Search

Introduction Excess mortality monitoring is not dependent on completeness or consistency of coding of causes of death and captures deaths caused directly and indirectly by COVID-19. It takes account of existing inequalities in the baseline rates and shows the additional impact of COVID-19. We report weekly on excess mortality by age, gender, geographical area, deprivation, and ethnicity. Methods A quasi-Poisson model was fitted to deaths data for 2015-2019 to estimate expected mortality in population sub-groups each week during the COVID-19 pandemic. This was compared with observed mortality reported each week. Information on deaths registered was obtained from death certificates. Ethnicity was obtained from hospital records linked to deaths data. Results Early in the pandemic, excess deaths exceeded official reported COVID-19 deaths every week. Throughout the pandemic there were stark inequalities in excess death rates. Based on data from 21 March 2020 to 9 April 2021, people living in the most deprived areas in England experienced more excess (1.21 times; 95% CI 1.21-1.22) compared with people living in the least deprived areas (1.17; 1.16-1.18). Black (1.56; 1.53-1.58) and Asian groups (1.55; 1.53-1.56) experienced more excess than the White group (1.16; 1.16-1.17). There was wide variation between English regions. Conclusions Reporting overall excess mortality early in the pandemic is important to inform policy makers and public about the true scale of the death toll when coding is inconsistent and developing. This approach has highlighted the large increases in already established inequalities in mortality. It provides rapid surveillance of developing disparities for national and local decision makers. It has been used to inform policy around reducing disparities and to revise messaging to encourage hospital attendance for non- COVID-19 health problems. Key messages Excess deaths from all causes is a robust measure of overall impact, unaffected by coding consistency. COVID-19 has dramatically worsened established inequalities between ethnic groups and deprivation groups.

Background Assessing mortality during the COVID-19 pandemic is vital for informing public health strategies and policy decision making. All-cause excess mortality provides an objective measure of the impact of the pandemic including both the direct and indirect effects. Our study considers the burden of mortality in the UK, Europe and the USA. We examine variation between countries, by age and sex. We explore the extent to which this variation is associated with COVID-19 case rates and other population characteristics. Methods The study is a secondary analysis of routine administrative population and mortality data. Weekly death occurrences and population estimates were obtained from Eurostat and national statistical agencies. Contextual information on COVID-19 case rates, population-level risk factors and healthcare were obtained from various open-source databases. Weekly age-standardised mortality rates (ASMRs) were calculated and presented relative to a baseline average from the preceding 5-year period. Relative cumulative (rc) ASMRs were then calculated to provide a comparable assessment of excess mortality at a point in time. Results Preliminary results show that, by end of the analysis period, England had an overall rcASMR of 10.09%. Higher excess mortality was identified for some countries (eg USA 14.58%) and lower - even below average mortality - for others (eg Norway -6.8%). Under 65 rcASMR showed substantial variation between countries. Cumulative COVID-19 case rates showed a moderate effect size (R2 = 0.51) when used to explain the proportion of variation observed between rcASMRs. Other population factors showed a smaller effect. Conclusions The burden of mortality experienced between countries and populations over the COVID-19 pandemic period has shown significant variation. Factors which may have contributed to the position of some countries should be further explored in order to inform ongoing management of Covid-19 and future pandemic events. Key messages Significant variation in all-cause excess mortality has been identified across the COVID-19 pandemic period between nations and particularly in younger age groups. COVID-19 case rates are associated with relative cumulative all-cause excess mortality among the nations assessed.

ObjectivesTo examine the impact of the Covid-19 pandemic on inequalities in premature mortality in England by deprivation and ethnicity. DesignA statistical model to estimate increased mortality in population sub-groups during the Covid-19 pandemic by comparing observed with expected mortality in each group based on trends over the previous five years. SettingInformation on deaths registered in England since 2015 was used, including age, sex, area of residence, and cause of death. Ethnicity was obtained from Hospital Episode Statistics (HES) records linked to death registration data. ParticipantsPopulation study of England, including all 569,824 deaths from all causes registered between 21 March 2020 and 26 February 2021. Main outcome measuresExcess mortality in each sub-group over and above the number expected based on trends in mortality in that group over the previous five years. ResultsThe gradient in excess mortality by deprivation was greater in the under 75s (most deprived had 1.25 times as many deaths as expected, least deprived 1.14) than in all ages (most deprived had 1.24 times as many deaths as expected, least deprived 1.20). Among the Black and Asian groups, all deprivation quintiles had significantly larger excesses than the most deprived White group and there were no clear gradients across quintiles. Among the White group, only the most deprived had more excess deaths than deaths directly involving Covid-19. Among the Black group all deprivation quintiles experienced more excess deaths than deaths directly involving Covid-19. ConclusionThe Covid-19 pandemic has widened inequalities in premature mortality by deprivation. Among those under 75, the direct and indirect effects of the pandemic on deaths have disproportionately impacted ethnic minority groups irrespective of deprivation, and the most deprived White group. Statistics limited to deaths directly involving Covid-19 understate the pandemics impact on inequalities by deprivation and ethnic group at younger ages. Key Messages What is already known on this topicO_LIEstimates of excess mortality for all ages combined for the period March 2020 to February 2021 show a small difference in the relative impact of Covid-19 on excess mortality between the most deprived and the least deprived C_LIO_LIThroughout the pandemic estimates of excess mortality have been greater for ethnic minority groups compared with the white group. C_LI What this study addsO_LIAmong the under 75s the gradient of excess mortality across the deprivation spectrum indicates a stark increase in already established inequalities in premature mortality C_LIO_LIIndependent of deprivation, excess mortality in Black and Asian ethnic groups is much higher than that of the white group, indicating that ethnicity is a determinant of excess mortality, regardless of level of area-based deprivation. C_LI

Background: Assessments of mortality continue to inform public health strategies and policy making during the COVID-19 pandemic. All-cause excess mortality is a robust measure of the impact of the pandemic. Our study assesses the relative burden of excess mortality in England during the pandemic compared with 28 European countries and the USA. Methods: Weekly deaths and population estimates were obtained from Eurostat or directly from national statistical and public health agencies. Contextual information on COVID-19 case rates and population-level risk factors were obtained from open-source databases. Weekly directly age-standardised mortality rates (ASMRs) during week 1 2020 to week 7 2021 were calculated and summed cumulatively. These were compared with weekly sums of mean ASMRs observed between 2015 and 2019 and presented relative to the mean cumulative 2015-2019 ASMR averaged over an equivalent period. Findings: By February 2021, England had an overall relative excess mortality of 10·05%. This was the fifth highest out of 29 countries, the USA (14·82%) being the highest. Five countries showed below average mortality, with Norway the lowest (-6·76%). The same statistic for deaths under 65 years showed substantial international variation, with England having the second highest excess of 11·46%. Cumulative COVID-19 case rates explained about half of the international variation in relative excess mortality. Interpretation: England has experienced comparably high all-cause excess mortality during the COVID-19 pandemic. Factors contributing to England’s relative position should be further explored, particularly the association of health inequalities and wider determinants of health on the mortality risk of younger age groups. Funding Information: This study was carried out as part of the PHE’s work during the pandemic and therefore funded by PHE. Declaration of Interests: All authors declare no conflicts of interest. Ethics Approval Statement: This study was carried out as part of the PHE responsibility to manage the COVID-19 pandemic. PHE has legal permission, provided by Regulation 3 of The Health Service (Control of Patient Information) Regulations 2002 to process confidential patient information (http://www.legislation.gov.uk/uksi/2002/1438/regulation/3/made) under Sections 3(i) (a) to (c), 3(i)(d) (i) and (ii) and 3(3) as part of its outbreak response activities. As such this work falls outside the remit for ethical review. The study was subject to an internal review by the PHE Research Ethics and Governance Group and was found to be fully compliant with all regulatory requirements. As a full ethical review is not a requirement for this type of study and as no ethical or regulatory issues had been identified the study was approved.

Background\ud Directly standardized rates (DSRs) adjust for different age distributions in different populations and enable, say, the rates of disease between the populations to be directly compared. They are routinely published but there is concern that a DSR is not valid when it is based on a “small” number of events. The aim of this study was to determine the value at which a DSR should not be published when analyzing real data in England.\ud \ud Methods\ud Standard Monte Carlo simulation techniques were used assuming the number of events in 19 age groups (i.e., 0–4, 5–9, ... 90+ years) follow independent Poisson distributions. The total number of events, age specific risks, and the population sizes in each age group were varied. For each of 10,000 simulations the DSR (using the 2013 European Standard Population weights), together with the coverage of three different methods (normal approximation, Dobson, and Tiwari modified gamma) of estimating the 95% confidence intervals (CIs), were calculated.\ud \ud Results\ud The normal approximation was, as expected, not suitable for use when fewer than 100 events occurred. The Tiwari method and the Dobson method of calculating confidence intervals produced similar estimates and either was suitable when the expected or observed numbers of events were 10 or greater. The accuracy of the CIs was not influenced by the distribution of the events across categories (i.e., the degree of clustering, the age distributions of the sampling populations, and the number of categories with no events occurring in them).\ud \ud Conclusions\ud DSRs should not be given when the total observed number of events is less than 10. The Dobson method might be considered the preferred method due to the formulae being simpler than that of the Tiwari method and the coverage being slightly more accurate.

For the past 3 years, Toronto East General Hospital staff and leadership have been involved in the design, implementation, and evaluation of a transformational change to the model of patient care. The purpose of the new model is to enhance quality, safety, and patient satisfaction through a redefinition of our approach to the patient experience. The evaluation framework for the Coordinated Care Team (CCT) model of care addressed safety and quality outcomes, patient satisfaction, staff and physician satisfaction, and resource impact. Results of the evaluation suggest that the introduction of the CCT model using the patient care bundle can have a significant impact on the patient experience through enhanced access to bedside care as well as improved quality and safety outcomes. This article is a follow-up to the article on the development of the model published in Forum (Fall 2009). It extends upon the previous article through an overview of the model as it evolved, a discussion of the first-year evaluation for three pilot units, and lessons learned regarding the change process.

Purpose \ud Abusive and neglectful parenting is an established determinant of adult mental illness, but longitudinal studies of the impact of less severe problems with parenting have yielded inconsistent findings. In the face of growing interest in mental health promotion, it is important to establish the impact of this potentially remediable risk factor.\ud Methods \ud Participants: 8,405 participants in the 1958 UK birth cohort study, and 5,058 in the 1970 birth cohort study Exposures: questionnaires relating to the quality of relationships with parents completed at age 16 years. Outcomes: 12-item General Health Questionnaire and the Malaise Inventory collected at age 42 years (1958 cohort) and 30 years (1970 cohort). Statistical methodology: logistic regression analyses adjusting for sex, social class and teenage mental health problems.\ud Results \ud 1958 cohort: relationships with both mother and father predicted mental health problems in adulthood; increasingly poor relationships were associated with increasing mental health problems at age 42 years. 1970 cohort: positive items derived from the Parental Bonding Instrument predicted reduced risk of mental health problems; negative aspects predicted increased risk at age 30 years. Odds of mental health problems were increased between 20 and 80% in fully adjusted models.\ud Conclusions \ud Results support the hypothesis that problems with parent–child relationships that fall short of abuse and neglect play a part in determining adult mental health and suggest that interventions to support parenting now being implemented in many parts of the Western world may reduce the prevalence of mental illness in adulthood.

The current crisis in Canada's health care system calls for transformational change in the way we deliver care. The Collaborative Model of Care is not a new concept, but has not been implemented in Canadian acute care hospitals until recently. Toronto East General Hospital developed and piloted a collaborative care model on three acute units and initial results are promising in terms of improved patient safety, patient satisfaction, job satisfaction and improved use of resources.

Aims To examine the hypothesis that coronary heart disease mortality and emergency hospital admission rates are higher in areas with higher outdoor air pollution levels. Methods and results Modelled nitrogen oxides (NO x ), particulate matter (PM10), and carbon monoxide (CO) levels were interpolated to 1030 census enumeration districts using an ecological study design. Results, based on 6857 deaths and 11 407 admissions from 1994–98 and a population of 199 682 aged ≥45 years, were adjusted for age, sex, deprivation, and smoking prevalence. Mortality rate ratios were 1.17 (95% CI 1.06–1.29), 1.08 (95% CI 0.96–1.20), and 1.05 (95% CI 0.95–1.16) in the highest relative to the lowest NO x , PM10, and CO quintile categories, respectively. Corresponding admission rate ratios were 1.00 (95% CI 0.90–1.10), 1.01 (95% CI 0.90–1.14), and 0.88 (95% CI 0.79–0.98). Conclusion The results are consistent with an excess risk of coronary heart disease mortality in areas with high outdoor NO x , a proxy for traffic-related pollution, but residual confounding cannot be ruled out. If causality were assumed, 6% of coronary heart disease deaths would have been attributable to outdoor NO x , and targeting pollution reduction measures at high pollution areas would be an option for coronary mortality prevention.

We review epidemiological studies of depression in Europe. Community surveys are essential. Methodological differences in survey methods, instruments, nuances in language and translation limit comparability, but consistent findings are emerging. Western European countries show 1 year prevalence of major depression of around 5%, with two-fold variation, probably methodological, and higher prevalences in women, the middle-aged, less privileged groups, and those experiencing social adversity. There is high comorbidity with other psychiatric and physical disorders. Depression is a major cause of disability. Incidence has been less studied and lifetime incidence is not clear, with longitudinal studies required. There is pressing need for prevalence studies from Eastern Europe. The considerable differences in health care systems among European countries may impact on proportions of depressives receiving treatment and its adequacy, particularly in the key area of primary care, and require further study. There is a need for public health programmes aimed at improving treatment, reducing rates and consequences of depressive disorders.

OBJECTIVE: Reports of increased rates of psychosis in prisons could be due to sampling and ascertainment differences. The authors compared two samples of subjects 16-64 years of age: those from the general population of residents in Great Britain and prisoners in England and Wales. METHOD: A random sample of remanded and sentenced male and female prisoners (N=3,142) and a two-phase, cross-sectional random sample of household residents (N=10,108) were assessed with structured questionnaires and the semistructured Schedules for Clinical Assessment in Neuropsychiatry. RESULTS: The weighted prevalence of probable functional psychosis in the past year was 4.5 per thousand (95% CI=3.1 to 5.8) in the household survey. In the prison survey, the weighted prevalence was over 10 times greater: 52 per thousand (95% CI=45 to 60). One in four prisoners with a psychotic disorder had psychotic symptoms attributed to toxic or withdrawal effects of psychoactive substances. The proportion of subjects with specific types of hallucinations or delusions did not differ between prison and household psychosis cases. CONCLUSIONS: This large study using standardized comparisons showed that the prevalence of psychosis in prisons is substantially higher than in the community and is deserving of greater attention to treatment and prevention. Apart from a minority of prisoners with symptoms attributable to psychoactive substances, the clinical symptom profile of psychosis is the same in both settings. Longitudinal research is needed to better understand these prevalence differences.

Within the European Mental Health Status Project, over 200 psychiatric surveys concerning members of the European Union (plus Norway) were examined for their potential for meta-analysis with regard to prevalence of psychiatric disorders and basic demographic and social variables. The diversity of samples, methods, analysis and presentation was such that only data derived from GHQ-12 and CIDI studies could be used, and those relating to sex differentials only. The statistical program ‘Stata’ was used to compute odds ratios (with confidence intervals) for individual studies, and to produce fixed and random effects estimates of the pooled odds ratio for all studies together, and a measure of heterogeneity. Forrest Plots were also produced. Analysis of GHQ-12 data with a cut-off point of 4, indicating a current or recent ‘probable mental health problem’, showed, as expected, that women had higher prevalence rates than men. However, there was a relatively high heterogeneity score, suggesting that these studies may not be measuring the same thing. Analysis of CIDI results showed homogeneity for major depressive disorder within the last 12 months, with the risk for men about half of that for women. In terms of advancing epidemiological knowledge, the results are trivial, at most confirming what is already well known. However, the study shows the potential for pooled analysis, with much greater power in epidemiological investigation if consistency could be achieved in research. Various ways in which this might be done are discussed. It also shows the value of personal knowledge and personal networks in fields which are not well handled by electronic literature databases.

The aims of this study were to describe the pattern of excess winter mortality and emergency hospital admissions in the South Yorkshire Coalfields Health Action Zone, and to examine the relationship between excess winter mortality and emergency hospital admissions and socio-economic deprivation at the enumeration district level. We analysed monthly deaths from 1981 to 1999 and monthly emergency hospital admissions from 1990 to 1999 for cardiovascular disease, respiratory disease and all other causes of death for people aged 45 years and above. We used the enumeration district level Townsend socio-economic deprivation score to categorize enumeration districts by quintile. Excess winter mortality ratios (observed/expected) for females and males, respectively, were 1.70 and 1.58 for respiratory disease, 1.25 and 1.20 for cardiovascular disease, and 1.09 and 1.07 for all other causes of death. The excess winter hospital admission ratio for respiratory disease was 1.80 for females and 1.58 for males. No excess was evident for the other two groups of conditions. We found no significant increase in excess winter mortality ratios with increasing socio-economic deprivation. There was also no significant increase in the excess winter respiratory admission ratio with increasing deprivation. With regard to age, we found P0.0001 and for all other diseases P0.001 and also in the excess winter hospital admission ratio for respiratory disease P0.0001 With regard to sex, the excess ratios were lower in men than in women for both respiratory mortality P0.05 and respiratory hospital admissions P0.0001 We also observed that excess winter mortality ratios decreased significantly over the 18-year period for cardiovascular disease P0.05 and for all other diseases P0.05. Our results suggest that measures to reduce excess winter mortality should be implemented on a population-wide basis and not limited to socio-economically deprived areas. There may also be a case for tailoring interventions to specifically meet the needs of older people.

A shortage of medium secure psychiatric beds is widely recognized, but there is little data on patients referred for admission but not accepted. This paper examines the relationships between assessed need for and admission to medium security. The method used was interview survey with principal clinical assessors of patients assessed for admission to medium secure units in England and Wales in the first half of 1999. A stratified random sample totalling 418 patients from 34 medium secure units, including 98% of relevant beds nationally was used. Factors associated with being assessed as needing medium security (but not necessarily being admitted) included having features of acute schizophrenia, non-compliance with treatment, a history of sexually inappropriate behaviour, and being referred because of self-harm. A ‘grave’ current offence and a history of recent or many past custodial sentences were also important. For patients seen in prison, NHS or community services, just under a fifth of those assessed a...

The needs of patients in medium secure psychiatric units are well documented, but little is known of the range of clinical and security needs of those assessed but put on waiting lists or not admitted. The aim of the study was to quantify needs for treatment and care of a nationally representative sample of patients assessed for admission to medium secure care. 34 units containing 98% of medium secure beds in England and Wales in 1999 participated. All assessments were logged. A random sub-sample was selected for detailed interviews with assessing clinicians. Higher sampling fractions were used in smaller units. Unit monthly waiting lists averaged 5 patients for each available bed. Common reasons for referral were aggressive behaviour, deteriorating mental state, need for diagnostic assessment, and non-compliance with treatment. 42 per cent of assessed patients needed medium secure care, one-third on a long-term basis. The assessing units refused some patients who needed medium secure care, and accepted s...

Background: Published studies linking the common mental disorders with social disadvantage lack basic comparability. This project aimed to estimate effect sizes and independence of social position markers as risk factors for common mental disorders. Disorders with disability were examined to identify groups with high clinical and policy priority. Methods: Data from the 1993 household survey of psychiatric morbidity in Great Britain were analysed using logistic regression models, using traditional and more specific markers of social position. Results: Of those with a common mental disorder, 22 % reported difficulty doing at least one activity of daily living, linked to their mental symptoms. In comprehensive statistical analyses, having two or more physical illnesses was associated with an odds ratio of 6.42 (95 % CI 4.34–9.51) for common mental disorder with disability, while odds ratios of 3 or more were present for being economically inactive or having had two or more recent adverse life events. Occupational social class was not an independent marker of raised rates of disorder. Similar patterns of result were present for common mental disorders irrespective of disability, although odds ratios were smaller. Conclusions: Several specific markers of less privileged status are independently associated with raised rates of common mental disorders, with or without disability. There may be scope to target specific high-risk groups within comprehensive programmes to reduce mental health inequalities.

It is well established that significant numbers of prisoners have psychosis, yet little is known of what happens to them over time. One hundred and forty prisoners with probable psychosis from the National Survey of Psychiatric Morbidity in Prisons were re-interviewed at one-year follow-up. During the follow-up year 10% (95% CI 2-17) were admitted to hospitals, detox or medium secure units. At follow-up, 65% (95% CI 52-77) had ‘caseness’ levels of current psychiatric illness, but less than a quarter had appointments with psychiatric professionals: for violent or sexual offenders, only 41% had such appointments. Three per cent of those released were in supported accommodation at follow-up.

Background Recently the Medical Devices Agency recommended that ‘ophthalmic devices that touch the surface of the eye should be restricted to single use’. Aim To evaluate one such device: a disposable tonometer prism for routine applanation tonometry. Methods The intraocular pressure (IOP) of 100 consecutive patients from a general eye clinic (197 eyes) was measured with both a disposable and the standard Goldmann tonometer (Goldmann). The level of agreement between the two methods of clinical measurement was assessed and the sensitivity and specificity of the disposable prism in detecting clinically significant raised IOP estimated. Results The mean difference in IOP measured by the two different prisms was 0.44 mmHg with a standard deviation (SD) of 1.54. The mean IOP for the disposable prism was 19.51 mmHg (SD 6.53 mmHg). The mean IOP for the standard Goldmann tonometer prism was 19.07 mmHg (SD 6.64 mmHg). The sensitivity to detect IOP > 21 mmHg was 95.9% (95% confidence interval (CI): 86.0-99.5%) and the specificity of 93.9% (95% CI: 88.8-97.2%). It gave a positive predictive value of 83.9% (95% CI: 71.7-92.4%). Conclusion There was close agreement between the IOP measurements obtained by the disposable tonometer prism and the Goldmann device for high and low pressures. If replicated, the high sensitivity and specificity would justify its use in screening.

Objective: To collect data on facilities and patient throughput in general ICUs throughout Yorkshire. Design: Prospective data collection on all admissions to 19 units over six months in 1992. A questionnaire to establish facilities in individual units. Participants: Eighteen of a possible 19 general units in Yorkshire. Results: Nineteen general ICUs in Yorkshire had 90 staffed beds. In six months 18 units admitted 3,185 patients. Many were potentially suitable for high-dependency unit (HDU) care as 36% were categorised as low nurse dependency and 27% had no significant therapeutic interventions. Ten units had no dedicated 24-hour medical cover. Facilities for children were inadequate in terms of local facilities and regional referral units. Conclusions: There is a real need for a reassessment of organisation and delivery of intensive care services at local and regional level. Of many options available, the provision of adequate high-dependency facilities would have a major impact on costs and pressure on...

A retrospective cohort analysis, using data extracted from clinical notes, examined the validity of standardized mortality ratios (SMRs) for cervical cancer as an indicator of the quality of health services by exploring the mortality at five years of patients presenting with cervical cancer, identifying factors associated with survival, and studying the relationship of those factors to SMRs for the disease. The subjects were 1038 women aged 15-64 registered at the Yorkshire Cancer Registry as having invasive cervical cancer between 1979 and 1983. It was found that independent risk factors for mortality within five years of presentation were stage at diagnosis and smoking habit. Method of treatment had an effect that failed to reach statistical significance. Independent risk factors for late stage at presentation were absence of a history of cervical smear and increasing age. Considerable variation remained unexplained in both models. District SMRs were not related to five-year survival, stage at presentation or screening history. SMRs were related to proportions of smokers. It is concluded that SMRs are subject to considerable influence from a range of unidentified factors, as well as identified risk factors. They are too broad an indicator to be a valid measure of health service performance. The health service's ability to reduce case fatality does not outweigh the effects of incidence and severity. Better indicators would be survival to five years of those presenting at stage II or less and distribution of stage at presentation.

Background There is substantial national interest in the widening gap in socio-economic inequalities. The aim of this study was to examine time trends in age-specific mortality in Trent Region comparing rates by socio-economic deprivation from 1988 to 1998. Methods Mortality rates from 1988 to 1998 were calculated for each of five deprivation categories (derived using 1991based enumeration district level Townsend scores) for men and women aged 45‐54, 55‐64, 65‐74 and 75‐84 years. Rate ratios (95 per cent confidence intervals) were calculated for the years 1988‐1990 and 1996‐1998, comparing the most deprived with the least deprived categories. Results For men aged 45‐54, the rate ratio for the most deprived relative to the least deprived category was 2.42 (2.2‐2.67) in 1988‐1990 and 2.4 (2.17‐2.65) in 1996‐1998. Amongst women the ratio fell from 2.14 (1.88‐2.42) to 1.67 (1.47‐1.88). For men aged 55‐64, the rate ratio fell from 2.07 (1.95‐2.19) to 1.79 (1.67‐1.91). For women the fall was from 1.99 (1.84‐2.14) to 1.59 (1.46‐1.73). For those aged 65‐74, the fall was from 1.65 (1.58‐1.72) to 1.33 (1.28‐1.39) for men and from 1.55 (1.47‐1.63) to 1.37 (1.30‐1.45) for women. For people aged 75‐84, no clear convergence in rates was seen. Conclusion There appear to be decreases in socio-economic inequalities in mortality between 1988 and 1998 in Trent Region. These trends run counter to those described in the majority of recent literature.

Background Assertive community treatment for the severely mentally ill is being implemented increasingly internationally. It is unclear whether recommended characteristics of assertive outreach (AO) teams influence care and outcomes. We hypothesised that recommended characteristics of AO teams such as joint health and social care management would predict reduced hospitalisation in the first year of an AO client programme and related outcomes throughout England. Methods A two-stage design was used: a stratified sample of 100 of the 186 'stand-alone' AO teams in England and a systematic sample of clients from each team with stratification for black and ethnic minority patients. Team characteristics, treatment and outcomes were collected from teams. Analyses took account of patients' histories, clustering and ethnic minority over-sampling. Results Under AO the proportion of time spent in hospital following admission decreased. Only 3/1,096 patients went missing in 9 months. Although patient' histories significantly predicted outcomes almost no team characteristics predicted re-admission or other patient outcomes after 1 and 3 years. Ethnic minority clients were more likely to be on compulsory orders only on jointly managed teams (P = 0.030). Multidisciplinary teams and teams not working out of hours significantly predicted that patients received psychological interventions, but only 17% of sampled patients received such treatments. Conclusions Characteristics of AO teams do not explain long-term patient outcomes. Since recommended team characteristics are not effective new models of care should be developed and the process of care tested. Managing teams to implement evidence-based psychological interventions might improve outcomes. © Springer-Verlag 2011.

Summary. The present state of epidemiological research in relation to mental retardation is described, with particular respect to taxonomic issues. A comprehensive taxonomy is proposed, and the problems of establishing it discussed.

(1990). Review: The use of aspirin in pregnancy. Journal of Obstetrics and Gynaecology: Vol. 10, No. 6, pp. 467-482.

Background A measure of general practice level socioeconomic deprivation can be used to explore the association between deprivation and other practice characteristics. An area-based categorisation is commonly chosen as the basis for such a deprivation measure. Ideally a practice population-weighted area-based deprivation score would be calculated using individual level spatially referenced data. However, these data are often unavailable. One approach is to link the practice postcode to an area-based deprivation score, but this method has limitations. This study aimed to develop a Geographical Information Systems (GIS) based model that could better predict a practice population-weighted deprivation score in the absence of patient level data than simple practice postcode linkage. Results We calculated predicted practice level Index of Multiple Deprivation (IMD) 2004 deprivation scores using two methods that did not require patient level data. Firstly we linked the practice postcode to an IMD 2004 score, and secondly we used a GIS model derived using data from Rotherham, UK. We compared our two sets of predicted scores to "gold standard" practice population-weighted scores for practices in Doncaster, Havering and Warrington. Overall, the practice postcode linkage method overestimated "gold standard" IMD scores by 2.54 points (95% CI 0.94, 4.14), whereas our modelling method showed no such bias (mean difference 0.36, 95% CI -0.30, 1.02). The postcode-linked method systematically underestimated the gold standard score in less deprived areas, and overestimated it in more deprived areas. Our modelling method showed a small underestimation in scores at higher levels of deprivation in Havering, but showed no bias in Doncaster or Warrington. The postcode-linked method showed more variability when predicting scores than did the GIS modelling method. Conclusion A GIS based model can be used to predict a practice population-weighted area-based deprivation measure in the absence of patient level data. Our modelled measure generally had better agreement with the population-weighted measure than did a postcode-linked measure. Our model may also avoid an underestimation of IMD scores in less deprived areas, and overestimation of scores in more deprived areas, seen when using postcode linked scores. The proposed method may be of use to researchers who do not have access to patient level spatially referenced data.

Background and Purpose— Current evidence suggests that stroke mortality and hospital admissions should be higher in areas with elevated levels of outdoor air pollution because of the combined acute and chronic exposure effects of air pollution. We examined this hypothesis using a small-area level ecological correlation study. Methods— We used 1030 census enumeration districts as the unit of analysis and examined stroke deaths and hospital admissions from 1994 to 1998, with census denominator counts for people ≥45 years. Modeled air pollution data for particulate matter (PM 10 ), nitrogen oxides (NO x ), and carbon monoxide (CO) were interpolated to census enumeration districts. We adjusted for age, sex, socioeconomic deprivation, and smoking prevalence. Results— The analysis was based on 2979 deaths, 5122 admissions, and a population of 199 682. After adjustment for potential confounders, stroke mortality was 37% (95% CI, 19 to 57), 33% (95% CI, 14 to 56), and 26% (95% CI, 10 to 46) higher in the highest, relative to the lowest, NO x , PM 10 , and CO quintile categories, respectively. Corresponding increases in risk for admissions were 13% (95% CI, 1 to 27), 13% (95% CI, −1 to 29), and 11% (95% CI, −1 to 25). Conclusion— The results are consistent with an excess risk of stroke mortality and, to a lesser extent, hospital admissions in areas with high outdoor air pollution levels. If causality were assumed, 11% of stroke deaths would have been attributable to outdoor air pollution. Targeting policy interventions at high pollution areas may be a feasible option for stroke prevention.

This paper reports the findings of an analytical comparison of several macro indicators collected routinely from institutional sources in Europe. We carried out a review of macro indicators capable of providing a synthetic description of mental health status and the availability of psychiatric care in European countries. These were collected routinely from sources such as WHO, OECD, EUROSTAT, and IMS. The evaluation of temporal trends in each nation permits subsequent comparisons between countries. In all European countries, a decreased trend of suicides was observed in the period 1980–2000, with the exception of Ireland and (partially) of Spain. In Ireland, the increased trend was particularly strong, with a high risk in young and adult males. Portugal and Greece had respectively the highest and the lowest rates of undetermined causes of death. Most countries that were high consumers of alcohol in the initial period of observation had a rate above the national mean until 1980, after which consumption decreased. Most nations that were low consumers in 1960 had rates below the mean until 1980,when the rates progressively increased. However, a general decrease of alcohol-related deaths was apparent in all countries. Mortality associated with mental disorder increased, most clearly during the mid 1980s. The number of psychiatrists per 100,000 inhabitants ranged from 3.6 in Spain to 17.5 in Finland; of child psychiatrists, from 0.9 in Germany to 5.1 in Portugal. Psychiatric beds ranged from 0.4 per 1,000 inhabitants in Italy and Spain to 1.3 in Ireland. Nine countries showed a trend towards a reduction in psychiatric beds, whilst in a further five countries no change was observed. Rates of long-stay patients varied from 9.5 in the UK to 84 in Belgium, with a generally decreasing trend. The use of outpatient facilities differed markedly between countries, although there was a general increase over time. Official data were scarce in relation to the sale of psychotropic drugs. IMS data indicated increasing consumption in all European countries for antidepressant and antipsychotic medication. The official data resources available for European countries seem to indicate some discrepancies, probably relating to methods of recording. Better co-ordination in the collection of data about mental health status in the European Union and an improvement of the quality in available services is needed.

EDITOR—In 1998 an audit of suicides in Doncaster identified the alarming rate of co-proxamol overdose as a method of suicide: of the 44 suicides with prescribed drugs between 1995 and 1998, 18 were with co-proxamol (41%).1 That this is much higher than the national figure of 18% quoted by Hawton et al2 may be because the rates of prescribing of co-proxamol …

In this paper we describe a simple physical test-bed, developed to allow practical experimentation in the use of Decentralised Data Function (DDF) in sensor-to-shooter applications. Running DDF over an ad hoc network of distributed sensors produces target location information. This is used to guide a Leica laser-tracker system to designate currently tracked targets. We outline how the system is robust to network and/or node failure. Moreover, we discuss the system properties that lead to it being completely “plug-and-play”, as, like the distributed sensor nodes, the “shooter” does not require knowledge of the overall network topology and can connect at any point.

The objective of this study was to develop a valid and reliable discriminative index that measures parent satisfaction with the medical care of their infant in the NICU. We developed an initial questionnaire (Item Reduction Questionnaire) by reviewing the literature, surveying 63 NICU clinicians, and interviewing 125 parents of infants in 2 tertiary level NICUs regarding what they liked and disliked about the medical care of their infants. We administered the Item Reduction Questionnaire, which included 154 items, to 60 parents, who rated the frequency and importance of these items. We included the items identified most frequently as sources of dissatisfaction and rated most important in a second, briefer instrument, the Neonatal Index of Parent Satisfaction (NIPS). To measure reliability we administered the NIPS to 47 parents twice, separated by a 1-week interval. We assessed validity by comparing actual to predicted correlations between NIPS scores and other measures: parent's global rating of satisfaction, medical caregiver ratings of mother's satisfaction, medical caregiver ratings of father's satisfaction, and parents' perception of their infant's health status. We also compared mean NIPS scores for parents who did and who did not report incidents when errors occurred in the medical care of the infant. Of 154 items generated, we included 27 in the NIPS. The intraclass correlation between two administrations of the NIPS to the same 47 parents was 0.71. As predicted, there was a high correlation (0.61) between the NIPS score and parent global rating of satisfaction, and much lower correlations with other variables. Mean NIPS scores for parents who did and who did not report errors differed significantly (difference, 14.6; 95% CI around difference, 5.8-23.5; p < 0.001). The NIPS is likely to be a useful measure for discriminating between parents who differ in terms of their satisfaction with the medical care of their infant in the NICU.

The incidence of chronic renal failure rises with age and is higher in men and in people of Asian and Afro-Caribbean origin. A study using data from 1991–3 found that renal replacement therapy rates were related to age, ethnicity, socioeconomic deprivation, and travel distance to renal units.1 In the Trent Region, UK, which served a population of 5.1 million, a review of renal services was undertaken in 2000. We examined utilisation rates in relation to socioeconomic deprivation and travel distance to renal units as part of the needs assessment and planning process. Patients in Trent Region who were receiving renal replacement therapy (haemodialysis, peritoneal dialysis, renal transplantation) in August/September 2000—that is, point prevalent cases—were categorised by enumeration district (ED), age band (15–24 to 80–84 years), and gender. (Data on acceptance of new patients were incomplete.) Data were obtained from renal units, including units outside Trent Region, which served patients resident in the Region. Corresponding 1991 census denominators, corrected for under-enumeration and scaled to 1998 Office for National Statistics mid-year estimates for the 11 health authorities in Trent, were obtained from an existing population dataset. The 1991 census based ED level Townsend score was categorised by quintile (with equal population in each category) and used as an indicator of socioeconomic deprivation.2 …

It will surprise few that mental health problems are common in people in prison, especially those on remand. 1 2 But in the light of the longstanding policy consensus that people with severe mental illness should be cared for in health and social services, the results of a recent national survey of mental disorders in prisons are still a shocking indication of inappropriate and inadequate psychiatric care on a huge scale. The survey, funded by the Department of Health,3 was based on semistructured clinical interviews and is the latest in the important series of studies of psychiatric epidemiology in Great Britain carried out by the Office for National Statistics.4 Its most dramatic finding is the high rate of functional psychosis: 7% of sentenced men, 10% of men on remand, and 14% of women in both categories were assessed as having a psychotic illness within the past year. Although methodological differences render comparisons with previous studies of prisoners difficult, the key comparative figure is 0.4% for adults in the general population.4People with a dual diagnosis of mental illness and substance abuse pose a special problem, also a current concern in the United States. …

Patients warned of a bleed may be more vigilant EDITOR,--John Weil and colleagues, in their large case-control study, do not mention that they have taken the possibility that their aspirin using subjects could have been more likely to spot a bleeding peptic ulcer because they …

EDITOR, - The finding of a higher infant mortality in Pakistani immigrants than in the indigenous population in Norway1 is similar to the findings of the Yorkshire infant mortality study, which took place for 22 months from 1 April 1991.2 Analysis on ethnic group was carried out for the nine districts for which denominators were available - namely, …

Describes a 4 bit expandable analog to digital converter capable of operation at clock rates of over 100 MHz in 8 bit systems under Nyquist limit sampling conditions. Essential to these high speeds are a fast (>5 GHz F/SUB T/) bipolar process and a design approach which takes every advantage of the components available.

The context and content of work undertaken with individual clients by community psychiatric nurses (CPNs) and mental health social workers (MHSWs) in Salford were found to be significantly different. Although there were some areas of overlap, the ways in which the two professions worked were quite distinct. MHSWs discussed a wide range of topics and were as concerned with clients' interactions with family and community networks as they were with symptoms. Their interviews with schizophrenic clients followed a similar pattern to those with other groups, and they worked closely with psychiatrists and other mental health staff. CPNs, on the other hand, focused mainly on psychiatric symptoms, treatment arrangements, and medications, and spent significantly less time with individual psychotic clients than they did with patients suffering from neuroses. They were as likely to be in contact with general practitioners as they were with psychiatrists, and had fewer contacts with other mental health staff than the MHSWs. There was evidence that the long-term care of chronic psychiatric patients living outside hospital required more co-ordinated long-term multidisciplinary input.

SummaryUsing data from the Salford Psychiatric Case Register, point-prevalence patterns of service use in Salford County Borough are compared for 1968 and 1978 with respect to type of care, age and diagnosis. In a declining population, overall point-prevalence ratios increased from 9.52 to 13.44/1,000 adults, due almost entirely to two extensive new services — “injection-only” nurse contact with out-patients, and community psychiatric nurse domiciliary contact. Their development has apparently hardly affected use of other services. The increase was similar in most age-groups and in the predominating diagnostic groups (schizophrenia and depression). Prevalence ratios for long-stay patients barely changed in total, and increased for those accumulated in a ten-year period, but there was an upward shift in age. Day care increased, but its contribution remained relatively small. The diagnostic distribution of social work contact changed, as community psychiatric nurses (CPNs) assumed domiciliary care of people with schizophrenia.

In Britain we have traditionally bemoaned the lack of accurate, comprehensive, mental health statistics. With the inherent problems of psychiatric diagnosis, the impossibility of defining "abnormal" in the absence of satisfactory standards of "normality," and the diffuseness and variety of agencies that offer help, this lack is neither surprising nor reprehensible. It does, however, make planning difficult. In recent years much progress has been made; and some gaps have been filled, not least by the psychiatric case registers, which have now provided at least a series of base-line statistical descriptions of the use of mental health services and offered opportunities for more effective evaluation (Wing & Hailey, 1972). The statistical descriptions themselves are not enough, of course; but even with very simple figures, questions relatingto social phenomena may be clarified and raised into prominence as important and susceptible to the attentions of both administrators and clinicians. Such statistics are greatly multiplied in usefulness, and general lessons may be learned, if several registers can produce comparable figures. This has recently been done by the Camberwell and Salford registers (Wing & Fryers, 1976). Both these areas are entirely urban and within large conurbations, Camberwell in S. E. London and Salford in Greater Manchester. The Camberwell service focuses on the Maudsley Hospital and has relatively high provision in most respects, but the Salford service can reasonably be considered fairly representative of psychiatric provision in urban England. This paper presents statistical data from studies in Salford, with some comparative data from the Camberwell register, which

A quad 512-b static shift register consuming 1.8 mW/stage designed to demonstrate the capabilities of an advanced bipolar silicon technology is discussed. The process uses 1- mu m lithography, trench isolation, polyemitter transistors, polysilicon resistors, and polycide layer for local interconnections. This VLSI circuit (over 35 K transistors, 86-mm/sup 2/ chip) has been implemented on a sea-of-cells structure. An appropriate scheme has been used for the clock distribution. The experimental results show operation at a clock frequency up to 950 MHz. >