Terminologies matter - the case of ICNP and SNOMED-CT

Terminologies can seem very abstract to end-users. While most health professionals will be familiar with some terminologies (for example MeSH (Medical Subject Headings), the controlled vocabulary thesaurus used for indexing articles for PubMed or ICD-10, WHO's terminology for disease coding), fewer will be aware of the depth and range of terminologies used in healthcare, nor of the central importance of multilingual standard terminologies in health care interoperability. Following a brief introduction to the use of terminologies, the integration of the International Classification for Nursing Practice (ICNP) the Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT) will be presented, as an example of the use of terminologies, and their ongoing curation, maintenance and development.

Predicting low cognitive ability at age 5 using machine learning methods and birth cohort data

Background

Early intervention is essential to address disparities in cognitive development. Current developmental screening will not detect the vast majority of children who go on to have below average cognitive ability at school age. In this study, we applied the random forest (RF) algorithm, a highly interpretable machine learning method, to birth-cohort data to train a model to predict low cognitive ability at 5 years of age using perinatal features.

Methods

Data was from 1,070 participants in the Irish population-based BASELINE birth cohort. A RF model was trained to predict an intelligence quotient (IQ) score <90 at age 5 years using a broad selection of maternal, infant, birth, and sociodemographic features, all of which could be easily measured at a population level in the perinatal period. Feature importance was examined using mean decrease in Gini impurity, mean decrease in accuracy, and mean minimal depth. Recursive feature elimination was used to develop a parsimonious model. Internal validation was performed using 10-fold cross validation repeated 5 times.

Results

The most predictive features for low cognitive ability at 5 years of age were the total years of maternal schooling, infant Apgar score at 1 minute, socioeconomic index, maternal BMI, and units of alcohol consumed in the first trimester. A parsimonious RF model based on 11 features showed excellent predictive ability, with a sensitivity of 0.89 and a specificity of 0.98, providing a foundation suitable for external validation in an unseen cohort.

Conclusions

Machine learning approaches to large existing datasets can provide accurate feature selection to improve risk prediction. Further validation of this model is required in additional cohorts, representative of the general population. Accurate risk prediction can facilitate targeted screening and intervention.

Key messages

• The application of machine learning to large population-based data can improve feature selection and accuracy in risk prediction models.

• Accurate risk prediction may enable early intervention to address disparities in cognitive development. Individual interventions must occur in conjunction with population level policy changes.

Complexities and complications of extreme obesity

Obesity is a common chronic disorder and has detrimental long-term consequences if left untreated. Herein, we report a case of a young lady who suffered from morbid obesity and many of its consequences, and we present a literature review of these complications. While the cause of obesity is multifactorial, the genetic component is particularly important in the pathophysiology of marked obesity. Resistance to Leptin is considered one of the main causes of obesity. There is a unique relationship between polycystic ovary syndrome and obesity, as observed in our case. Obesity is associated with cardiovascular and lung diseases such as heart failure, thromboembolic disease, sleep apnea, and pulmonary hypertension. Our patient had cardiomegaly (730 gm) with eccentric hypertrophy of left and right ventricles. The coronary arteries and aorta were free of atherosclerosis, which is a surprising finding that relates to the mysterious phenomenon of obesity paradox. The terminal event in our young woman was multiple segmental and subsegmental pulmonary arterial thrombi/thromboemboli superimposed on chronic cardiopulmonary stress due to massive obesity.

Pathways through rehabilitation for traumatic brain injury: preliminary results from an Irish study

Background

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. In Ireland, little data exists on the number of TBI survivors or the availability of brain injury rehabilitation services. To address this, we examined nationally representative data to estimate the number of moderate to severe TBI survivors and to learn of their rehabilitation experiences.

Methods

A two-year mixed-methods, observational, cohort study was used to investigate the rehabilitation pathways of moderate to severe TBI survivors (N = 120). Participants were surveyed on two occasions six months apart using a range of standardised instruments (EQ-5D-3L, WHOQOL BREF and EBIQ). Preliminary findings from first surveys are reported.

Results

Fifty percent of participants reported having received some rehabilitation during their initial hospitalization. Following discharge, inpatient rehabilitation was recommended in 55.8% of cases (N = 67); 62.5% (N = 75) in an outpatient setting and 52.1% (N = 62) in a specialised brain injury community-based setting. Rehabilitation was not recommended in 9.2% (N = 11) of cases. Univariant analyses showed statistically significant differences between the experiences of males (N = 87) and females (N = 33) in three main elements; Isolation: males (M), mean 1.88, SD .488, females (F) mean 1.64, SD .476, (p = .015); Communication: M mean 1.85, SD .565, F mean 1.57, SD .469 (p = .012); Cognitive difficulties: M mean 1.81, SD .456, F mean 1.59, SD .426 (p = .020).

Discussion

Referrals to rehabilitation services varied substantially in this cohort of TBI survivors with evidence to suggest that, overall, males experience greater impacts on quality of life than do females. These findings support the need to, a) increase political priority and resource allocation for rehabilitation services for TBI survivors in Ireland and b) further study gender differences in TBI survivor outcome.

Key messages

Survivors of moderate to severe brain injury in Ireland have very divergent, and often inadequate experiences of rehabilitation. There is some evidence that male survivors of moderate to severe traumatic brain injury face more challenges than do female survivors.

Early cognitive ability and emotional-behavioural development in childhood

Background

Children with below average cognitive ability represent a substantial yet under-researched population for whom cognitive and social demands, which increase in complexity year by year, may pose significant challenge. This study compares trajectories in emotional-behavioural development for children with and without below average cognitive ability and examines the independent association between cognitive ability and clinically significant emotional-behavioural difficulty (EBD) in childhood.

Methods

Participants consist of 7,000 children and caregivers from the Growing Up in Ireland survey. Cognitive ability was measured at age 3 using the Picture Similarities Scale. A t-score 1-2 standard deviations below the mean was categorised as below average cognitive ability (n = 767), and scores above this as average/above (n = 6418). EBD was measured using the Strengths and Difficulties Questionnaire (SDQ) at age 3,5 and 9 years. A generalised linear mixed model with repeated measures was used to examine the relationship between cognitive ability and SDQ. Logistic regression examined the independent association between cognitive ability and clinically significant EBDs between age 3-9 years.

Results

The change in mean total SDQ score over time differed significantly between the cognitive ability groups (F(2)=8·817, p < 0·001). Between 5-9 years, there was no change in SDQ for those with average/above cognitive ability. For those with below average ability there was a significant increase of 0·48 points (95% CI 0·34 - 0·62, p < 0·001). After adjustment, the odds of a clinically significant EBD between age 3-9 were 1.4 times higher for those with below average cognitive ability (AOR 1.39, 95% CI 1.17-1.66, p < 0.001).

Conclusions

Children with below average cognitive ability are at higher risk of EBD in childhood. A scalable method of early identification should be a research priority for public health, enabling early intervention for cognitive and adaptive outcomes.

Key messages

Children with below average cognitive ability experience higher mean emotional-behavioural difficulty scores throughout childhood compared to those with average or above cognitive ability. Early life is a critical period for cognitive development. Public health research must focus on the early identification of at risk children to enable cognitive and adaptive functioning interventions.

Predictive utility of the ages and stages questionnaire for below average cognitive ability at age 5

Background

The first 1000 days of life are a period of unique sensitivity and plasticity during which critical cognitive abilities are formed. For children at risk of later cognitive difficulties, this period is the ideal target for early intervention initiatives. Routine developmental screening tools aim to identify infants who would benefit from early intervention. While these tools have been validated for detecting children with more severe neurodevelopmental disorders, their ability to identify the larger proportion with below average cognitive ability has not been sufficiently explored. The aim of this study was to examine the predictive utility of the Ages and Stages Questionnaire (ASQ), for identifying children with later below average cognitive function.

Methods

The study population (n = 8260) is formed from two national cohort studies, the Growing Up in Ireland Infant cohort (n = 7,444) and the Cork BASELINE cohort (n = 816). The ASQ was completed at 8- and 24-months respectively. Cognitive assessments were performed at age 5. Those scoring <1 standard deviation below the mean were categorised as below average cognitive ability. Applying the currently used onward referral criterion (one fail in any domain) the sensitivity, specificity, positive and negative predictive values of the 8- and 24-month ASQ for detecting children with later below average cognitive function were calculated.

Results

The sensitivities of the 8-month and 24-month ASQ for detecting children with below average cognitive ability were 16.4% (95% CI 14.0-19.0) and 20.8% (95% CI 13.6-30.2) respectively, with specificity of 92.0% (95% CI 91.3-92.6) and 91.1% (95% CI 88.6-93.2).

Conclusions

The ASQ has a low sensitivity for identifying children with below average cognitive ability at age 5. The findings of this study suggest that if we are to intervene early in the developmental trajectory for children with below average cognitive ability alternative methods of identifying high risk infants are needed.

Key messages

The ages and stages questionnaire, a widely used routine infant developmental screening tool, has a low sensitivity between 16%-21% for detecting later below average cognitive ability. To enable intervention in the first 1000 days of life for children at risk of later below average cognitive ability alternative methods of screening and risk identification require investigation.

Accuracy of identifcation of traumatic brain injuries in routine hospital data

Background

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Much work on the epidemiology of TBI uses routinely collected health care data. There is no separate code for TBI in ICD-10, a common coding system for acute care. One reason for reported variations in TBI prevalence between countries is differences in the identification of TBI from routine data. This study assessed the performance of an Australian classification system (Pozzatto et al 2019), using a standardised approach to ICD-10 codes to identify cases of likely TBI in routine hospital discharge data.

Methods

The original study was done on hospital data from New South Wales. We replicated their approach using Irish hospital data, held by Health Intelligence, from 2013 to 2020. Cases not classified as TBI by this system, but with codes, such as loss-of-consciousness, skull fracture or intra-cranial injury were manually reviewed.

Results

All 98,419 discharges with any code in S00 to S99 were reviewed. 27,851 (28.3%) had a skull fracture or intracranial injury. 12,106 (12.3%) had loss-of-consciousness and/or post-traumatic amnesia. 11,976 (98.9%) of these (12.2% of the total) had either a skull fracture or an intra-cranial injury reported. 26,085 (26.5%) of the original 98,419 cases were classified as TBI using the NSW classification. Manual review of 1.3% (1,356) cases added a maximum of 0.32% (321) further possible cases of TBI, suggesting a sensitivity of the classification of 98.8% (95% CI 98.6% - 98.9%).

Discussion

The main limitation is that it is not possible to identify false positive cases - those coded as TBI, but where no TBI was present. This approach to identifying TBI works well, and is feasible for wider implementation. It provides comparability between different studies.

Pozzato I et al. (2019), Epidemiology of hospitalised traumatic brain injury in the state of New South Wales, Australia: a population-based study. Australian and New Zealand Journal of Public Health. 2019

Key messages

There are problems comparing data on TBI between different countries because no single code for TBI exists in ICD-10, and this is a real challenge for epidemiologists and health services researchers. The use of an agreed system, developed in Australia, for recoding injury data to identify TBI has promise, and shows excellent sensitivity in two countries.

Use and impact of smartphone apps in mental health

As smartphone usage is more and more ubiquitous, the app market is flourishing in all fields, including health. Indeed, the availability and use of smartphone apps (SAs) in health has exponentially grown in recent years. It has been estimated that in 2018 there were over 97,000 health apps available and that, 15% and 8% of US phone users aged 18-29 and 30-49 years respectively had health apps installed on their mobile devices. Health apps might potentially support people health paths in multiple ways: channeling health education, enabling personal health data tracking, self-monitoring and goals setting, facilitating access to health records or compliance to treatment, fostering effective communication with healthcare providers and health services, as well as supporting clinical decision-making.

Despite such large potential, still scant evidence is available on the impact of SAs on clinical outcomes in different fields of medicine, including mental health. With an estimated prevalence of around 450 million people currently suffering from mental disorders and 1 in 4 people in the world affected at some point in own life, mental disorders are a leading cause of ill-health and disability worldwide whose prevention and care might be enhanced by mHealth technology.

The general aim of the presentation is to provide an overview on the use and impact of SAs in the field of mental health. Specific objectives are: i) to present a conceptual framework on how SAs might support mental disorders prevention, diagnosis and treatment, ii) to report on SAs use in mental health in different settings, iii) to collect and pool available evidence from observational and experimental studies on the impact of SAs use on different mental health outcomes, iv) to explore the quality, effectiveness and attributes of top-rated smartphone mental health apps and lastly, v) to suggest gaps in knowledge to be filled by future research.

Visualising Q - from the bootstrap to interactive graphics

Introduction

The MIDAS (Meaningful Integration of Data Analytics and Services) project is developing a big data platform to maximize the use of health & social care data. The goal is to link data sources to support senior managers & policy makers in delivering services. The project includes 4 case studies, in 4 countries. As part of the evaluation, we need to understand the perspectives of the users, developers, and senior managers involved, and to see how these change over time. We employ Q-methodology, an objective mixed method for the study of human perspectives, to do this. In this paper we describe the use of bootstrap methods, and visualizations to assist in the execution and interpretation of the first round of our Q study.

Methods

A concourse of 36 items was developed from the literature, a logic model for the project, and a series of semi-structured interviews with project participants. Sixteen people (3 female, and 13 male) took part in the Q study, six developers, five managers, two health professionals, and 3 others. The 36 statements on the concourse were ranked online, by each participant, using the HTMLQ software, in order of their agreement with each statement. These are then subjected to a form of factor analysis, but by person, not by statement, using the qmethod package in R.

For each Q-sort 1,000 bootstrap replications were done, using sampling with replacement. A range of visualisations were prepared, using ggplot2.

Results

Visualizations of bias and variability showed modest levels of both, suggesting that the Q-method model fitted well. Interactive visualizations of the factors, and respondents, were done. These showed distinct clusters of respondents, with divergent perspectives on the project. These assisted in making final decisions, both on the number of factors to report on, and the interpretation of those factors.

Further use of advance visualisations is recommended for future Q-studies.

Funded by the European commission under contract 727721

Key messages

Q methodology is useful across many areas of public health, and is a valuable way of studying individual perspectives. Modern statistical visualisation tools can enhance the interpretation of Q methodology studies.

Q-Methodology Evaluation of a European Health Data Analytic End User Framework

Background

MIDAS (Meaningful Integration of Data Analytics and Services) project is developing a big data platform to use a wide range of health and social care data to support better policy making. As part of the project evaluation, we have used Q-methodology, a well established approach, to understand the perspectives of the individual participants on their needs and how the MIDAS system is meeting them, at its current stage of development.

Methods

We defined a concourse of 36 statements relevant to project implementation and goals, by working from a logic model for the evaluation, and structured interviews with project participants. This was delivered online to participants. Analyses were done in the qmethod package. The first q-sort was done at 14 months into the project.

Results

16 people took part, 6 developers, 5 managers, 2 health professionals and 3 others. Three factors were identified in the data. These were tentatively labelled ‘Technical optimism’, ‘End-user focus’ and ‘End-user optimism’. These loaded well onto individuals, and there were few consensus statements. There were significant differences in perspectives between different groups of participants. In particular, two of the developers held opposite perspectives to most other participants on the third perspective identified. This was drawn to the attention of the participants, and a more intensive process of communication was set-up, seeking to reduce the divergence.

Conclusions

A Q-methodological approach to evaluating the implementation of a large and complex health ICT system showed considerable divergence between the perspectives of users, developers, and managers. Such divergences can lead to project failure. Q-methodology is a valuable tool has seldom been used in public health research.

Keywords: Q-Methodology, Public Health, Data Analytics, Decision Support.

The meaningfulness of open data in Public Health and Healthcare

Background

The growing challenges and opportunities of Big Data for Public Health have revealed the potential to improve the efficiency and cost-effectiveness of public policy, for example through better targeting of resources with regard to General Practice (GP) prescribing. Open data has an important role due to its easy access and potential to complement proprietary data sources from, e.g., regional hospitals, and also itself be complemented with social data acquired by specialized approaches.

Methods

MIDAS pipeline of open source tools aiming integrating, analysing and visualising Open Data enabling health professionals and decision-makers to: (i) improve the usability of open data in combination with proprietary data through combining multiple visualisation tools in an integrated dashboard (ii) to explore the meaning of data in a global/local context based on new information using tone analysis and natural language techniques; and (iii) to have better informed decision-making based on evidence from trusted knowledge-bases. Specific data sources used have included information extracted from the biomedical database MEDLINE, worldwide news and government open data. Social media sources have also been used to gather information from the general public.

Results

Results include a strong correlation between antidepressant prescribing and economic deprivation, and a wide variation in how individual GP practices respond to demographic conditions. Automated anomaly detection based on the Local Outlier Probability has also been shown to be an easily understood and controllable approach to identifying prescribing outliers.

Conclusions

MIDAS demonstrates the significant value of open data from heterogeneous sources as basis decision-making in public health and healthcare, particularly when it is combined with proprietary or closed datasets. A key challenge in this regard is the ability to integrate and utilize data from diverse sources in a variety of formats and standards.

Key messages

MIDAS is exemplar on tackling the need for improved standards of open data, and new software architectures, tools and platforms addressing a complex ecosystem of heterogenous data sources and formats. MIDAS demonstrates the significant value of open data from heterogeneous sources as basis decision-making in public health and healthcare, particularly when combined with proprietary datasets.

Operationalisation of the European Protocol for Autism Prevalence (EPAP) for Autism Spectrum Disorder Prevalence Measurement in Ireland

The European Autism Information System project highlighted the lack of systematic and reliable data relating to the prevalence of autism spectrum disorders in Europe. A protocol for the study of ASD prevalence at European level was developed to facilitate a common format for screening and diagnosing children across the EU. This is the first study to operationalise and screen national school children for ASDs using this protocol. National school children 6-11 years (N = 7951) were screened males 54 % (N = 4268) females 46 % (N = 3683). Screening children for ASD implementing the EAIS protocol using the Social Communication Questionnaire (Rutter et al. in Social Communication Questionnaire (SCQ). Western Psychological Services, Los Angeles, ) as a first level screening instrument in a non-clinical setting of Irish national schools was demonstrated.

Neighbourhood characteristics and the incidence of first-episode psychosis and duration of untreated psychosis

BACKGROUND

The incidence of psychotic disorders varies between geographical areas and it has been hypothesized that neighbourhood-level factors may influence this variation. It is also plausible that the duration of untreated psychosis (DUP) is associated with neighbourhood characteristics. The aims of this study were to determine whether the incidence of first-episode psychosis (FEP) and the DUP are associated with the level of social deprivation, fragmentation, social capital and population density.

METHOD

All individuals with a FEP from a geographical defined catchment area over a 5-year period were included. Age-standardized incidence rates were calculated for each neighbourhood factor.

RESULTS

A total of 292 cases of FEP were included in the study and 45% had a diagnosis of a schizophrenia-spectrum disorder. The age standardized incidence rate of FEP in the most deprived area was 72.4 [95% confidence interval (CI) 26.4-162.7] per 100 000 person-years compared with 21.5 (95% CI 17.6-26.0) per 100 000 person-years in the most affluent areas. This represents a 3.4-fold increase in FEP incidence in the most deprived areas. The incidence of FEP was also increased in neighbourhoods that were more socially fragmented [incidence rate ratio (IRR) = 2.40, 95% CI 1.05-5.51, p = 0.04] and there was a trend for the incidence to be increased in neighbourhoods with lower social capital (IRR = 1.43, 95% CI 0.99-2.06, p = 0.05). The median DUP was 4 months and was higher in more socially fragmented neighbourhoods.

CONCLUSIONS

The incidence of psychotic disorders is related to neighbourhood factors and it may be useful to consider neighbourhood factors when allocating resources for early intervention services.

Patient journey to a specialist amyotrophic lateral sclerosis multidisciplinary clinic: an exploratory study

Background

The multidisciplinary approach in the management of Amyotrophic Lateral Sclerosis (ALS) has been shown to provide superior care to devolved care, with better survival, improved quality of care, and quality of life. Access to expert multidisciplinary management should be a standard for patients with ALS. This analysis explores the patient journey from symptom onset and first engagement with health services, to the initial visit to a specialist ALS Multidisciplinary Clinic (MDC) in Dublin, Ireland.

Methods

A retrospective exploratory multi-method study details the patient journey to the MDC. Data from medical interviews and systematic chart review identifies interactions with the health services and key timelines for thirty five new patients presenting with a diagnosis of ALS during a 6 month period in 2013.

Results

The time from first symptom to diagnosis was a mean of 16 months (median 13 months), with a mean interval of 19 months (median 14.6) from first symptoms to arrival at the MDC. The majority of patients were seen by a general practitioner, and subsequently by neurology services. There was an average of four contacts with health services and 4.8 investigations/tests, prior to their first Clinic visit. On the first visit to the MDC patients are linked into an integrated ‘system’ that can provide specialist care and link with voluntary, palliative and community services as required.

Conclusions

Engagement with a multidisciplinary team has implications for service utilization and quality of life of patients and their families. We have demonstrated that barriers exist that delay referral to specialist services. Comprehensive data recording and collection, using multiple data sources can reconstruct the timelines of the patient journey, which can in turn be used to identify pathways that can expedite early referral to specialist services.

Occupational exposure to endocrine disruptors and lymphoma risk in a multi-centric European study

BACKGROUND

Incidence rates of lymphoma are usually higher in men than in women, and oestrogens may protect against lymphoma.

METHODS

We evaluated occupational exposure to endocrine disrupting chemicals (EDCs) among 2457 controls and 2178 incident lymphoma cases and subtypes from the European Epilymph study.

RESULTS

Over 30 years of exposure to EDCs compared to no exposure was associated with a 24% increased risk of mature B-cell neoplasms (P-trend=0.02). Associations were observed among men, but not women.

CONCLUSIONS

Prolonged occupational exposure to endocrine disruptors seems to be moderately associated with some lymphoma subtypes.

The RICHE taxonomy - an innovative means of classification of child health research

BACKGROUND

Research outputs increase inexorably. Health is now a required element in all policies of the European Union. There is a need for a system that helps to navigate the vast body of children's health research, identify pertinent research institutions, discover ongoing and recently funded research projects and identify gaps where there is little knowledge.

METHODS

The European Commission funded the Research Inventory of Child Health in Europe (RICHE) project through the Framework 7 Programme, to identify gaps in child health research in Europe. A necessary first step was to identify and index current research, for which a website repository was created. As a basis for this task, an innovative taxonomy was necessary to encompass the many arenas of children's health and development, including subjects outside the traditional areas of children's health. Drawing inspiration from existing taxonomies, library systems and other forms of classification, a multi-axial approach was selected as the best way to encompass the many influences on children's health. Six axes were identified and their contents defined. All of the axes can be viewed and searched independently, as well as in relation to each other. The axes encompass factors and service areas that impact on children, including health, education, justice, the environment and others. This has created a system that is consistent and impartial, but adaptable to an enormous variety of uses.

RESULTS

The taxonomy has been tested and validated by a number of well-respected academics, researchers and practitioners across Europe. It forms the basis of an intuitive and accessible database. This allows research knowledge to be easily identified and for networking to take place.

CONCLUSIONS

The RICHE taxonomy facilitates retrieval of knowledge - ongoing research as well as findings - in order to inform researchers and policy makers who wish to include children's health as an element of new policy.

A meta-analysis of Hodgkin lymphoma reveals 19p13.3 TCF3 as a novel susceptibility locus

Recent genome-wide association studies (GWAS) of Hodgkin lymphoma (HL) have identified associations with genetic variation at both HLA and non-HLA loci; however, much of heritable HL susceptibility remains unexplained. Here we perform a meta-analysis of three HL GWAS totaling 1,816 cases and 7,877 controls followed by replication in an independent set of 1,281 cases and 3,218 controls to find novel risk loci. We identify a novel variant at 19p13.3 associated with HL (rs1860661; odds ratio (OR)=0.81, 95% confidence interval (95% CI) = 0.76-0.86, P(combined) = 3.5 × 10(-10)), located in intron 2 of TCF3 (also known as E2A), a regulator of B- and T-cell lineage commitment known to be involved in HL pathogenesis. This meta-analysis also notes associations between previously published loci at 2p16, 5q31, 6p31, 8q24 and 10p14 and HL subtypes. We conclude that our data suggest a link between the 19p13.3 locus, including TCF3, and HL risk.

Occupational exposure to trichloroethylene and risk of non-Hodgkin lymphoma and its major subtypes: a pooled InterLymph [correction of IinterLlymph] analysis

OBJECTIVES

We evaluated the association between occupational exposure to trichloroethylene (TCE) and risk of non-Hodgkin lymphoma (NHL) in a pooled analysis of four international case-control studies.

METHODS

Overall, the pooled study population included 3788 NHL cases and 4279 controls. Risk of NHL and its major subtypes associated with TCE exposure was calculated with unconditional logistic regression and polytomous regression analysis, adjusting by age, gender and study.

RESULTS

Risk of follicular lymphoma (FL), but not NHL overall or other subtypes, increased by probability (p=0.02) and intensity level (p=0.04), and with the combined analysis of four exposure metrics assumed as independent (p=0.004). After restricting the analysis to the most likely exposed study subjects, risk of NHL overall, FL and chronic lymphocytic leukaemia (CLL) were elevated and increased by duration of exposure (p=0.009, p=0.04 and p=0.01, respectively) and with the combined analysis of duration, frequency and intensity of exposure (p=0.004, p=0.015 and p=0.005, respectively). Although based on small numbers of exposed, risk of all the major NHL subtypes, namely diffuse large B-cell lymphoma, FL and CLL, showed increases in risk ranging 2-3.2-fold in the highest category of exposure intensity. No significant heterogeneity in risk was detected by major NHL subtypes or by study.

CONCLUSIONS

Our pooled analysis apparently supports the hypothesis of an increase in risk of specific NHL subtypes associated with occupational exposure to TCE.

Cigarette smoking and risk of Hodgkin lymphoma and its subtypes: a pooled analysis from the International Lymphoma Epidemiology Consortium (InterLymph)

BACKGROUND

The etiology of Hodgkin lymphoma (HL) remains incompletely characterized. Studies of the association between smoking and HL have yielded ambiguous results, possibly due to differences between HL subtypes.

PATIENTS AND METHODS

Through the InterLymph Consortium, 12 case-control studies regarding cigarette smoking and HL were identified. Pooled analyses on the association between smoking and HL stratified by tumor histology and Epstein-Barr virus (EBV) status were conducted using random effects models adjusted for confounders. Analyses included 3335 HL cases and 14 278 controls.

RESULTS

Overall, 54.5% of cases and 57.4% of controls were ever cigarette smokers. Compared with never smokers, ever smokers had an odds ratio (OR) of HL of 1.10 [95% confidence interval (CI) 1.01-1.21]. This increased risk reflected associations with mixed cellularity cHL (OR = 1.60, 95% CI 1.29-1.99) and EBV-positive cHL (OR = 1.81, 95% CI 1.27-2.56) among current smokers, whereas risk of nodular sclerosis (OR = 1.09, 95% CI 0.90-1.32) and EBV-negative HL (OR = 1.02, 95% CI 0.72-1.44) was not increased.

CONCLUSION

These results support the notion of etiologic heterogeneity between HL subtypes, highlighting the need for HL stratification in future studies. Even if not relevant to all subtypes, our study emphasizes that cigarette smoking should be added to the few modifiable HL risk factors identified.

Menstrual and reproductive factors, and hormonal contraception use: associations with non-Hodgkin lymphoma in a pooled analysis of InterLymph case-control studies

BACKGROUND

The two most common forms of non-Hodgkin lymphoma (NHL) exhibit different sex ratios: diffuse large B-cell lymphoma (DLBCL) occurs more frequently in men and follicular lymphoma (FL) more frequently in women. Looking among women alone, this pooled analysis explores the relationship between reproductive histories and these cancers.

MATERIALS AND METHODS

Self-reported reproductive histories from 4263 women with NHL and 5971 women without NHL were pooled across 18 case-control studies (1983-2005) from North America, Europe and Japan. Study-specific odd ratios (ORs) and confidence intervals (CIs) were estimated using logistic regression and pooled using random-effects meta-analyses.

RESULTS

Associations with reproductive factors were found for FL rather than NHL overall and DLBCL. In particular, the risk of FL decreased with increasing number of pregnancies (pooled OR(trend) = 0.88, 95% CI 0.81-0.96). FL was associated with hormonal contraception (pooled OR = 1.30, 95% CI 1.04-1.63), and risks were increased when use started after the age of 21, was used for <5 years or stopped for >20 years before diagnosis. DLBCL, on the other hand, was not associated with hormonal contraception (pooled OR = 0.87, 95% CI 0.65-1.16).

CONCLUSIONS

Hormonal contraception is associated with an increased risk of FL but not of DLBCL or NHL overall.

Cost of care for colorectal cancer in Ireland: a health care payer perspective

OBJECTIVE

Management options for colorectal cancer have expanded in recent years. We estimated average lifetime cost of care for colorectal cancer in Ireland in 2008, from the health care payer perspective.

METHOD

A decision tree model was developed in Microsoft EXCEL. Site and stage-specific treatment pathways were constructed from guidelines and validated by expert clinical opinion. Health care resource use associated with diagnosis, treatment and follow-up were obtained from the National Cancer Registry Ireland (n=1,498 cancers diagnosed during 2004-2005) and three local hospital databases (n=155, 142 and 46 cases diagnosed in 2007). Unit costs for hospitalisation, procedures, laboratory tests and radiotherapy were derived from DRG costs, hospital finance departments, clinical opinion and literature review. Chemotherapy costs were estimated from local hospital protocols, pharmacy departments and clinical opinion. Uncertainty was explored using one-way and probabilistic sensitivity analysis.

RESULTS

In 2008, the average (stage weighted) lifetime cost of managing a case of colorectal cancer was €39,607. Average costs were 16% higher for rectal (€43,502) than colon cancer (€37,417). Stage I disease was the least costly (€23,688) and stage III most costly (€48,835). Diagnostic work-up and follow-up investigations accounted for 4 and 5% of total costs, respectively. Cost estimates were most sensitive to recurrence rates and prescribing of biological agents.

CONCLUSION

This study demonstrates the value of using existing data from national and local databases in contributing to estimating the cost of managing cancer. The findings illustrate the impact of biological agents on costs of cancer care and the potential of strategies promoting earlier diagnosis to reduce health care resource utilisation and care costs.

Cost-effectiveness of population-based screening for colorectal cancer: a comparison of guaiac-based faecal occult blood testing, faecal immunochemical testing and flexible sigmoidoscopy

BACKGROUND

Several colorectal cancer-screening tests are available, but it is uncertain which provides the best balance of risks and benefits within a screening programme. We evaluated cost-effectiveness of a population-based screening programme in Ireland based on (i) biennial guaiac-based faecal occult blood testing (gFOBT) at ages 55-74, with reflex faecal immunochemical testing (FIT); (ii) biennial FIT at ages 55-74; and (iii) once-only flexible sigmoidoscopy (FSIG) at age 60.

METHODS

A state-transition model was used to estimate costs and outcomes for each screening scenario vs no screening. A third party payer perspective was adopted. Probabilistic sensitivity analyses were undertaken.

RESULTS

All scenarios would be considered highly cost-effective compared with no screening. The lowest incremental cost-effectiveness ratio (ICER vs no screening euro 589 per quality-adjusted life-year (QALY) gained) was found for FSIG, followed by FIT euro 1696) and gFOBT (euro 4428); gFOBT was dominated. Compared with FSIG, FIT was associated with greater gains in QALYs and reductions in lifetime cancer incidence and mortality, but was more costly, required considerably more colonoscopies and resulted in more complications. Results were robust to variations in parameter estimates.

CONCLUSION

Population-based screening based on FIT is expected to result in greater health gains than a policy of gFOBT (with reflex FIT) or once-only FSIG, but would require significantly more colonoscopy resources and result in more individuals experiencing adverse effects. Weighing these advantages and disadvantages presents a considerable challenge to policy makers.

Factors that influence the patient uptake of diabetic retinopathy screening

AIM

To assess whether patients were receiving regular diabetic retinopathy screening and to examine factors influencing screening uptake.

METHODS

A questionnaire covering demographics, diabetic medical history and the knowledge of and attitudes to diabetic retinopathy was administered to all adults who were due to attend diabetes clinics in two centres in Dublin, Ireland over two months in 2001/2002.

RESULTS

Of the 209 people who completed the questionaire, 169 (81%) had a dilated fundal examination within the last year. The most significant predictor for receiving screening was a previous physician recommendation about the necessity of a regular eye examination. The main barriers to receiving adequate screening were lack of knowledge regarding the need for ocular examination and the effect of mydriasis in prohibiting driving.

CONCLUSIONS

It is essential that patients are fully aware of the need for a regular eye examination. Once a physician recommends this the screening rate improves.

Pathways to services for children with cerebral palsy in Selangor and the Federal Territory, Kuala Lumpur

Cerebral Palsy (CP) describes a group of chronic conditions affecting body movement and muscle coordination caused by damage to one or more areas of the brain, occurring at any time during foetal development to infancy. This research was carried out to learn how parents of children with cerebral palsy (CP) had found and accessed services provided for them in Selangor and Kuala Lumpur. It was based in the Spastic Children's Association of Selangor and Federal Territory (SCAS&FT) among 96 of 201 parents of children who use the facilities and services provided by the SCAS&FT through questionnaires and face-to-face interviews. There was a satisfactory level of availability and accessibility of contacting and using the services provided by SCAS&FT in terms of respondent satisfaction. However, parents had varying levels of awareness of the different classes and activities carried out by the school. Efforts to improve knowledge regarding the services available for children with CP in the general population and among parents of these children should be promoted.

What would encourage blood donation in Ireland?

BACKGROUND

Recent changes have resulted in the loss of 4% of the donor panel in the Republic of Ireland and 3% in Northern Ireland. In order to increase the number of donors in these two regions, it is important that transfusion service providers explore and understand the reasons, which prevent individuals from donating. The aim of this study was to explore these issues particularly in non-donors and those who had lapsed.

METHODS

This 7-month all-Ireland study was conducted by computer-assisted telephone interview. Data collected included sociodemographic history, donation status, as well as barriers/deterrents to donation.

RESULTS

There were 4166 completed questionnaires (44% donors; 56% non-donors). Of the donors, 13% had donated blood within the last 2 years. Current donors cited 'awareness of patients needs' (88%), 'trust in the blood transfusion service' (70%), and 'an advertising campaign' (70%) as reasons encouraging them to donate blood. Lapsed donors and non-donors cited 'more frequent mobile clinics/sessions' (30% lapsed donors; 53% non-donors), 'if I was asked' (28% lapsed donors; 53% non-donors), and 'more flexible opening hours' (23% lapsed donors; 44% non-donors) as reasons that would encourage them to donate. The main reasons cited by non-donors for never having donated included 'medical reasons' (41% Republic of Ireland; 43% Northern Ireland), 'lack of information' (20% Republic of Ireland; 22% Northern Ireland), 'fear of needles' (15% Republic of Ireland; 17% Northern Ireland), and 'time constraints' (12% Republic of Ireland; 13% Northern Ireland). Among the non-donor group, 10% (Republic of Ireland) and 6% (Northern Ireland) claimed that they are not permitted to donate.

CONCLUSION

Replacing regular donors is a major challenge for the transfusion service providers. This study shows that by facilitating the general public by introducing more mobile clinics/sessions, more flexible opening hours and having a better level of knowledge in the community about blood donation may encourage lapsed donors and new donors to become regular donors.

Hepatitis A antibody prevalence among people with an intellectual disability in Ireland

This manuscript aims to determine the prevalence of antibody to and risk factors for hepatitis A virus (HAV) in individuals attending three intellectual disability services through a cross-sectional survey held in Dublin, Ireland. Participants were 636 individuals aged four to 78 years attending three intellectual disability services. The main outcome measure was the measurement of anti-HAV (IgG antibody) in oral fluid swabs using an antibody capture enzyme immunoassay (EIA) technique. Risk factor information was obtained by questionnaire from the individual’s medical record.

Emerging advantages and drawbacks of telephone surveying in public health research in Ireland and the U.K

BACKGROUND

Telephone surveys have been used widely in public health research internationally and are being increasingly used in Ireland and the U.K.

METHODS

This study compared three telephone surveys conducted on the island of Ireland from 2000 to 2004, examining study methodology, outcome measures and the per unit cost of each completed survey. We critically examined these population-based surveys which all explored health related attitudes and behaviours.

RESULTS

Over the period from 2000 to 2005 the percentage of calls which succeeded in contacting an eligible member of the public fell, from 52.9% to 31.8%. There was a drop in response rates to the surveys (once contact was established) from 58.6% to 17.7%. Costs per completed interview rose from 4.48 euro to 15.65 euro. Respondents were prepared to spend 10-15 minutes being surveyed, but longer surveys yielded poorer completion rates. Respondents were willing to discuss issues of a sensitive nature. Interviews after 9 pm were less successful, with complaints about the lateness of the call. Randomisation from electronic residential telephone directory databases excluded all ex-directory numbers and thus was not as representative of the general population as number generation by the hundred-bank method. However the directory database was more efficient in excluding business and fax numbers.

CONCLUSION

Researchers should take cognisance of under-representativeness of land-line telephone surveys, of the increasing difficulties in contacting the public and of mounting personnel costs. We conclude that telephone surveying now requires additional strategies such as a multimode approach, or incentivisation, to be a useful, cost-effective means of acquiring data on public health matters in Ireland and the U.K.

Tobacco smoking, alcohol drinking and Hodgkin's lymphoma: a European multi-centre case-control study (EPILYMPH)

We analysed the effects of tobacco and alcohol in the aetiology of Hodgkin's lymphoma (HL), based on 340 cases and 2465 controls enrolled in Spain, France, Italy, Germany, Ireland and Czech Republic, between 1998 and 2004. Current smokers showed a significantly increased odds ratio (OR) of HL of 1.39 (95% confidence interval (CI) = 1.04-1.87). Analyses were also conducted separately for subjects younger than 35 years (179 cases) and for older subjects (161 cases). For subjects below age 35, no association was observed between tobacco and HL, whereas for older subjects, ever-smokers experienced a doubled risk of HL as compared to never smokers and the OR of HL for current smoking was 2.35 (95% CI = 1.52-3.61), with suggestion of a dose-response relationship. A protective effect of alcohol was observed in both age groups. The OR for ever-regular drinking was 0.58 (95% CI = 0.38-0.89) for younger subjects and 0.50 (95% CI = 0.34-0.74) for older subjects. There was no evidence of interaction between tobacco and alcohol. Our results are consistent with previous studies, suggesting a protective effect of alcohol on HL. An effect of tobacco was suggested for HL occurring in middle and late age, although this finding might have occurred by chance.

An investigation of the impact of prolonged waiting times on blood donors in Ireland

BACKGROUND AND OBJECTIVES

The aim of this study was to investigate the impact of prolonged queuing times on blood donors, by measuring their satisfaction levels, and positive and negative affects. As donation times have increased over the past number of years within the Irish Blood Transfusion Service, this is an important issue to examine in a climate where voluntary donors are becoming scarce and demands on people's time are increasing.

MATERIALS AND METHODS

Eighty-five blood donors were sampled from one urban and one rural blood donor clinic. The respondents conducted a questionnaire by means of face-to-face interview, while waiting in the clinic. The questionnaire contained the Positive and Negative Affect Scale (PANAS), and a waiting satisfaction scale. Both actual and perceived waiting times of the donors were noted.

RESULTS

Waiting time was found to be negatively related to satisfaction. Inexperienced donors expressed higher levels of negative affect than experienced donors. Urban donors were significantly more satisfied than rural donors. There was a significant difference in perceived waiting time between lone donors and those queuing in a group, with those waiting alone perceiving their wait as shorter. While all respondents stated that they intended to donate again, over one-third stated that prolonged waiting times would be their most likely deterrent. However, only 15% stated that long queuing times might actually prevent them from donating in the future, and almost all respondents said that they would recommend donation to a friend, despite long queuing times.

CONCLUSIONS

Although our results show that the respondents were not satisfied with current waiting times, it did not seem to affect their future intentions to donate. These findings provide some optimism for the future of blood donation in Ireland, as they suggest a strong sense of commitment to donation within the population sampled. Future research could explore the application of 'the service industry' approach to waiting times to blood donation clinics.