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Abstract Background Maternity services should take into account the needs of all women, including those related to disability. No reliable information, however, exists on the extent and characteristics of disability in this population in the UK. This brief report provides an overview of the prevalence of disability in women giving birth in the UK as measured by the presence of a limiting longstanding illness (LLI). The demographic, socio-economic, lifestyle and pregnancy related characteristics and child health outcomes are summarised to inform maternity and postnatal care service planning, and policy development. Methods Secondary analysis of data on 18,231 mother-child pairs from the nationally representative UK Millennium Cohort Study. The baseline interviews with families were carried out in 2001-2002. The LLI prevalence in women who had recently delivered was estimated, and relevant characteristics and differences in outcomes compared using descriptive statistics taking into account the study design and non-response. Results 9.4% (95% CI 8.7-10.0) of women who had recently given birth reported having an LLI. Musculoskeletal, respiratory and mental disorders accounted for most of the health problems. A significantly higher proportion of women with an LLI received means-tested financial benefits, had no educational qualifications and suffered from intimate partner violence compared to women who did not have an LLI (49.3% vs 35.3%, 20.4% vs 15.0%, 6.0% vs 3.3%, respectively). They were also more likely to smoke throughout pregnancy than women without an LLI (29.2% vs 20.8%), have a preterm birth (10.9% vs 6.8%) and be lone parents (19.5% vs 13.9%). Only 25.6% of children of mothers with an LLI were breastfed for more than three months compared to 33.4% of infants of mothers who did not have an LLI. At the age of seven years, 12.0% of children of mothers with an LLI had an activity limiting health problem themselves compared to 6.2% of children of mothers without an LLI. Conclusions Disability in women who had recently delivered is relatively common. It is associated with social and economic inequalities and worse pregnancy and child related outcomes. Apart from condition-specific support during and after pregnancy, disabled women may require extra help from health professionals to quit smoking, continue breastfeeding, and reduce intimate partner violence.

Background: Shiga toxin-producing Escherichia coli (STEC) infections are a significant public health concern as they can cause serious illness and outbreaks. In England, STEC incidence is highest among children and guidance recommends that children under six diagnosed with STEC are excluded from childcare until two consecutive stool cultures are negative. We aimed to describe the barriers and facilitators to implementing exclusion and the impact of exclusion policies on young children and their families., Methods: Individual level data was obtained from a wider study focusing on shedding duration among STEC cases aged < 6 years between March 2018 - March 2022. Data was extracted from England's public health case management system. The case management system includes notes on telephone conversations, email correspondence and meeting minutes relating to the case. Collected data consisted of free text in three forms: (1) quotes from parents, either direct or indirect, (2) direct quotes from the case record by health protection practitioners or environmental health officers, and (3) summaries by the data collector after reviewing the entire case record. We analysed free text comments linked to 136 cases using thematic analysis with a framework approach., Results: The median age of included cases was 3 years (IQR 1.5-5), with males accounting for 49%. Nine key themes were identified. Five themes focused on barriers to managing exclusion, including (i) financial losses, (ii) challenges with communication, engagement and collaboration, (iii) issues with sampling, processing, and results, (iv) adverse impact on children and their families and (v) conflicting exclusion advice. Four themes related to facilitators to exclusion, including (i) good communication with parents and childcare settings, (ii) support with childcare, (iii) improvements to sampling, testing, and reporting of results, and (iv) provision of supervised control measures., Conclusions: Qualitative analysis of public health case records can provide evidence-based insights around complex health protection issues to inform public health guidelines. Our analysis highlights the importance of considering wider social and economic consequences of exclusion when developing policies and practices for the management of STEC in children., (© 2024. The Author(s).)

Emotions play an important role in human-computer interaction, but there is limited research on affective and emotional virtual agent design in the area of teaching simulations for healthcare provision. The purpose of this work is twofold: firstly, to describe the process for designing affective intelligent agents that are engaged in automated communications such as person to computer conversations, and secondly to test a bespoke prototype digital intervention which implements such agents. The presented study tests two distinct virtual learning environments, one of which was enhanced with affective virtual patients, with nine 3rd year nursing students specialising in mental health, during their professional practice stage. All (100%) of the participants reported that, when using the enhanced scenario, they experienced a more realistic representation of carer/patient interaction; better recognition of the patients' feelings; recognition and assessment of emotions; a better realisation of how feelings can affect patients' emotional state and how they could better empathise with the patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Loizou, Arnab, Lameras, Hartley, Loizides, Kumar and Sumilo.)

Excluding children with Shiga toxin-producing Escherichia coli (STEC) from childcare until microbiologically clear of the pathogen, disrupts families, education, and earnings. Since PCR introduction, non-O157 STEC serotype detections in England have increased. We examined shedding duration by serotype and transmission risk, to guide exclusion advice. We investigated STEC cases aged <6 years, residing in England and attending childcare, with diarrhoea onset or sample date from 31 March 2018 to 30 March 2022. Duration of shedding was the interval between date of onset or date first positive specimen and earliest available negative specimen date. Transmission risk was estimated from proportions with secondary cases in settings attended by infectious cases. There were 367 cases (STEC O157 n  = 243, 66.2%; STEC non-O157 n  = 124, 33.8%). Median shedding duration was 32 days (IQR 20-44) with no significant difference between O157 and non-O157; 2% ( n  = 6) of cases shed for ≥100 days. Duration of shedding was reduced by 17% (95% CI 4-29) among cases reporting bloody diarrhoea. Sixteen settings underwent screening; four had secondary cases (close contacts' secondary transmission rate = 13%). Shedding duration estimates were consistent with previous studies (median 31 days, IQR 17-41). Findings do not warrant guidance changes regarding exclusion and supervised return of prolonged shedders, despite serotype changes.

Objectives: To investigate the association of birthweight percentile with cord blood glucose, lipids, and insulin levels., Study Design: Data obtained from 1522 newborns were included in the Born in Guangzhou Cohort study. The generalized additive model and multivariable linear regression model were used to explore the nonlinear and linear relationships between birthweight and cord blood metabolic measures, and to evaluate the differences of metabolic measures Z-scores among small for gestational age, appropriate for gestational age, and large for gestational age babies., Results: Birthweight Z-score was linearly associated with increased cord blood insulin Z-score (adjusted β = 0.30; 95% CI, 0.22-0.37). Compared with appropriate for gestational age babies, neonates born small for gestational age had significantly higher cord blood triglycerides Z-score (adjusted mean difference [MD adj ], 0.60; 95% CI, 0.40-0.79) and lower cord blood insulin (MD adj , -0.37; 95% CI, -0.57 to -0.16), high-density lipoprotein cholesterol (MD adj , -0.34; 95% CI, -0.55 to -0.13), total cholesterol (MD adj , -0.26; 95% CI, -0.47 to -0.05), and low-density lipoprotein (MD adj , -0.23; 95% CI, -0.43 to -0.02) Z-scores, and neonates born large for gestational age had higher cord blood insulin Z-score (MD adj , 0.31; 95% CI, 0.09 to 0.52)., Conclusions: Our findings support the hypothesis that babies born small for gestational age and large for gestational age are exposed to different intrauterine environments, which may contribute to altered fat accumulation patterns with implications for the risk of metabolic dysfunction later in life. There is a need to consider the development of tailored intervention strategies to prevent metabolic dysfunction in adult life for these babies., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Context: Mortality and infection-related hospital admissions are increased in patients with primary adrenal insufficiency (PAI). However, the risk of primary care-managed infections in patients with PAI is unknown., Objective: To estimate infection risk in PAI due to Addison's disease (AD) and congenital adrenal hyperplasia (CAH) in a primary care setting., Design: Retrospective cohort study using UK data collected from 1995 to 2018., Main Outcome Measures: Incidence of lower respiratory tract infections (LRTIs), urinary tract infections (UTIs), gastrointestinal infections (GIIs), and prescription counts of antimicrobials in adult PAI patients compared to unexposed controls., Results: A diagnosis of PAI was established in 1580 AD patients (mean age 51.7 years) and 602 CAH patients (mean age 35.4 years). All AD patients and 42% of CAH patients were prescribed glucocorticoids, most frequently hydrocortisone in AD (82%) and prednisolone in CAH (50%). AD and CAH patients exposed to glucocorticoids, but not CAH patients without glucocorticoid treatment, had a significantly increased risk of LRTIs (adjusted incidence rate ratio AD 2.11 [95% confidence interval (CI) 1.64-2.69], CAH 3.23 [95% CI 1.21-8.61]), UTIs (AD 1.51 [95% CI 1.29-1.77], CAH 2.20 [95% CI 1.43-3.34]), and GIIs (AD 3.80 [95% CI 2.99-4.84], CAH 1.93 [95% CI 1.06-3.52]). This was mirrored by increased prescription of antibiotics (AD 1.73 [95% CI 1.69-1.77], CAH 1.77 [95% CI 1.66-1.89]) and antifungals (AD 1.89 [95% CI 1.74-2.05], CAH 1.91 [95% CI 1.50-2.43])., Conclusions: There is an increased risk of infections and antimicrobial use in PAI in the primary care setting at least partially linked to glucocorticoid treatment. Future studies will need to address whether more physiological glucocorticoid replacement modes could reduce this risk., (© Endocrine Society 2019.)

Aims: Non-Alcoholic Fatty Liver Disease (NAFLD) is one of the leading causes of liver transplantation in the West. This study seeks to examine whether women with gestational diabetes mellitus (GDM) are at increased risk of developing NAFLD compared to women without GDM., Methods: We conducted a population-based retrospective matched-controlled cohort study utilising The Health Improvement Network (THIN), a large primary care database representative of the United Kingdom population, between 01/01/1990 to 31/05/2016 followed by systematic review of available literature. The study population included 9640 women with GDM and 31,296 controls without GDM, matched for age, body mass index (BMI) and time of pregnancy. All study participants were free from NAFLD diagnosis at study entry. Patients with GDM and patients developing NAFLD were identified by clinical codes., Results: The median (range) follow-up duration was similar in women with and without GDM (2.95 (1.21-6.01) vs 2.85 (1.14-5.75) years respectively). Unadjusted incidence rate ratio (IRR) for NAFLD development in women with vs without GDM was 3.28 (95% CI 2.14-5.02), which remained significant after adjustment for wide range of potential confounders (IRR 2.70; 95% CI 1.744-4.19). The risk of NAFLD in GDM remained high (IRR 2.46: 95% CI 1.51-4.00) despite women being censored after they developed type 2 diabetes. The meta-analysis of 3 studies (including the current study) showed increased NAFLD risk in women with vs without GDM (OR 2.60; 95% CI 1.90-3.57, I 2  = 0%). As our study is based on routine clinical diagnosis of NAFLD, this study could potentially have underestimated the risk of NAFLD development., Conclusions: Women with GDM are at increased risk of developing NAFLD in their later life compared to women without GDM regardless of the development of type 2 diabetes. Clinicians should have a low threshold to investigate women with history of GDM for the presence of NAFLD. Further studies to identify screening strategies are needed., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: Obesity is very common in patients with obstructive sleep apnoea (OSA) and polycystic ovary syndrome (PCOS). Longitudinal studies assessing OSA risk in PCOS and examining the role of obesity are lacking. Our objective was to assess the risk of OSA in women with vs without PCOS and to examine the role of obesity in the observed findings., Design: Population-based retrospective cohort study utilizing The Health Improvement Network (THIN), UK., Methods: 76 978 women with PCOS and 143 077 age-, BMI- and location-matched women without PCOS between January 2000 and May 2017 were identified. Hazard ratio (HR) for OSA among women with and without PCOS were calculated after controlling for confounding variables using multivariate Cox models., Results: Median patient age was 30 (IQR: 25-35) years; median follow-up was 3.5 (IQR: 1.4-7.1) years. We found 298 OSA cases in PCOS women vs 222 in controls, with incidence rates for OSA of 8.1 and 3.3 per 10 000 person years, respectively. Women with PCOS were at increased risk of developing OSA (adjusted HR = 2.26, 95% CI: 1.89-2.69, P < 0.001), with similar HRs for normal weight, overweight and obese PCOS women., Conclusions: Women with PCOS are at increased risk of developing OSA compared to control women irrespective of obesity. Considering the significant metabolic morbidity associated with OSA, clinicians should have a low threshold to test for OSA in women with PCOS. Whether OSA treatment has an impact on PCOS symptoms and outcomes needs to be examined.

Objective: To explore the association between maternal disability as measured by the presence of a limiting longstanding illness (LLI) 9 months postpartum and subsequent child health at the age of 7 years., Design: Nationally representative prospective longitudinal study., Setting: England, Scotland, Wales and Northern Ireland., Participants: Secondary analysis of data on 11 807 mother-child pairs recruited to the UK Millennium Cohort Study. Baseline interviews with mothers were carried out in 2001-2002. When the children were 7 years old, the follow-up survey included questions about limiting longstanding health conditions in the child., Primary Outcome Measure: Any longstanding condition that was reported to limit the children's activities in any way., Results: Nearly 7% of all children were reported to have an LLI at the age of 7 years. The majority (88.1%, 95% CI 85.6% to 90.2%) of children whose mother was disabled did not have an LLI themselves. The children of disabled mothers, however, had higher odds of LLI (OR=1.9, 95% CI 1.5 to 2.5) independently of different maternal, pregnancy and birth characteristics and breast feeding duration. Inclusion of poverty measures in the model did not significantly affect the odds (OR=1.8, 95% CI 1.4 to 2.4), suggesting that maternal LLI around the time of birth increases the odds of child LLI at the age of 7 years independently of starting life in poverty., Conclusions: There is a strong positive association between maternal and child LLI. Health professionals should work together with social care and other relevant service providers to identify the individual needs of disabled parents and provide adequate support throughout the pregnancy and after the child is born. Further research is important to clarify the exact nature of the associations for different types of maternal and child disability.

Although the presence of tick-borne encephalitis (TBE) virus circulating in tick populations depends on large-scale patterns of climate, and the local density of infected ticks depends on the abundance of mammalian hosts, the risk of human infection depends on the access and use by human populations of tick-infested habitats, particularly forests, at the landscape level. We investigated the incidence of reported TBE cases in rural parishes (i.e., municipalities) in Latvia. The following major characteristics of parishes were considered: whether their environment is suitable for tick and tick-host populations (depending on land cover); whether the local human population is likely to enter the forest on a regular base (depending on land use); and whether the spatial distributions of these two aspects are likely to intersect, through access rules (as a function of land ownership). The results indicated that all three aspects are important in explaining and predicting the spatial distribution of TBE cases in the rural areas of Latvia. The concept of landscape is here given new depth by consideration of its physical structure, its use by human populations, and its accessibility as modulated by ownership.

Tick-borne encephalitis (TBE) incidence increased markedly in the Baltics and Slovenia in the early 1990s, but then declined again in some places. Our analyses of temporal and spatial data on TBE incidence and vaccination revealed that over 1970-2005 up-take of vaccination varied in both time and space according to incidence, i.e. was apparently responsive to perceived risk. Since 1999, however, decreases in incidence in many counties within each country have far exceeded vaccination rates or immunity through natural exposure, and in Latvia and Lithuania these changes are correlated with previous incidence. Survey data on human activities in Latvia revealed that people in socio-economic groups whose behaviour put them at highest risk of exposure to ticks in forests, including people with lower education and lowest incomes, are least likely to be vaccinated. We conclude that risk avoidance through changing human behaviour has driven incidence-dependent decreases in TBE infection, but targeted vaccination campaigns could provide more secure protection.

Tick-borne encephalitis (TBE), the most serious widespread vector-borne disease of humans in Europe, increased from 2- to 30-fold in many Central and Eastern European countries from 1992 to 1993, coinciding with independence from Soviet rule. Unemployment and low income have been shown in Latvia to be statistically associated with high-risk behaviour involving harvest of wild foods from tick-infested forests, and also with not being vaccinated against TBE. Archival data for 1970--2005 record major changes in the agricultural and industrial sectors, and consequent changes in the abiotic and biotic environment and socio-economic conditions, which could have increased the abundance of infected ticks and the contact of humans with those ticks. For example, abandoned agricultural fields became suitable for rodent transmission hosts; use of pesticides and emissions of atmospheric industrial pollutants plummeted; wildlife hosts for ticks increased; tick populations appear to have responded; unemployment and inequality increased in all countries. These factors, by acting synergistically but differentially between and within each country, can explain the marked spatio-temporal heterogeneities in TBE epidemiology better than can climate change alone, which is too uniform across wide areas. Different degrees of socio-economic upheaval caused by political transition in Estonia, Latvia, Lithuania, Slovenia and the Czech Republic can apparently explain the marked variation in TBE upsurge. Causal linkage between national socio-economic conditions and epidemiology is strongly indicated by striking correlations across eight countries between the degree of upsurge of TBE and both poverty and household expenditure on food (R2 = 0.533 and 0.716, respectively).

Background: Pathogens transmitted by ticks cause human disease on a greater scale than any other vector-borne infections in Europe, and have increased dramatically over the past 2-3 decades. Reliable records of tick-borne encephalitis (TBE) since 1970 show an especially sharp upsurge in cases in Eastern Europe coincident with the end of Soviet rule, including the three Baltic countries, Estonia, Latvia and Lithuania, where national incidence increased from 1992 to 1993 by 64, 175 and 1,065%, respectively. At the county level within each country, however, the timing and degree of increase showed marked heterogeneity. Climate has also changed over this period, prompting an almost universal assumption of causality. For the first time, we analyse climate and TBE epidemiology at sufficiently fine spatial and temporal resolution to question this assumption., Methodology/principal Finding: Detailed analysis of instrumental records of climate has revealed a significant step increase in spring-time daily maximum temperatures in 1989. The seasonal timing and precise level of this warming were indeed such as could promote the transmission of TBE virus between larval and nymphal ticks co-feeding on rodents. These changes in climate, however, are virtually uniform across the Baltic region and cannot therefore explain the marked spatio-temporal heterogeneity in TBE epidemiology., Conclusions/significance: Instead, it is proposed that climate is just one of many different types of factors, many arising from the socio-economic transition associated with the end of Soviet rule, that have acted synergistically to increase both the abundance of infected ticks and the exposure of humans to these ticks. Understanding the precise differential contribution of each factor as a cause of the observed epidemiological heterogeneity will help direct control strategies.

This paper presents preliminary results in our investigations of the biological (abiotic and biotic) and non-biological causes of the spatial heterogeneity and temporal change of tick-borne encephalitis (TBE), both within and between Estonia, Latvia, and Lithuania. Spatial analysis revealed that the land cover and precise seasonal patterns of climatic indices (temperature and normalized difference vegetation index) can explain 55% of the observed spatial variation in TBE incidence over the period 1993-98 across all the Baltic States. Temporal analysis of climatic variables indicates a very specific change in spring temperature conditions from 1993 onwards that could enhance the transmission of TBE virus. Further time series analysis of climate, together with analysis of biotic factors, socio-economic conditions, and human behaviour is being undertaken to explain the epidemiological patterns more fully.