record linkage was used to match the national tuberculosis and HIV/AIDS surveillance databases to identify all cases of tuberculosis and determine the proportion of patients with tuberculosis co-infected with HIV. The distribution and characteristics of the cases were determined and the trend examined by year. Results: Of 30 670 cases of tuberculosis reported in England and Wales between 1999 and 2003, an estimated 1743 (5.7%) were co-infected with HIV. There was a year on year increase in the proportion from 3.1% (169/5388) in 1999 to 8.3% (548/6584) in 2003 (p for trend <0.0001). Co-infected patients contributed to almost a third of the increase in the number of cases of tuberculosis during the 5 year period. Patients co-infected with HIV were predominantly those born abroad. 18.5% (n = 323) of co-infected patients had not been reported as active cases of tuberculosis on the national tuberculosis database. Conclusion: The proportion of patients with tuberculosis co-infected with HIV in England and Wales is increasing, with the greatest impact on those born abroad regardless of their ethnic origin. With HIV infection contributing substantially to the increase in the number of cases of tuberculosis, close cooperation in the clinical management and accurate notification of patients is vital if appropriate care and public health action is to be achieved. [ABSTRACT FROM AUTHOR]

Objective: To provide the first valid and reliable estimate of the health status of Gypsies and Travellers in England by using standardised instruments to compare their health with that of a UK resident non-Traveller sample, drawn from different socioeconomic and ethnic groups, matched for age and sex. Design: Epidemiological survey, by structured interview, of quota sample and concurrent age-sex-matched comparators. Setting: The homes or alternative community settings of the participants at five study locations in England. Participants: Gypsies and Travellers of UK or Irish origin (n = 293) and an age-sex-matched comparison sample (n = 260); non-Gypsies or Travellers from rural communities, deprived inner-city White residents and ethnic minority populations. Results: Gypsies and Travellers reported poorer health status for the last year, were significantly more likely to have a long-term illness, health problem Or disability, which limits daily activities or work, had more problems with mobility, self-care, usual activities, pain or discomfort and anxiety or depression as assessed using the EuroQol-5D health utility measure, and a higher overall prevalence of reported chest pain, respiratory problems, arthritis, miscarriage and premature death of offspring. No inequality was reported in diabetes, stroke and cancer. Conclusions: Significant health inequalities exist between the Gypsy and Traveller population in England and their non-Gypsy counterparts, even when compared with other socially deprived or excluded groups, and with other ethnic minorities. [ABSTRACT FROM AUTHOR]

Objectives: To examine the epidemiology of HIV among block and minority ethnic (BME) men who have sex with men (MSM) in England and Wales (E&W). Methods: Ethnicity data from two national HIV/AIDS surveillance systems were reviewed (1997-2002 inclusive), providing information on new HIV diagnoses and those accessing NHS HIV treatment and care services. In addition, undiagnosed HIV prevalence among MSM offending 14 genitourinary medicine (GUM) clinics participating in the Unlinked Anonymous Prevalence Monitoring Programme and having routine syphilis serology was examined by world region of birth. Results: Between 1997 and 2002, 1040 BME MSM were newly diagnosed with HIV in E&W, representing 12% of all new diagnoses reported among MSM. of the 1040 BME MSM, 27% were black Caribbean, 12% black African, 10% black other, 8% Indian/Pakistani/Bangladeshi, and 44% other/mixed. Where reported (n = 395), 58% of BME MSM were probably infected in the United Kingdom. An estimated 7.4% (approximate 95% CI: 4.4% to 12.5%) of BME MSM aged 16-44 in E&W were living with diagnosed HIV in 2002 compared with 3.2% (approximate 95% CI: 2.6% to 3.9%) of white MSM (p<0.001). Of Caribbean born MSM attending GUM clinics between 1997 and 2002, the proportion with undiagnosed HIV infection was 15.8% (95% CI: 11 .7% to 20.8%), while among MSM born in other regions it remained below 6.0%. Conclusions: Between 1997-2002, BME MSM accounted for just over one in 10 new HIV diagnoses among MSM in E&W; more than half probably acquired their infection in the United Kingdom. In 2002, the proportion of BME MSM living with diagnosed HIV in E&W was significantly higher than white MSM. Undiagnosed HIV prevalence in Caribbean born MSM was high. These data confirm the need to remain alert to the sexual health needs and evolving epidemiology of HIV among BME MSM in E&W. [ABSTRACT FROM AUTHOR]

Aim: To assess the impact of measles/mumps/rubella (MMR) vaccine on the epidemiology of subacute sclerosing panencephalitis (SSPE) in England and Wales. Methods: Cases of SSPE resident in England and Wales with onset between 1990 and 2002 were reviewed. Results: A total of 47 cases were identified, 31 male and 16 female. There was an average annual decline of 14% in SSPE onset over the period, consistent with the decline in notified measles over the last 20 years. A history of measles was present in 35 (median age 1 .3 years), the most recent recorded date being 1994; the interval from measles to onset of SSPE ranged from 2.7 to 23.4 years. Four children with a history of receipt of a measles containing vaccine were reported not to have had measles; two of these cases had a brain biopsy, and nucleotide sequence data confirmed wild measles infection. Brain biopsy specimens from a further three cases with a history 0f measles, of whom two had also had a history of vaccination, th showed wild-type strain. Conclusion: The prevention of endemic circulation of measles virus in England and Wales through the high coverage achieved with MMR vaccine, together with the measles/rubella vaccination campaign of 1994,. has resulted in the near elimination of SSPE. However, the recent decline in MMR vaccine coverage, with the associated increase in localised measles outbreaks and cases in young infants, is of concern. It underlines the importance of maintaining high vaccine coverage in order to protect indirectly those most vulnerable to SSPE, namely infants too young to be vaccinated. [ABSTRACT FROM AUTHOR]

Background: A description is given of a major outbreak of isoniazid monoresistant tuberculosis (TB) chiefly in north London, including prisons. The earliest case was diagnosed in 1995 with most cases appearing after 1999.Methods: Confirmation of a local cluster of cases was confirmed by restriction fragment length polymorphism (RFLP IS6110) typing or "rapid epidemiological typing" (RAPET). Further cases were found by retrospective analysis of existing databases, prospective screening of new isolates, and targeted epidemiological case detection including questionnaire analysis.Results: By the end of 2001, 70 confirmed cases in London had been linked with a further 13 clinical cases in contacts and nine epidemiologically linked cases outside London. The epidemic curve suggests that the peak of the outbreak has not yet been reached. Cases in the outbreak largely belong to a social group of young adults of mixed ethnic backgrounds including several individuals from professional/business backgrounds. Compared with other cases of TB reported to the enhanced surveillance scheme in London during 1999-2001, the cases are more likely to be of white (26/70 (37%) v 1308/7666 (17%)) or black Caribbean ethnicity (17/70 (24%) v 312/7666 (4%)), born in the UK (41/70 (59%) v 1335/7666 (17%)), and male (52/70 (74%) v 4195/7666 (55%)). Drug misuse and/or prison detention are factors common to many cases.Conclusions: The investigation of the outbreak revealed significant problems on an individual patient and population based level including difficulties with contact tracing, compliance, and the risk of developing multidrug resistance. This incident has demonstrated the value of molecular strain typing in investigating an extensive outbreak of TB. This is the first documented outbreak involving a UK prison. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the personal exposure of members of the general public to atmospheric benzene, toluene, and the xylenes, excluding exposure from active smoking.Method: 50 volunteers were equipped with active air samplers for direct measurement of personal exposure to monoaromatic hydrocarbons (MAH) and an activity diary was completed during each sampling period. Exposures were also estimated indirectly by combining activity data with independent measurements of hydrocarbon concentrations in several microenvironments.Results: Personal exposure were generally well in excess of those which would be inferred from outdoor measurements from an urban background monitoring station. A wide range of sources contribute to exposure, with indoor and in car concentrations generally exceeding those measured at background outdoor locations. Environments contaminated with tobacco smoke were among those exhibiting the highest concentrations. Personal exposures determined indirectly from activity diaries/microenvironment measurements were well correlated with those determined directly with personal samplers. Personal 12 hour daytime exposures to benzene ranged from 0.23-88.6 ppb (mean 3.81 ppb), with 12 hour night time exposures of 0.61-5.67 ppb (mean 1.94 ppb) compared with an annual average concentration of 1.18 ppb at the nearest suburban fixed site monitoring station. The excess of personal exposure over fixed site concentrations was greater for benzene and toluene than for the xylenes.Conclusion: A wide range of sources contribute to personal exposures to monoaromatic hydrocarbons with exposure duration being as important a determinant of total exposure as concentrations. Exposures generally exceed those estimated from concentrations measured by background fixed point monitors. Microenvironment sampling combined with activity diary information can provide satisfactory estimates of personal exposure to these compounds. [ABSTRACT FROM AUTHOR]

Objective: To define the mean intraindividual biological variation in urinary concentrations of cadmium and retinol binding protein (RBP) in untimed, random urine samples and the influence of creatinine or specific gravity correction on reducing this variation. The relation between biological variation and analytical variation in defining uncertainty in a single measurement and significant differences between successive measurements was explored.Methods: Repeat measurement study in subjects with either high historical exposure to cadmium but without current exposure, or unexposed volunteers. Standard statistical tools used in clinical laboratory medicine were applied to define intraindividual biological and analytical variation.Results and Conclusion: Both creatinine and specific gravity correction of urinary cadmium measurements in random urine samples seem to reduce the intraindividual variability compared with uncorrected values. With a standard definition, acceptable long term analytical precision for measurements of cadmium and RBP combined with creatinine analyses should be < 9% and < 15% respectively. The mean intraindividual biological variation of cadmium and RBP, expressed as creatinine corrected, was 18% and 40% respectively in the subjects exposed to cadmium. With the analytical precision used, significant differences (p < 0.05) between consecutive measurements for creatinine corrected urinary cadmium and RBP would need to show changes of > 54% and > 110% respectively. The relation between significant differences in consecutive results and differences in the analytical precision of the method used to measure the samples is described. [ABSTRACT FROM AUTHOR]

Background A Heat-Health Watch system has been established in England and Wales since 2004 as part of the national heatwave plan following the 2003 Europeanwide heatwave. One important element of this plan has been the development of a timely mortality surveillance system. This article reports the findings and timeliness of a daily mortality model used to 'nowcast' excess mortality (utilising incomplete surveillance data to estimate the number of deaths in near-real time) during a heatwave alert issued by the Met Office for regions in South and East England on 24 June 2011. Methods Daily death registrations were corrected for reporting delays with historical data supplied by the General Registry Office. These corrected counts were compared with expected counts from an age-specific linear regression model to ascertain if any excess had occurred during the heatwave. Results Excess mortality of 367 deaths was detected across England and Wales in $85-year-olds on 26 and 27 June 2011, coinciding with the period of elevated temperature. This excess was localised to the east of England and London. It was detected 3 days after the heatwave. Conclusion A daily mortality model was sensitive and timely enough to rapidly detect a small excess, both, at national and regional levels. This tool will be useful when future events of public health significance occur. [ABSTRACT FROM AUTHOR]