Caring for the health of the public: cross sectional study of the activities of UK public health departments

The relative time spent in different areas of work in public health departments in the UK was assessed by means of a postal questionnaire. Departments spend one third of their time on population health work, this being similar to the amount of time spent on planning health services. Having a planning department in the health authority did not affect the amount of time spent in any area of work. Having a greater number of consultants in the department was associated with a tendency to spend more time on population health and being involved in training was associated with spending less time on planning. Public health departments in the UK are the only part of the health service with responsibility for the broader aspects of public health. Whilst the tensions between medical care and the wider influences upon population health may represent a false dichotomy, public health professionals must maintain a central focus of their work on the wider influences upon population health if balance is to be maintained within the National Health Service.

Sexual intercourse and risk of ischaemic stroke and coronary heart disease: the Caerphilly study

OBJECTIVE

To examine the relation between frequency of sexual intercourse and risk of ischaemic stroke and coronary heart disease.

DESIGN

Cohort study with 20 year follow up.

SETTING

The town of Caerphilly, South Wales and five adjacent villages.

SUBJECTS

914 men aged 45-59 years at time of recruitment in 1979 to 1983.

MAIN OUTCOME MEASURES

Ischaemic stroke and coronary heart disease, all first events and fatal events.

RESULTS

Of the 914 men studied, 197 (21.5%) reported sexual intercourse less often than once a month, 231 (25.3%) reported sexual intercourse twice or more a week, and the remaining 486 (53.2%) men fell into the intermediate category. Frequency of sexual intercourse was not associated with all first ischaemic stroke events: age adjusted odds ratios (95% CI) for intermediate and low frequency of sexual intercourse of 0.61 (0.32 to 1.16) and 0.71 (0.34 to 1.49) respectively compared with the reference category of high frequency. A graded relation with fatal coronary heart disease events was observed in events recorded up to 10 years. The age adjusted relative risk (95% CI) of fatal coronary heart disease contrasting low frequency of sexual intercourse (that is, less than monthly) with the highest group (at least twice a week) was 2.80 (1.13 to 6.96, test for trend, p=0.04) which was not attenuated by adjustment for a wide range of potential confounders. Longer follow up to 20 years showed attenuation of this risk with odds of 1.69 (95% CI 0.90 to 3.20), contrasting low frequency of sexual intercourse with the highest group.

CONCLUSIONS

The differential relation between frequency of sexual intercourse, stroke and coronary heart disease suggests that confounding is an unlikely explanation for the observed association with fatal coronary heart disease events. Middle aged men should be heartened to know that frequent sexual intercourse is not likely to result in a substantial increase in risk of strokes, and that some protection from fatal coronary events may be an added bonus.

The population requirement for cataract extraction: a cross-sectional study

PURPOSE

To examine the distribution in the population of indications for cataract extraction in order to relate demand for this procedure to the capacity for satisfying it.

METHODS

An age-stratified random population sample of 2783 individuals aged 55 years and over was taken from inner-city, urban and rural areas of Avon and Somerset. The requirement for cataract extraction was estimated on the basis of measures of vision-related quality of life, refracted visual acuity, and application of the Oxford Clinical Cataract Classification and Grading System. Data were also collected concerning suitability for surgery, including relative contraindications to surgery and whether participants considered their eyesight bad enough to merit surgery. Three sets of composite indications were defined.

RESULTS

Estimated prevalent requirements for cataract extraction for the three sets of composite criteria were: 29 per 1000 aged over 55 years (95% CI 20-41) for the most inclusive criterion; 17 per thousand (95% CI 10-27) for the intermediate criterion; and 7 per thousand (95% CI 3-14) for the most stringent criterion. These rates are equivalent to a national prevalent requirement for England of 384,000 for the most inclusive criterion. If the approximately 15% of individuals whose desire or fitness for surgery was questionable are removed from this estimate, the prevalent requirement, including the backlog from previous unsatisfied demand, becomes 325,000 individuals.

CONCLUSIONS

The findings suggest only a modest imbalance between supply and demand for cataract surgery. In particular there was a very small prevalence of untreated severe cataract, less than the annual health service surgical capacity, suggesting that the current National Health Service surgical capacity is adequate for cases of severe cataract.

Vision-related quality of life impairment in an elderly UK population: associations with age, sex, social class and material deprivation

PURPOSE

To describe the prevalence of vision-related quality of life (VR-QOL) impairment in an elderly UK population sample.

METHOD

The survey, using the VCM1 questionnaire, was based on an age- and sex-stratified random population sample of 2783 individuals aged 55 years or over.

RESULTS

One thousand eight hundred and forty-six (69.7%) of 2647 eligible subjects responded. One thousand six hundred and eighty-three individuals completed all 10 VCM1 items. Overall the prevalence of a VCM1 score >2.0 ('more than a little' concern about vision) was 4.6% (95% CI = 3.7% to 5.7%), leading to an estimate of more than 550,000 individuals in England with substantial VR-QOL impairment. The prevalence increased with age from 2.1% in the 55-64 year age group to 17.9% in the group aged 85 years and older. The prevalence also increased as social class became lower, from 0 in social class I to 10.2% in social class V, and increased with increasing material deprivation, from 1.2% in the most affluent quintile to 6.8% in the most deprived quintile. Multivariable logistic regression analysis showed that age (p = 0.0001), decreasing social class (p = 0.03) and increasing material deprivation (p = 0.008) were independently associated with VR-QOL impairment (VCM1 score >2.0), whilst gender and means of questionnaire administration were not associated with VR-QOL impairment at the 5% level.

CONCLUSIONS

The findings suggest a substantial national prevalence of VR-QOL impairment, and are consistent with earlier studies linking ocular disease with social deprivation. Consideration should be given to directing resources more carefully towards groups at higher risk of VR-QOL impairment, in particular the very elderly and socially deprived.

Secular trends in antidepressant prescribing in the UK, 1975-1998

BACKGROUND

We have examined secular trends in age- and sex-specific prescribing of antidepressants to determine whether these mirror changes in other population measures of mental health.

METHOD

An analysis was carried out of age- and sex-specific rates of antidepressant prescribing by a representative sample or panel of UK general practitioners (GPs) in the period 1975-1998.

RESULTS

The number of antidepressant prescriptions issued increased more than twofold in the period 1975-1998 and, in 1998, a total of 23.4 million antidepressant prescriptions were issued by GPs in the United Kingdom. Rates of antidepressant prescribing increased markedly in all age and sex groups with as much as a threefold increase in the older age groups. With the exception of 12-19-year-olds, these increases have been more marked in males, although absolute levels of prescribing are still at least two times higher in females.

CONCLUSIONS

Antidepressant prescribing has increased in all age and sex groups. This indicates either that there have been changes in the presentation, recognition and management of depression in general practice or that the prevalence of depression has increased, or a combination of these two phenomena. The higher prescribing rate in females is in keeping with evidence from psychiatric morbidity surveys suggesting that women experience higher levels of psychiatric morbidity than men. Decreases in the ratio of female to male prescribing, however, support other data indicating that, relative to females, the mental health of young males has declined in recent years. Changes in patterns of help-seeking may also contribute to the observed trends.

Hydroxychloroquine for the treatment of chronic graft-versus-host disease

Chronic graft-versus-host disease (GVHD) is a major complication of allogeneic bone marrow transplantation. Both the disease and the medications used to treat it are associated with significant morbidity and mortality. The manifestations of chronic GVHD often resemble those of autoimmune disorders. Hydroxychloroquine (HCQ) is a 4-aminoquinoline antimalarial drug used for the treatment of autoimmune diseases. HCQ interferes with antigen processing and presentation, cytokine production, and cytotoxicity and is synergistic with cyclosporine and tacrolimus in vitro. Forty patients with steroid-resistant or steroid-dependent chronic GVHD were enrolled in a phase 2 trial of HCQ 800 mg (12 mg/kg) per day. Three complete responses and 14 partial responses were seen in 32 evaluable patients (53% response rate). All responders tolerated a >50% reduction in their steroid dose while receiving HCQ. Clinical response occurred at a median of 8 weeks (range, 4 to 24 weeks). No hematologic, hepatic, renal, or retinal toxicity was associated with HCQ. In light of its mechanisms of action, clinical activity for GVHD, and low toxicity profile, HCQ may be useful in a multiagent approach for the treatment of extensive chronic GVHD.

Childhood housing conditions and later mortality in the Boyd Orr cohort

STUDY OBJECTIVES

To examine associations between five measures of housing conditions during childhood and subsequent mortality from all causes, coronary heart disease, stroke, and cancer.

DESIGN

Historical cohort study.

SETTING

Data on housing conditions were collected from survey centres in 16 areas of England and Scotland.

PARTICIPANTS

Children of families participating in the Carnegie Survey of Family Diet and Health in pre-war Britain (1937-1939). Analyses are based on a subset of 4168 people who were traced and alive on 1 January 1948.

MAIN RESULTS

Poorer housing conditions were generally associated with increased adult mortality. After adjustment for childhood and adult socioeconomic factors, statistically significant associations were only found between lack of private indoor tapped water supply and increased mortality from coronary heart disease (hazard ratio 1.73, (95% CI 1.13, 2.64); and between poor ventilation and overall mortality (hazard ratio for people from households with poorest ventilation relative to best ventilation 1.30, 95% CI 0.97, 1.74).

CONCLUSIONS

This study provides evidence that associations between housing conditions in childhood and mortality from common diseases in adulthood are not strong, but are in some respects distinguishable from those of social deprivation.

The incidence and aetiology of stroke in the Caerphilly and Speedwell Collaborative Studies I: methods and incidence of events

Stroke mortality and morbidity remain high despite downward trends in incidence and case fatality. Population-based longitudinal studies which include collection of risk factor data are required for a better understanding of stroke aetiology. From a representative cohort of men from South Wales and South-west England, followed up for a median of 17 y, details of possible cerebrovascular events were collected from questionnaires, hospital admission data, general practitioner records, death certificates, radiology records and post-mortem reports. Radiology records, and strokes and transient ischaemic attacks were independently validated. There were 433 strokes and 163 transient ischaemic attacks identified during follow-up. Of these, 333 were the first ever in a lifetime strokes of which 139 were definite ischaemic, 20 were haemorrhagic and 168 were probable ischaemic strokes. The crude incidence rate for stroke was 445 (95% confidence interval 398-493) per 100 000 person years. The age-standardised rates for 10 y age-bands were: 45-54 y 91 (10-172); 55-64 y 351 (269-432) and 65-74 y 855 (669-1040). The 30 d case-fatality rate was 21.0% (70/333) for all strokes and 19.2% (60/312) for ischaemic strokes. For transient ischaemic attacks the age-standardised incidence rates for the same 10 y age bands were 92 (4-179), 111 (64-157), and 273 (167-80), respectively. These rates for stroke transient ischaemic attack are likely to be accurate given the high ascertainment of events in this representative population of middle-aged men. Such studies, reporting reliable measures of cerebrovascular events, are important for measuring burden of disease, and for analysis of risk factor associations to help improve understanding of stroke aetiology and inform preventive efforts.

The incidence and aetiology of stroke in the Caerphilly and Speedwell Collaborative Studies II: risk factors for ischaemic stroke

Reduction of stroke burden requires preventive interventions targeted at important risk factors. This report presents the analysis of risk factors for ischaemic stroke from a representative cohort of middle aged men from South Wales and south-west England. Data on risk factors were collected through validated questionnaires and physical and clinical measurements. Details of possible cerebrovascular events were retrieved, classified into ischaemic, haemorrhagic and uncertain subtypes, and validated. The ratio of definite ischaemic to definite haemorrhagic strokes was calculated. This showed that the vast majority of strokes of unknown subtype were likely to ischaemic. After exclusion of known haemorrhagic strokes and subarrachnoid haemorrhages the remaining strokes were labelled ischaemic. Hazard ratios for possible risk factors were calculated for all ischaemic, and for fatal and non-fatal strokes. There were 293 ischaemic strokes. Statistically significant age-adjusted hazard ratios were: 1.50 (95% confidence interval 1.16-1.95) for being in a manual social class, 1.82 (1.24-2.67) if smoking >15 cigarettes/d at enrollment, 1.19 (1.13-1.24) and 1.23 (1.14-1.34) per 10 mmHg increase in systolic and diastolic blood pressure, respectively, 0.67 (0.46-0.96) for the top quintile high density lipoprotein-cholesterol:cholesterol ratio compared to the bottom quintile, 2.04 (1.40-2.99) for presence of angina, 3.90 (2.01-7.58) for presence of atrial fibrillation, and 3.35 (1.90-5.80) for presence of diabetes. Risk factors were more strongly associated with fatal than non-fatal strokes. Multivariate analyses revealed that, while there was some attenuation of the effect of social class, angina and elevated BP, the risks from atrial fibrillation and diabetes were increased.

Transcutaneous immunization: a human vaccine delivery strategy using a patch

Transcutaneous immunization, a topical vaccine application, combines the advantages of needle-free delivery while targeting the immunologically rich milieu of the skin. In animal studies, this simple technique induces robust systemic and mucosal antibodies against vaccine antigens. Here, we demonstrate safe application of a patch containing heat-labile enterotoxin (LT, derived from Escherichia coli) to humans, resulting in robust LT-antibody responses. These findings indicate that TCI is feasible for human immunization, and suggest that TCI may enhance efficacy as well as improve vaccine delivery.

Use of PEG-rHuMGDF in platelet engraftment after autologous stem cell transplantation

This paper summarizes a pilot, sequential dose-escalation study of PEG-rHuMGDF in patients with advanced malignancies who had delayed platelet recovery after autologous stem cell transplantation (ASCT). Patients were randomized to receive either placebo (n = 11) or PEG-rHuMGDF at 5 (n = 9), 10 (n = 6), or 25 (n = 7) microg/kg/day by subcutaneous injection for 14 days and were monitored for 5 weeks. Across all treatment groups, eight patients had platelet recovery to > or = 20 x 10(9)/l by day 21. The proportion of patients achieving platelet recovery, the median number of days and units of platelet transfusions were similar for the placebo and the PEG-rHuMGDF groups. PEG-rHuMGDF was well tolerated at all dosages. The incidence rates of adverse events in all groups were similar. No deaths on study, no drug-related serious adverse events, and no development of neutralizing antibodies to MGDF occurred.

Method availability and the prevention of suicide--a re-analysis of secular trends in England and Wales 1950-1975

BACKGROUND

In England and Wales in the 1960s there were marked declines in suicide rates. These reductions were partly attributable to the detoxification of the domestic gas supplies; however, their extent varied by age and gender, with the most striking effects seen in older men. The objective of this study was to investigate method-specific trends in suicide between 1950 and 1975 to elucidate possible explanations for the patterns seen in different demographic groups.

METHODS

An analysis of age-standardised method-specific suicide rates for England and Wales between 1950 and 1975 was carried out using routinely available mortality and population statistics.

RESULTS

As has previously been shown, there were marked reductions in suicides by gassing in men and women of all ages between 1960 and 1975. In women and younger men, the effects of these reductions on overall suicide rates were partially offset by rises in drug overdose deaths (method substitution), but there were no immediate increases in the use of other suicide methods. In contrast, in older men, reductions in suicide by gassing were accompanied by only a slight increase in overdose suicides as well as reductions in rates of suicide using all other methods. The modest rise in overdose fatalities in older men occurred despite the fact that they were more often prescribed barbiturates and tricyclic antidepressants than younger men.

CONCLUSIONS

Accessibility to and the lethality of particular methods of suicide may have profound effects on overall suicide rates. Such effects appear to depend upon the popularity of the method and the extent to which alternative methods that are acceptable to the individual are available. Social and psychological interpretations of fluctuations in suicide rates should only be made after assessing the possible contribution to these of changes in method availability and lethality.

Measures of Proscar, Hytrin, and Cardura side effects

The importance of reporting correlations among side effects is examined using studies of BPH drugs as examples. The special relation of placebo effects in studying side-effects of drugs, as opposed to their efficacies, is introduced, and the need for special new controls is presented.

How accurately are height, weight and leg length reported by the elderly, and how closely are they related to measurements recorded in childhood?

BACKGROUND

This paper examines (1) the accuracy of self-reported height, leg length and weight in a group of subjects aged 56-78; (2) whether recent measurement of height and weight influences the accuracy of self-reporting and (3) associations between childhood and adult height, leg length and BMI measured in old age.

METHODS

All 3182 surviving members of the Boyd Orr cohort were sent postal questionnaires in 1997-1998 and a sub-sample (294) was also clinically examined.

RESULTS

Self-reported height was overestimated and body mass index (BMI), based on reported height and weight, underestimated. The mean difference between self-report and measured values were for height: 2.1 cm in males and 1.7 cm in females; for BMI the difference was -1.3 kg/m(2) in males and -1.2 kg/m(2) in females. Shorter individuals and older subjects tended to over-report their height more than others. The overweight under-reported their weight to a greater extent. Recent measurement appeared to decrease over-reporting of height but not weight. Correlations between self-report and measured height and BMI were generally over 0.90, but weaker for leg length (r = 0.70 in males and 0.71 in females). Adult height and leg length were quite closely related to their relative values in childhood (correlation coefficients ranged from 0.66 to 0.84), but associations between adult and childhood BMI were weak (r = 0.19 in males and 0.21 in females).

CONCLUSIONS

Self-reported measures of height and weight may be used in studies of the elderly although systematic reporting errors may bias effect estimates. As overweight individuals tend to under-report and the short and underweight tend to over-report, studies investigating associations of disease with height and weight using self-reported measures will underestimate effects. The weak associations between childhood and adult BMI indicate that associations between childhood adiposity and adult cardiovascular disease found in this cohort may reflect the specific effect of childhood overweight, rather than its persistence into adulthood. This suggests that avoidance of adiposity may be as important in childhood as in adulthood.

The effects of dietary supplementation on growth and adult mortality: a re-analysis and follow-up of a pre-war study

The aim of this study was to re-analyse a diet supplementation study conducted in the 1930s and investigate the effects of food supplementation on children's growth and later adult mortality. A non-randomised controlled trial was carried out in eight of the sixteen centres participating in the Carnegie Survey of Diet and Health in pre-war Britain (1937-39). Food supplements were given for 12 months either at school or as food parcels sent to the family home. 545 children aged 2-14 received food supplements and 494 children of a similar age acted as their controls. The children came from 465 families. The increase in childhood height and its components-leg length and trunk length-over 12 months follow-up were measured. Mortality from all causes over 60 years follow-up to 1998 was also assessed. There were important differences between fed and control children at baseline. Supplemented children came from larger families with poorer diets and most were examined, on average, 12 days later than control children. After adjustment for baseline imbalances those receiving supplements increased in height by 3.7 mm (95% CI 1.9-5.5) more than the controls. After adjustment, most of the difference in growth appeared to arise as a result of increases in leg length. After adjustment for confounding factors measured in childhood, no significant effect of childhood food supplements on adult mortality was seen. The age-adjusted hazard ratio for all cause mortality was higher in the supplemented compared to control subjects: 1.13 95% CI (0.77-1.64). We found that provision of childhood food supplements led to increased growth amongst supplemented children. The increases in height in this study were mainly as a result of increases in leg length and are similar to those found in a more recent randomised trial in South Wales. Whilst other analyses suggest that childhood height is important in predicting adult mortality patterns, we found no significant effect of childhood food supplements on adult mortality patterns in this study, although the study lacked statistical power to detect small but, nevertheless, important differences in mortality. Larger randomised trials with long term follow-up would be required to investigate the impact of childhood food supplementation on adult health.

Childhood socioeconomic position and adult cardiovascular mortality: the Boyd Orr Cohort

The relation between childhood socioeconomic position and adult cardiovascular mortality is examined in 3,750 individuals whose families took part in the Carnegie survey of family diet and health in England and Scotland between 1937 and 1939. The trend in coronary heart disease mortality across social position groups was not statistically significant at conventional levels (p = 0.12), while a strong linear trend was seen for stroke mortality (p = 0.01). Adjustment for the Townsend deprivation index of area of residence during adult life did not materially alter these findings, indicating that the effects of socioeconomic influences upon particular cardiovascular diseases differ according to the age at which they are experienced.

Separating in-utero and postnatal influences on later disease

Associations of birthweight with leg length and trunk length are similar. Childhood exposures rather than in-utero programming may underlie specific associations seen between leg length and mortality.