Mortality and cancer incidence in UK military veterans involved in human experiments at Porton Down: 48-year follow-up

BACKGROUND

We investigated whether military personnel involved in chemical warfare agent research at Porton Down had increased rates of mortality or cancer incidence.

METHODS

This was a historical cohort study comprising male UK veterans who participated in the 'Service Volunteer Programme', 1941-89, identified from Porton Down experiment books, and a comparison group of similar 'non-Porton Down' veterans identified from military personnel files. Of 19 233 records retrieved for each group, 18 133 (94%) Porton Down and 17 591 (92%) non-Porton Down were included in our analytical sample. Mortality and cancer incidence data were obtained from national registries up to December 2019.

RESULTS

Over a median follow-up of 48.1 years, 10 935 Porton Down veterans (60.3%) and 10 658 non-Porton Down veterans (60.6%) had died. After adjustment for age, year of birth and military service characteristics, overall, Porton Down veterans had a 6% higher rate of all-cause mortality compared with non-Porton Down veterans [hazard ratio (HR) = 1.06, 95% confidence interval (CI) 1.03-1.09]. For cause-specific mortality, Porton Down veterans had higher rates of death from genitourinary diseases (HR = 1.34, 95% CI 1.05-1.70) and deaths attributable to alcohol (HR = 1.44, 95% CI 1.07-1.94), with weaker associations observed for deaths from infectious and parasitic diseases (HR = 1.32, 95% CI 0.99-1.78), lung cancer (HR = 1.10, 95% CI 1.01-1.20) and external causes (HR = 1.15, 95% CI 1.00-1.32). Associations with all-cause mortality were stronger for veterans who attended Porton Down between 1960 and 1964 (HR = 1.34, 95% CI 1.19-1.50); likelihood-ratio test, P = 0.006. There was no association between attendance at Porton Down and overall cancer incidence (HR = 1.00, 95% CI 0.95-1.03).

CONCLUSIONS

Overall, mortality rates were slightly higher in Porton Down veterans, but there was no difference in cancer incidence. Associations for mortality were stronger in Porton Down veterans who attended in the early 1960s.

The Impact of Prehabilitation on Patient Outcomes in Hepatobiliary, Colorectal, and Upper Gastrointestinal Cancer Surgery: A PRISMA-Accordant Meta-analysis

OBJECTIVE

To determine the impact of prehabilitation on hospital length of stay, functional capacity, complications, and mortality after surgery in patients with hepatobiliary, colorectal, and upper gastrointestinal cancer.

BACKGROUND

"Prehabilitation" encompasses exercise, nutrition, and psychosocial interventions to optimize health before surgery. The benefits of prehabilitation are ill-defined.

METHODS

Medline, Embase and Cochrane Databases were searched systematically for the terms "prehabilitation AND exercise," "perioperative care AND cancer surgery," and "colorectal AND hepatobiliary AND hepatopancreatobiliary AND esophagogastric AND recovery AND outcomes." Primary outcomes analyzed were hospital length of stay, functional capacity, significant postoperative complications (Clavien Dindo ≥ III), and mortality. A meta-analysis was conducted on the effect of all-modality prehabilitation for patients with colorectal, hepatopancreatobiliary and upper gastrointestinal cancer surgery using the raw mean difference, risk difference, and a random-effects model.

RESULTS

Three hundred and seventy seven original titles were identified. Fifteen studies (randomized controlled trials; n = 9 and uncontrolled trials; n = 6) were included in the meta-analysis. Prehabilitation reduced hospital length of stay by 1.78 days versus standard care (95% CI: -3.36, -0.20, P < 0.05). There was no significant difference in functional capacity with prehabilitation determined using the 6-minute walk test (P = 0.816) and no significant reduction in postoperative complications (P = 0.378) or mortality rates (P = 0.114).

CONCLUSIONS

Prehabilitation was associated with reduced hospital length of stay but had no effect on functional capacity, postoperative complications, or mortality rates. Thus, prehabilitation should be recommended to accelerate recovery from cancer surgery, demonstrated by reduced hospital length of stay.

The effect of individual-level factors in survival prognosis for colorectal cancer in Malaysia

Background: In Malaysia, colorectal cancer is the second most common type of cancer for both sexes, represents 10.2% of total cancer cases in Malaysia. This study aims to identify the effect of individual-level factors on survival prognosis for patients with colorectal cancer in Malaysia.Methods: The study involved 4412 of colorectal cancer patients in Malaysia with histologically verified primary colorectal cancer, diagnosed between 2008 and 2013 (ICD-10, C18-C20), recorded in the database of National Cancer Patient Registry- Colorectal Cancer (NCPR-CC) Malaysia. We investigated the effect of individual characteristics such as age, gender, education as well as clinical characteristics such as cancer staging, cancer site and treatment modalities on survival prognosis after a diagnosis of colorectal cancer using a Cox regression survival model.Results: Patients diagnosed at stage IV had an almost 6-fold greater risk of dying from colorectal cancer than those with stage I. Age, third-degree education, poor tumour differentiation, the presence of distant metastases and receiving ‘other’ treatments were the other factors that increased the risk of death for colorectal cancer patients in Malaysian population.Conclusions: Our analysis revealed that the severity of the disease lead to poor prognosis in colorectal cancer in the population after adjusting for other individual characteristics. Health education programs targeting high risk group and emphasizing the importance of early detection of cancer as well as knowledge on the importance of cancer treatment should be implemented. Formulation of a better screening program needs to be extended so that it is a genuinely national program.

Factors associated with length of stay in care homes: a systematic review of international literature

BACKGROUND

A number of studies have explored factors associated with resident length of stay in care homes; however the findings of these studies have not been synthesized. The aim of this paper is to provide a systematic review of factors associated with length of stay until death and the strength of evidence supporting each of these factors.

METHODOLOGY

This is a systematic review; databases included MEDLINE, EMBASE, PsycINFO, CINAHL, Proquest, the Cochrane Library and Web of Science were searched. Observational studies, either prospective or retrospective, that explored multiple factors associated with length of stay until death in care homes were included. Studies that met the inclusion criteria were sourced, data extracted and assessed for quality. Data synthesis combined the direction and significance of association with the quality of the study, resulting in strong, moderate, weak or inconclusive evidence for each factor identified.

RESULTS

Forty-seven studies were identified as meeting the inclusion criteria. After quality assessment, 14 studies were judged to be of a high quality, 31 of a moderate quality and 2 of a low quality. Three factors had strong evidence to support their association with shorter lengths of stay: shortness of breath, receipt of oxygen therapy and admission to a facility providing nursing care.

CONCLUSIONS

This review summarized the factors associated with length of stay. It found stronger evidence for physical functioning being associated with shorter lengths of stay than for cognitive functioning. An understanding of expected length of stay for older adults admitted to a care home is important for estimating lifetime costs and the implications of reforming funding arrangements for social care. Further research is needed to explore heterogeneity in this area.

The change of Barthel Index scores from the time of discharge until 3-month post-discharge among acute stroke patients in Malaysia: A random intercept model

Background

Acute stroke results in functional disability measurable using the well-known Barthel Index. The objectives of the study are to describe the change in the Barthel Index score and to model the prognostic factors for Barthel Index change from discharge up to 3 months post-discharge using the random intercept model among patients with acute first ever stroke in Kelantan, Malaysia.

Methods

A total 98 in-hospital first ever acute stroke patients were recruited, and their Barthel Index scores were measured at the time of discharge, at 1 month and 3 months post-discharge. The Barthel Index was scored through telephone interviews. We employed the random intercept model from linear mixed effect regression to model the change of Barthel Index scores during the three months intervals. The prognostic factors included in the model were acute stroke subtypes, age, sex and time of measurement (at discharge, at 1 month and at 3 month post-discharge).

Results

The crude mean Barthel Index scores showed an increased trend. The crude mean Barthel Index at the time of discharge, at 1-month post-discharge and 3 months post-discharge were 35.1 (SD = 39.4), 64.4 (SD = 39.5) and 68.8 (SD = 38.9) respectively. Over the same period, the adjusted mean Barthel Index scores estimated from the linear mixed effect model increased from 39.6 to 66.9 to 73.2. The adjusted mean Barthel Index scores decreased as the age increased, and haemorrhagic stroke patients had lower adjusted mean Barthel Index scores compared to the ischaemic stroke patients.

Conclusion

Overall, the crude and adjusted mean Barthel Index scores increase from the time of discharge up to 3-month post-discharge among acute stroke patients. Time after discharge, age and stroke subtypes are the significant prognostic factors for Barthel Index score changes over the period of 3 months.

Differences in survival among adults with HIV-associated Kaposi's sarcoma during routine HIV treatment initiation in Zomba district, Malawi: a retrospective cohort analysis

Background

The HIV epidemic is a major public health concern throughout Africa. Malawi is one of the worst affected countries in sub-Saharan Africa with a 2014 national HIV prevalence currently estimated at 10% (9.3-10.8%) by UNAIDS. Study reports, largely in the African setting comparing outcomes in HIV patients with and without Kaposi's sarcoma (KS) indicate poor prognosis and poor health outcomes amongst HIV+KS patients. Understanding the mortality risk in this patient group could help improve patient management and care.

Methods

Using data for the 559 adult HIV+KS patients who started ART between 2004 and September 2011 at Zomba clinic in Malawi, we estimated relative hazard ratios for all-cause mortality by controlling for age, sex, TB status, occupation, date of starting treatment and distance to the HIV+KS clinic.

Results

Patients with tuberculosis (95% CI: 1.05-4.65) and patients who started ART before 2008 (95% CI: 0.34-0.81) were at significantly greater risk of dying. A random-effects Cox model with Log-Gaussian frailties adequately described the variation in the hazard for mortality.

Conclusion

The year of starting ART and TB status significantly affected survival among HIV+KS patients. A sub-population analysis of this kind can inform an efficient triage system for managing vulnerable patients.

Childhood Malnutrition and Its Determinants among Under-Five Children in Ghana

BACKGROUND

Childhood malnutrition adversely affects short- and long-term health and economic well-being of children. Malnutrition is a global challenge and accounts for around 40% of under-five mortality in Ghana. Limited studies are available indicating determinants of malnutrition among children. This study investigates prevalence and determinants of malnutrition among children under-five with the aim of providing advice to policymakers and other stakeholders responsible for the health and nutrition of children.

METHODS

The study used data from the 2008 Ghana Demographic and Health Survey (GDHS). Analyses were conducted on 2083 children under 5 years old nested within 1641 households with eligible anthropometric measurements, using multilevel regression analysis. Results from the multilevel models were used to compute probabilities of malnutrition.

RESULTS

This study observed that 588 (28%), 276 (13%), and 176 (8%) of the children were moderately 'stunted', moderately 'underweight', and moderately 'wasted' respectively. Older ages are associated with increased risk of stunting and underweight. Longer breast-feeding duration, multiple births, experience of diarrhoeal episodes, small size at birth, absence of toilet facilities in households, poor households, and mothers who are not covered by national health insurance are associated with increased risk of malnutrition. Increase in mother's years of education and body mass index are associated with decreased malnutrition. Strong residual household-level variations in childhood nutritional outcomes were found.

CONCLUSION

Policies and intervention strategies aimed at improving childhood nutrition and health should address the risk factors identified and the need to search for additional risk factors that might account for the unexplained household-level variations.

Seasonal Influenza Vaccination amongst Medical Students: A Social Network Analysis Based on a Cross-Sectional Study

Introduction

The Chief Medical Officer for England recommends that healthcare workers have a seasonal influenza vaccination in an attempt to protect both patients and NHS staff. Despite this, many healthcare workers do not have a seasonal influenza vaccination. Social network analysis is a well-established research approach that looks at individuals in the context of their social connections. We examine the effects of social networks on influenza vaccination decision and disease dynamics.

Methods

We used a social network analysis approach to look at vaccination distribution within the network of the Lancaster Medical School students and combined these data with the students’ beliefs about vaccination behaviours. We then developed a model which simulated influenza outbreaks to study the effects of preferentially vaccinating individuals within this network.

Results

Of the 253 eligible students, 217 (86%) provided relational data, and 65% of responders had received a seasonal influenza vaccination. Students who were vaccinated were more likely to think other medical students were vaccinated. However, there was no clustering of vaccinated individuals within the medical student social network. The influenza simulation model demonstrated that vaccination of well-connected individuals may have a disproportional effect on disease dynamics.

Conclusions

This medical student population exhibited vaccination coverage levels similar to those seen in other healthcare groups but below recommendations. However, in this population, a lack of vaccination clustering might provide natural protection from influenza outbreaks. An individual student’s perception of the vaccination coverage amongst their peers appears to correlate with their own decision to vaccinate, but the directionality of this relationship is not clear. When looking at the spread of disease within a population it is important to include social structures alongside vaccination data. Social networks influence disease epidemiology and vaccination campaigns designed with information from social networks could be a future target for policy makers.

Residential distance at birth from overhead high-voltage powerlines: childhood cancer risk in Britain 1962-2008

Background:

We extend our previous study of childhood leukaemia and proximity to high-voltage powerlines by including more recent data and cases and controls from Scotland, by considering 132-kV powerlines as well as 275 and 400 kV and by looking at greater distances from the powerlines.

Methods:

Case–control study using 53 515 children from the National Registry of Childhood Tumours 1962–2008, matched controls, and calculated distances of mother's address at child's birth to powerlines at 132, 275, and 400 kV in England, Wales and Scotland.

Results:

Our previous finding of an excess risk for leukaemia at distances out to 600 m declines over time. Relative risk and 95% confidence interval for leukaemia, 0–199 m compared with>1000 m, all voltages: 1960s 4.50 (0.97–20.83), 2000s 0.71 (0.49–1.03), aggregate over whole period 1.12 (0.90–1.38). Increased risk, albeit less strong, may also be present for 132-kV lines. Increased risk does not extend beyond 600 m for lines of any voltage.

Conclusions:

A risk declining over time is unlikely to arise from any physical effect of the powerlines and is more likely to be the result of changing population characteristics among those living near powerlines.

Case-control study of paternal occupation and social class with risk of childhood central nervous system tumours in Great Britain, 1962-2006

BACKGROUND

Paternal occupational exposures have been proposed as a risk factor for childhood central nervous system (CNS) tumours. This study investigates possible associations between paternal occupational exposure and childhood CNS tumours in Great Britain.

METHODS

The National Registry of Childhood Tumours provided all cases of childhood CNS tumours born and diagnosed in Great Britain from 1962 to 2006. Controls without cancer were matched on sex, period of birth and birth registration sub-district. Fathers' occupations were assigned to one or more of 33 exposure groups. A measure of social class was also derived from father's occupation at the time of the child's birth.

RESULTS

Of 11 119 cases of CNS tumours, 5 722 (51%) were astrocytomas or other gliomas, 2 286 (21%) were embryonal and 985 (9%) were ependymomas. There was an increased risk for CNS tumours overall with exposure to animals, odds ratio (OR) 1.40 (95% confidence intervals (CIs) 1.01, 1.94) and, after adjustment for occupational social class (OSC), with exposure to lead, OR 1.18 (1.01, 1.39). Exposure to metal-working oil mists was associated with reduced risk of CNS tumours, both before and after adjustment for OSC, OR 0.87 (0.75, 0.99).Risk of ependymomas was raised for exposure to solvents, OR 1.73 (1.02,2.92). For astrocytomas and other gliomas, risk was raised with high social contact, although this was only statistically significant before adjustment for OSC, OR 1.15 (1.01,1.31). Exposure to paints and metals appeared to reduce the risk of astrocytomas and embryonal tumours, respectively. However, as these results were the result of a number of statistical tests, it is possible they were generated by chance.Higher social class was a risk factor for all CNS tumours, OR 0.97 (0.95, 0.99). This was driven by increased risk for higher social classes within the major subtype astrocytoma, OR 0.95 (0.91, 0.98).

CONCLUSION

Our results provide little evidence that paternal occupation is a significant risk factor for childhood CNS tumours, either overall or for specific subtypes. However, these analyses suggest that OSC of the father may be associated with risk of some childhood CNS cancers.

Spatial analysis of health effects of large industrial incinerators in England, 1998-2008: a study using matched case-control areas

OBJECTIVES

To assess whether residential proximity to industrial incinerators in England is associated with increased risk of cancer incidence and mortality.

DESIGN

Retrospective study using matched case-control areas.

SETTING

Five circular regions of radius 10 km near industrial incinerators in England (case regions) and five matched control regions, 1998-2008.

PARTICIPANTS

All cases of diseases of interest within the circular areas.

PRIMARY AND SECONDARY OUTCOME MEASURES

Counts of childhood cancer incidence (<15 years); childhood leukaemia incidence (<15 years); leukaemia incidence; liver cancer incidence; lung cancer incidence; non-Hodgkin's lymphoma incidence; all-cause mortality; infant mortality (<1 year) and liver cancer mortality.

RESULTS

The estimated relative risks for case circles versus control circles for the nine outcomes considered  range from 0.94 to 1.14, and show neither elevated risk in case circles compared to control areas nor elevated risk with proximity to incinerators within case circles.

CONCLUSIONS

This study applies statistical methods for analysing spatially referenced health outcome data in regions with a hypothesised exposure relative to matched regions with no such exposure. There is no evidence of elevated risk of cancer incidence or mortality in the vicinity of large industrial incinerators in England.

Cancer morbidity in British military veterans included in chemical warfare agent experiments at Porton Down: cohort study

OBJECTIVE

To determine cancer morbidity in members of the armed forces who took part in tests of chemical warfare agents from 1941 to 1989.

DESIGN

Historical cohort study, with cohort members followed up to December 2004.

DATA SOURCE

Archive of UK government research facility at Porton Down, UK military personnel records, and national death and cancer records.

PARTICIPANTS

All veterans included in the cohort study of mortality, excluding those known to have died or been lost to follow-up before 1 January 1971 when the UK cancer registration system commenced: 17,013 male members of the UK armed forces who took part in tests (Porton Down veterans) and a similar group of 16,520 men who did not (non-Porton Down veterans).

MAIN OUTCOME MEASURES

Cancer morbidity in each group of veterans; rate ratios, with 95% confidence intervals, adjusted for age group and calendar period.

RESULTS

3457 cancers were reported in the Porton Down veterans compared with 3380 cancers in the non-Porton Down veterans. While overall cancer morbidity was the same in both groups (rate ratio 1.00, 95% confidence interval 0.95 to 1.05), Porton Down veterans had higher rates of ill defined malignant neoplasms (1.12, 1.02 to 1.22), in situ neoplasms (1.45, 1.06 to 2.00), and those of uncertain or unknown behaviour (1.32, 1.01 to 1.73).

CONCLUSION

Overall cancer morbidity in Porton Down veterans was no different from that in non-Porton Down veterans.

Mortality in British military participants in human experimental research into chemical warfare agents at Porton Down: cohort study

OBJECTIVE

To investigate any long term effects on mortality in participants in experimental research related to chemical warfare agents from 1941 to 1989.

DESIGN

Historical cohort study. Data sources Archive of UK government research facility at Porton Down, UK military personnel records, and national death and cancer records. Participants 18,276 male members of the UK armed forces who had spent one or more short periods (median 4 days between first and last test) at Porton Down and a comparison group of 17,600 non-Porton Down veterans followed to 31 December 2004.

MAIN OUTCOME MEASURES

Mortality rate ratio of Porton Down compared with non-Porton Down veterans and standardised mortality ratio of each veteran group compared with the general population. Both ratios adjusted for age group and calendar period.

RESULTS

Porton Down veterans were similar to non-Porton Down veterans in year of enlistment (median 1951) but had longer military service (median 6.2 v 5.0 years). After a median follow-up of 43 years, 40% (7306) of Porton Down and 39% (6900) of non-Porton Down veterans had died. All cause mortality was slightly greater in Porton Down veterans (rate ratio 1.06, 95% confidence interval 1.03 to 1.10, P<0.001), more so for deaths outside the UK (1.26, 1.09 to 1.46). Of 12 cause specific groups examined, rate ratios in Porton Down veterans were increased for deaths attributed to infectious and parasitic (1.57, 1.07 to 2.29), genitourinary (1.46, 1.04 to 2.04), circulatory (1.07, 1.01 to 1.12), and external (non-medical) (1.17, 1.00 to 1.37) causes and decreased for deaths attributed to in situ, benign, and unspecified neoplasms (0.60, 0.37 to 0.99). There was no clear relation between type of chemical exposure and cause specific mortality. The mortality in both groups of veterans was lower than that in the general population (standardised mortality ratio 0.88, 0.85 to 0.90; 0.82, 0.80 to 0.84).

CONCLUSIONS

Mortality was slightly higher in Porton Down than non-Porton Down veterans. With lack of information on other important factors, such as smoking or service overseas, it is not possible to attribute the small excess mortality to chemical exposures at Porton Down.

Childhood leukaemia near British nuclear installations: methodological issues and recent results

In 2008, the German Childhood Cancer Registry published the results of the Kinderkrebs in der Umgebung von Kernkraftwerken (KiKK) study of childhood cancer and leukaemia around German nuclear power stations. The positive findings appeared to conflict with the results of a recent British analysis carried out by the Committee on Medical Aspects of Radiation in the Environment (COMARE), published in 2005. The present paper first describes the COMARE study, which was based on data from the National Registry of Children's Tumours (NRCT); in particular, the methodology used in this study is described. Although the results of the COMARE study were negative for childhood leukaemia, this apparent discrepancy could be accounted for by a number of differences in approach, especially those relating to the distances from the power stations and the ages of the children studied. The present study was designed to match the KiKK study as far as possible. The incidence observed (18 cases within 5 km against 14.58 expected, p = 0.21) was not significantly raised. The risk estimate for proximity in the regression fitted was actually negative, though the confidence intervals involved are so wide that the difference from that reported in the KiKK study is only marginally statistically significant (p = 0.063).

Dispersion of As and selected heavy metals around a coal-burning power station in central Slovakia

A power station in central Slovakia emitted arsenic (As) in large quantities for over 30 years as a result of burning As-rich brown coal. Nowadays emissions of As are low. Over the lifetime of the plant's operation over 3000 tonne of As have been emitted into the environment. This paper aims to examine the concentrations of As in the soil around the power station, and also to investigate whether the coal burnt in the plant, and consequently the emissions from it, contained raised levels of six further heavy metals. Soil concentrations were compared to ground level air As concentrations predicted by an air dispersion model. Coal samples were taken from the power station and analysed to determine concentrations of As, Zn, Pb, Cu, Cr, Ni and Cd. Soil samples (n=113) were taken up to 12 km from the plant along a transect designed to follow the valley floor in which the power station is situated. Soil samples were analysed for concentrations of those elements for which coal was tested. Concentrations of As in coal were high (AM 518 mug/g). Those of other heavy metals were, in general, low. Concentrations of soil As were substantially raised in the near vicinity of the plant but decreased within 5 km to concentrations similar to those in the rest of the district. Overall, levels within 10 km of the plant were slightly above those recommended for residential levels in the UK. Soil concentrations of other heavy metals were higher in the vicinity of the plant but none, overall was raised. Comparison of results from a previous air dispersion model of ground level air arsenic concentrations showed a moderate correlation (r=0.6) between modelled and measured values. Over its period of operation the power plant has contributed to raised levels of soil As in the local soils, though not substantially of other elements. Though now airborne As emissions are controlled, concern remains regarding soil arsenic concentrations and fugitive emissions from the plant that could be contributing to exposure of the local population and of the workforce.

Increase in mortality rates from intrahepatic cholangiocarcinoma in England and Wales 1968-1998

BACKGROUND

The age standardised mortality rate per 100 000 population for all causes of liver tumours (International Classification of Disease 9 (ICD-9) 155) has almost doubled in England and Wales during the period 1979-1996. We further analysed the mortality statistics to determine which anatomical subcategories were involved.

METHODS

Mortality statistics for liver tumours of ICD-9 155, 156, and subcategories, and for tumours of the pancreas (ICD-9 157), in England and Wales were investigated from the Office for National Statistics, London, from 1968 to 1996 inclusive. Data for 1997 and 1998 were also available on intrahepatic cholangiocarcinomas.

RESULTS

There has been a marked rise in age standardised mortality rates for intrahepatic cholangiocarcinoma. Since 1993, it represents the commonest recorded cause of liver tumour related death in England and Wales. This is evident in age groups older than 45 years. In contrast, mortality trends from other primary liver tumours, including hepatocellular carcinoma, were unremarkable.

CONCLUSIONS

The observed increase in mortality from intrahepatic cholangiocarcinoma may represent better case ascertainment and diagnosis due to improved diagnostic imaging, use of image guided biopsies, or increased use of ERCP. However, the trend started before ERCP was introduced nationally, mortality rates have continued to increase steadily thereafter, and there is no clear evidence that diagnostic transfers easily explains the findings. Alternatively, these observations may represent a true increase in intrahepatic bile duct tumours. Epidemiological studies are required to determine whether there is any geographical clustering of cases around the UK.