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ObjectiveDoes TEN4 categorisation of bruises to the torso, ear or neck or any bruise in DesignProspective comparative longitudinal study.SettingCommunity.PatientsChildren InterventionsThe number and location of bruises compared for 2568 data collections from 328 children in the community, 1301 from 106 children with IBD and 342 abuse cases.Main outcome measuresLikelihood ratios (LRs) for the number of bruises within the TEN and non-TEN locations for pre-mobile and mobile children: abuse vs accidental injury, IBD vs accident, abuse vs IBD.ResultsAny bruise in a pre-mobile child was more likely to be from abuse/IBD than accident. The more bruises a pre-mobile child had, the higher the LR for abuse/IBD vs accident. A single bruise in a TEN location in mobile children was not supportive of abuse/IBD. For mobile children with more than one bruise, including at least one in TEN locations, the LR favouring abuse/IBD increased. Applying TEN4 to collections from abused and accidental group ConclusionsThese data support further child protection investigations of a positive TEN4 screen in any pre-mobile children with a bruise and in mobile children with more than one bruise. TEN4 did not discriminate between IBD and abuse, thus IBD needs to be excluded in these children. Estimated sensitivity and specificity of TEN4 was appreciably lower than previously reported.

Interaction between arterial stiffness and hypertension plays an important role in the development of cardiovascular disease. Accordingly, assessment of arterial stiffness may provide a tool for estimating cardiovascular risk and monitoring therapy in hypertensive patients. Radiofrequency-based vascular ultrasound allows accurate noninvasive assessment of local mechanical properties of large arteries, but for its use in clinical practice, reference values according to age and sex are mandatory for each vascular site. To provide reference values for common carotid artery stiffness as assessed by an echo-tracking imaging system Hitachi-Aloka, we pooled measurements collected in 1847 healthy subjects aged 3–74 years (1008 males and 839 females) recruited in 14 European centers in the E-tracking International Collaboration (ETIC). Statistical models were developed to describe relationships of different stiffness indices with age and to calculate median values and Z-scores corresponding to ± 1 and ± 2 standard deviations. In our apparently healthy population, age accounted for 53% of variability in the elastic modulus (epsilon), 39% in arterial compliance, 47% in stiffness index (β), and 56% in local pulse wave velocity; on average, blood pressure accounted for a further 7.5% of variability. Dependence on age was not linear; changes in mean values increased at older ages, especially for epsilon and β. There was an interaction between age and gender for arterial compliance, which was higher in males. We present nomograms and a software that can be used for the automated calculation of Z-scores for local carotid stiffness in individual patients. These tools can be used to establish prognostic indicators or surrogate targets for treatment monitoring.

Dear Editors, We read with interest the review by Dr Kohlmeier in which he reported a correlation between COVID-19 mortality among African-Americans across the USA and northern latitude.1 We previously reported a north–south gradient in global COVID-19 mortality but were conscious that lack of ultraviolet exposure and consequent vitamin D insufficiency was not the only possible explanation.2 We have now investigated the relationships between latitude, age of population, population density and pollution with COVID-19 mortality. COVID-19 mortality per million by country was downloaded from https://www.worldometers.info/coronavirus/ on 18 May 2020.3 We included all 117 countries with population >1 million and ≥150 COVID-19 cases. Data by country for population %≥65 years, population density and air pollution (particles of matter

IntroductionEarly infant diet might influence the risk of subsequent allergic disease.MethodsThe Merthyr Allergy Prevention Study (MAPS) was a randomised controlled trial in infants at high risk of allergic disease. The trial determined whether a cow’s milk exclusion diet for the first 4 months of life decreased the risk of allergic disease including asthma compared with a normal diet. A soya milk preparation was offered to those in the intervention group. A standardised questionnaire for allergic disease was completed at ages 1, 7, 15 and 23 years, with clinical assessment at 1, 7 and 23 years. The effect of the intervention on the risk of atopy, asthma and wheeze at age 23 years was determined.Findings487 subjects entered the study; at age 23 years 299 completed the questionnaire, of which 119 attended clinical assessment. Subjects randomised to the intervention group had a significantly increased risk of atopy (adjusted OR 2.97, 95% CI 1.30 to 6.80; p=0.01) and asthma (OR 2.07, 95%CI 1.09 to 3.91; p=0.03) at age 23 years, but not wheeze (OR 1.43, 95%CI 0.87 to 2.37; p=0.16). Earlier exposure to cow’s milk was associated with a decreased risk of wheeze and asthma at age 23 years, while earlier exposure to soya milk was associated with an increased risk of atopy and asthma.InterpretationIn infants at high risk of allergic disease, either cow’s milk exclusion or early soya milk introduction for the first 4 months of life increases the risk of atopy, wheeze and asthma in adulthood.

BackgroundPoor-quality housing adversely affects residents’ health but there is a paucity of high-quality evidence to support this.ObjectiveThis research investigated the health impact of bringing housing to a national quality standard.DesignA natural experiment of improvements to housing quality analysed using repeated measures of health-care utilisation and economic outcomes at an individual person level.SettingCarmarthenshire, UK.ParticipantsA total of 32,009 residents registered for a minimum of 60 days at 8558 social homes that received housing improvements between January 2005 and March 2015.InterventionsMultiple internal and external housing improvements, including wall and loft insulation, windows and doors, heating system upgrades, new kitchens and bathrooms, garden path safety improvements and electrical system upgrades (adding power sockets, and extractor fans in kitchens and bathrooms).Main outcome measuresEmergency hospital admissions for cardiorespiratory conditions and injuries. Primary health-care utilisation for respiratory and common mental health disorders, emergency department injury attendances and health-care utilisation costs.Data sourcesCarmarthenshire County Council home address and intervention records were anonymously linked within the Secure Anonymous Information Linkage databank to demographic information from the Welsh Demographic Service data set; hospital admission data from the Patient Episode Dataset for Wales; primary care contacts and prescribed medications from general practice data; emergency department attendances from the Emergency Department Data Set; and deaths from the Office for National Statistics mortality register.MethodsThe study used a longitudinal panel design to examine changes in standard of eight housing cointervention from intervention records, and linked to individuals registered at intervention homes. Health outcomes were obtained retrospectively for each individual in a dynamic cohort and were captured for up to 123 consecutive months. An additional local authority region could not be utilised as a comparator owing to different reporting pressures resulting in the recording of a different intervention. The exposure group for each cointervention was compared with an internal reference group of people living in homes that did not receive the cointervention during their tenancy. A multilevel modelling approach was used to account for repeated observations for individuals living in intervention homes. Counts of health outcomes were analysed using negative binomial regression models to determine the effect of each cointervention that reached housing quality standards during an individual’s period of tenancy, compared with those living in properties that did not. We adjusted for potential confounding factors and for background trends in the regional general population. A cost–consequences analysis was conducted as part of the health economic evaluation.ResultsResidents aged ≥ 60 years living in homes in which electrical systems were upgraded were associated with 39% fewer admissions than those living in homes in which they were not [incidence rate ratio (IRR) 0.61, 95% confidence interval (CI) 0.53 to 0.72;p p p p p = 0.072), loft insulation (IRR 0.98, 95% CI 0.86 to 1.11;p = 0.695), kitchens (IRR 0.98, 95% CI 0.83 to 1.17;p = 0.843) or bathrooms (IRR 0.93, 95% CI 0.81 to 1.06;p = 0.287).LimitationsThere was no randomisation, there were incomplete data on the scale of the intervention for individual households and there were no estimates for the impact of the whole programme.ConclusionsThis complex interdisciplinary study found that hospital admissions could be avoided through improving housing quality standards.Future workAt their initiation, future non-health projects should have a built-in evaluation to allow intervention exposures to be randomly allocated to residents, with the simultaneous analysis of multiple health outcomes in one statistical model.FundingThe National Institute for Health Research Public Health Research programme.

We have taken advantage of a natural experiment to measure the impact of the phased abolition of prescription co-payments in Wales. We investigated 3 study periods covering the phased abolition: from £6 to £4, £4 to £3, and £3 to £0. A difference-in-difference modelling was adopted and applied to monthly UK general practice level dispensing data on 14 selected medicines which had the highest percentage of items dispensed subject to a co-payment prior to abolition. Dispensing from a comparator region (North East of England) with similar health and socio-economic characteristics to Wales, and where prescription co-payments continued during the study periods, was used to isolate any non-price effects on dispensing in Wales. Results show a small increase in dispensing of 14 selected medicines versus the comparator. Compared with NE England, monthly average Welsh dispensing was increased by 11.93 items (7.67%; 95% CI [7.2%, 8.1%]), 6.37 items (3.38%; 95% CI [2.9%, 3.7%]) and 9.18 items (4.54%; 95% CI [4.2%, 4.9%]) per practice per 1,000 population during the periods when co-payment was reduced. Price elasticities of the selected medicines utilisation were -0.23, -0.13, and -0.04 in 3 analyses, suggesting the abolition of co-payment had small effect on Welsh dispensing.

Objective Examine the health and economic impact of extending screening intervals in people with Type 2 diabetes (T2DM) and Type 1 diabetes (T1DM) without diabetes-related retinopathy (DR). Setting Diabetic Eye Screening Wales (DESW). Study design Retrospective observational study with cost-utility analysis (CUA) and Decremental Cost-Effectiveness Ratios (DCER) study. Intervention Biennial screening versus usual care (annual screening). Inputs Anonymised data from DESW were linked to primary care data for people with two prior screening events with no DR. Transition probabilities for progression to DR were estimated based on a subset of 26,812 and 1232 people with T2DM and T1DM, respectively. DCER above £20,000 per QALY was considered cost-effective. Results The base case analysis DCER results of £71,243 and £23,446 per QALY for T2DM and T1DM respectively at a 3.5% discount rate and £56,822 and £14,221 respectively when discounted at 1.5%. Diabetes management represented by the mean HbA1c was 7.5% for those with T2DM and 8.7% for T1DM. Sensitivity analysis Extending screening to biennial based on HbA1c, being the strongest predictor of progression of DR, at three levels of HbA1c 6.5%, 8.0% and 9.5% lost one QALY saving the NHS £106,075; £58,653 and £31,626 respectively for T2DM and £94,696, £37,646 and £11,089 respectively for T1DM. In addition, extending screening to biennial based on the duration of diabetes > 6 years for T2DM per QALY lost, saving the NHS £54,106 and for 6-12 and > 12 years for T1DM saving £83,856, £23,446 and £13,340 respectively. Conclusions Base case and sensitivity analyses indicate biennial screening to be cost-effective for T2DM irrespective of HbA1c and duration of diabetes. However, the uncertainty around the DCER indicates that annual screening should be maintained for those with T1DM especially when the HbA1c exceeds 80 mmol/mol (9.5%) and duration of diabetes is greater than 12 years.

Aims The TEN4 rule (bruising to the Trunk, Ear, Neck or in a child Methods Between 2003–2012, bruising patterns on three groups of children ( Results There were 781 children (350 PA, 103 IBD, 328 controls). Bruising frequency at any location increased with increasing mobility, and both PA and IBD children had a greater frequency and greater number of bruises than controls. In pre-mobile children one or more bruise in any location had >5 times the likelihood of PA and >7 times of IBD than controls, the more bruises that a child had, the greater the likelihood of PA/IBD. Pre-mobile children who had a bruise in the TEN location were significantly more likely to have PA than have IBD. Once mobile children had more than one bruise including one in a TEN location the likelihood of PA/IBD was higher than controls (LR PA >2.5, IBD >3.3). In children with multiple bruises (>2), children with a ‘TEN’ bruise were twice as likely to be PA than IBD. Conclusions Application of the TEN4 rule is effective at indicating pre-mobile children and mobile children with multiple bruises that warrant further investigation. However, as it is poorer at discriminating between IBD and abuse cases, all those children who score positively must have a coagulation screen in addition to child abuse evaluation.

Background and objective\ud \ud Health status in childhood is correlated with educational outcomes. Emergency hospital admissions during childhood are common but it is not known how these unplanned breaks from schooling impact on education outcomes. We hypothesised that children who had emergency hospital admissions had an increased risk of lower educational attainment, in addition to the increased risks associated with other health, social and school factors.\ud \ud \ud Methods\ud \ud This record-linked electronic birth cohort, included children born in Wales between 1 January 1998 and 31 August 2001. We fitted multilevel logistic regression models grouped by schools, to determine whether emergency hospital inpatient admission before age 7 years was associated with the educational outcome of not attaining the expected level in a teacher-based assessment at age 7 years (KS1). We adjusted for pregnancy, perinatal, socio-economic, neighbourhood, pupil mobility and school-level factors.\ud \ud \ud Results\ud \ud The cohort comprised 64 934 children. Overall, 4680 (7.2%) did not attain the expected educational level. Emergency admission to hospital was associated with poor educational attainment (OR 1.12 95% Credible Interval (CI) 1.05, 1.20 for all causes during childhood, OR 1.19 95%CI 1.07, 1.32 for injuries and external causes and OR 1.31 95%CI 1.04, 1.22 for admissions during infancy), after adjusting for known determinants of education outcomes such as extreme prematurity, being small for gestational age and socio-economic indicators, such as eligibility for free school meals.\ud \ud \ud Conclusion\ud \ud Emergency inpatient hospital admission during childhood, particularly during infancy or for injuries and external causes was associated with an increased risk of lower education attainment at age 7 years, in addition to the effects of pregnancy factors (gestational age, birthweight) and social deprivation. These findings support the need for injury prevention measures and additional support in school for affected children to help them to achieve their potential.

Background: There are conflicting findings regarding the impact of residential mobility on immunisationstatus. Our aim was to determine whether there was any association between residential mobility andtake up of immunisations and whether they were delayed in administration.\ud \ud Methods: We carried out a cohort analysis of children born in Wales, UK. Uptake and time of immunisationwere collected electronically. We defined frequent movers as those who had moved: 2 or more times inthe period prior to the final scheduled on-time date (4 months) for 5 in 1 vaccinations; and 3 or moretimes in the period prior to the final scheduled on-time date (12 months) for MMR, pneumococcal andmeningitis C vaccinations. We defined immunisations due at 2–4 months delayed if they had not beengiven by age 1; and those due at 12–13 months as delayed if they had not been given by age 2.\ud \ud Results: Uptake rates of routine immunisations and whether they were given within the specified time-frame were high for both groups. There was no increased risk (odds ratios (95% confidence intervals)between frequent movers compared to non-movers for the uptake of: primary MMR 1.08 (0.88–1.32);booster Meningitis C 1.65 (0.93–2.92); booster pneumococcal 1.60 (0.59–4.31); primary 5 in 1 1.28(0.92–1.78); and timeliness: primary MMR 0.92 (0.79–1.07); booster Meningitis C 1.26 (0.77–2.07);booster pneumococcal 1.69 (0.23–12.14); and primary 5 in 1 1.04 (0.88–1.23).\ud \ud Discussion: Findings suggest that children who move home frequently are not adversely affected in termsof the uptake of immunisations and whether they were given within a specified timeframe. Both werehigh and may reflect proactive behaviour in the primary healthcare setting to meet Government coveragerates for immunisation.

IntroductionThis study aims to identify the prevalence and pattern of bruises in preschool children over time, and explore influential variablesMethodsProspective longitudinal study of children (Results3523 bruises recorded from 2570 data collections from 328 children (mean age 19 months); 6.7% of 1010 collections from premobile children had at least one bruise (2.2% of babies who could not roll over and 9.8% in those who could), compared with 45.6% of 478 early mobile and 78.8% of 1082 walking child collections. The most common site affected in all groups was below the knees, followed by ‘facial T’ and head in premobile and early mobile. The ears, neck, buttocks, genitalia and hands were rarely bruised (ConclusionsThese data should help clinicians understand the patterns of ‘everyday bruising’ and recognise children who have an unusual numbers or distribution of bruises who may need assessment for physical abuse or bleeding disorders.

Background National housing quality standards are being applied throughout the UK. A housing improvement programme was delivered through a local authority to bring nearly 9000 homes up to the Welsh Housing Quality Standard (WHQS). Homes received multiple elements, including new kitchens, bathrooms, windows and doors, insulation, and heating and electrical systems, through an eight-year rolling work programme. The study aimed to determine the impacts of the different housing improvements on hospital emergency admissions for all residents. Methods Intervention homes, council homes that received at least one element of work, were data linked to individual health records of residents. Counts of admissions relating to respiratory and cardiovascular conditions, and falls and burns, were obtained retrospectively for each individual in a dynamic housing cohort (January 2005–March 2015). The intervention cohort criterion was for someone to have lived in any one of the intervention homes for at least three months within the intervention period. Counts were captured for up to 123 consecutive months for 32 009 individuals in the intervention cohort and analysed using a multilevel approach to account for repeated observations for individuals, nested within geographic areas. Negative Binomial regression models were constructed to determine the effect for each element of work on emergency admissions for those people living in homes in receipt of the intervention element, compared to those living in homes that did not meet quality standards at that time. We adjusted for background trends in the regional general population, as well as for other confounding factors. Results People of all ages had 34% fewer admissions for cardiovascular and respiratory conditions, and fall and burn injuries while living in homes when the electrical systems were upgraded, compared to the reference group (IRR=0.66, 95% CI 0.58–0.76). Reduced admissions were also found for new windows and doors (IRR=0.78, 0.70–0.87), wall insulation (IRR=0.80, 0.73–0.87) and garden paths (IRR=0.81, 0.73–0.90). There were no associations of change in emergency admissions with upgrading heating (IRR=0.92, 0.85–1.01), loft insulation, (IRR=1.02, 0.93–1.13), kitchens (IRR=1.01, 0.87–1.18), or bathrooms (IRR=0.99, 0.87–1.13). Conclusion Improving housing to national standards reduces the number of emergency admissions to hospital for residents. Strengths of the data linkage approach included the retrospective collection of complete baseline and follow up using routine data for a long-term intervention, and large scale regional adjustment.

ObjectivesThe ELAStiC (Electronic Longitudinal Alcohol Study in Communities) project was established to determine factors that predict pathways into alcohol misuse and the life-course effects of alcohol use and misuse on health and well-being. This is achieved through accessing existing longitudinal data that are key sources of evidence for social and health policy, developing statistical methods and modelling techniques from a diverse range of disciplines, working with stakeholders in both policy, practice and the third sector to bring relevance to the work, and to bring together a diverse team of experts to collaborate and facilitate learning across diverse fields. ApproachThe project will link data that include cohort studies such as; UK Biobank, ALSPAC (Avon Longitudinal Study of Parents and Children), Millennium Cohort Study, British Household Panel Survey, Understanding Society, E_CATALyST (Caerphilly Health and Social Needs Electronic Cohort Study) and WECC (Wales Electronic Cohort for Children). These data will be linked with routine data from primary and secondary healthcare in England, Scotland and Wales. Additional data from education and police data source will also be linked as part of the project. The main work packages for the project are: Methodological InnovationsMethodological developments in mechanisms for correcting bias in reporting alcohol consumption and for combining routine data with cohort data; the application of Markov models for examining the extent to which past behaviour influences future behaviour, and econometric hedonic pricing methods for providing insights into the costs of alcohol-related harm. Pathways into HarmDo family structure, household composition, youngsters’ previous ill-health and educational attainment predict their use of alcohol and what socio-economic factors and household transitions contribute to hazardous alcohol consumption in adults? Secondary HarmsWhat is the effect on children’s health and educational achievement of living in households in which one or more adults has experienced alcohol-related harm? Mental Health & Well-BeingWhat is the relationship between alcohol consumption, hospital admission and mental health in adults and children? ResultsThe results of the data linkage between the multiple cohorts and health, education and police data will be reported. The challenges of linking cohort and other data types from different nations will be discussed. ConclusionsOur project will aim to provide evidence that informs the UK Government’s commitment to “radically reshape the approach to alcohol and reduce the number of people drinking to excess”, by working with existing longitudinal data collected in the UK to inform policy and practice.

ObjectivesA social housing regeneration programme, delivered by one Welsh local authority, has invested £204M (US$308M) to upgrade its housing stock in order to meet a national housing quality standard; the Welsh Housing Quality Standard (WHQS). Homes may receive new bathrooms, kitchens, heating, windows and doors, and insulation. Our objective is to evaluate the effect of implementing the concentrated WHQS investment policy on the physical and mental health of the residents compared to the standard ‘business as usual’ policy of housing stock maintenance. ApproachUsing housing and regeneration data from the Local Authority and an anonymised databank (Secure Anonymised Information Linkage, SAIL) we have established a residence-based cohort. The primary outcome is a relative change in emergency hospital admissions (injuries, cardiovascular and respiratory conditions) following housing improvements; secondary outcomes include health care utilisation costs, primary care mental health conditions and deaths. Different comparator groups will be used to adjust for trends over time. ResultsWe have linked housing data to individuals and their health data using a novel data linkage system. There are about 32 000 residents in the intervention group, 49 000 in a social housing comparator group; and 231 000 in a large general comparator group. Residents who migrate within the social housing cohort are retained using data linkage methods. Records relating to respiratory and cardiovascular conditions as well as falls and burns were obtained retrospectively for each individual, from 2005 to 2015, with measurements captured in 123 monthly time intervals. We are using a three-level negative binomial model, in which time is nested within individuals within properties, to examine the effects of the housing improvements on the mean number of emergency hospital admissions, whilst adjusting for individual-level explanatory variables such as gender, age and comorbidities. Conclusion We discuss the challenges and benefits of linking routine housing and health data to evaluate a natural experiment. We have identified differences between residents in the study area and the comparator groups to evaluate the health benefits of a targeted housing improvement program to implement the WHQS. The evaluation was funded by the National Institute for Health Research, Public Health Research Programme, United Kingdom. (http://www.nets.nihr.ac.uk/projects/phr/09300602).

Aims Determine the prevalence and severity of diabetic retinopathy (DR) and risk factors in a large community based screening programme, in order to accurately estimate the future burden of this specific and debilitating complication of diabetes. Methods A cross-sectional analysis of 91 393 persons with diabetes, 5003 type 1 diabetes and 86 390 type 2 diabetes, at their first screening by the community based National Diabetic Retinopathy Screening Service for Wales from 2005 to 2009. Image capture used 2×45° digital images per eye following mydriasis, classified by qualified retinal graders with final grading based on the worst eye. Results The prevalence of any DR and sightthreatening DR in those with type 1 diabetes was 56.0% and 11.2%, respectively, and in type 2 diabetes was 30.3% and 2.9%, respectively. The presence of DR, non-sight-threatening and sight-threatening, was strongly associated with increasing duration of diabetes for either type 1 or type 2 diabetes and also associated with insulin therapy in those with type 2 diabetes. Conclusions Prevalence of DR within the largest reported community-based, quality assured, DR screening programme, was higher in persons with type 1 diabetes; however, the major burden is represented by type 2 diabetes which is 94% of the screened population.

OBJECTIVE: To investigate the risk of emergency respiratory hospital admission during childhood associated with gestational age at birth and growth restriction in utero. METHODS: The study included a total population electronic birth cohort with anonymized record-linkage of multiple health and administrative data sets. Participants were 318 613 children born in Wales, United Kingdom, between May 1, 1998, and December 31, 2008. The main outcome measure was emergency respiratory hospital admissions. RESULTS: The rate of admission in the first year of life ranged from 41.5 per 100 child-years for infants born before 33 weeks’ gestation to 9.8 per 100 child-years for infants born at 40 to 42 weeks’ gestation. The risk of any emergency respiratory admission up to age 5 years increased as gestational age decreased to CONCLUSIONS: The risk of emergency respiratory admission up to age 5 years decreased with each successive week in gestation up to 40 to 42 weeks. Although the magnitude of increased risk associated with moderate and late preterm births is small, the number of infants affected is large and therefore presents a significant impact on health care services.

Objective To describe the characteristics of bruising and mode of presentation of children referred to the paediatric child protection team with suspected physical abuse (PA), and the extent to which these differ between the children where abuse was confirmed and those where it was excluded. Design Cross-sectional study. Setting and patients 519 children

There are currently no data available regarding the normal levels of DNA found on the skin of children engaging in routine day to day activities to assist with the forensic interpretation of DNA profiles generated from skin surface swabs. To address this deficit, skin surface swab samples were collected from 12 face/neck sites and 20 body sites on 50 children less than 5 years old. After exclusion of spoilt samples, 60 sets of swabs from 47 children (30 face/neck, 30 body) comprising of 944 individual samples were analysed. The number of alleles observed which could have originated from the child and the number which must have come from another source (non-child) were analysed. The following variables were evaluated: age, kissing, feeding and washing practices, number of contacts and application of cream. Overall, extremely small amounts of non-child DNA were retrieved from skin swabs. Child only (46.3 %) or no DNA at all (18.6 %) was observed for 64.9 % of all swabbed samples. Low levels of non-child DNA (1–5 alleles) were observed on 31.6 % of all swabs tested with only 3.4 % of swabs showing six or more alleles. A great deal of variation between children and between sites in the levels of both child DNA and non-child DNA was observed. A multilevel model, taking account of clustering within children, showed that there was a strong direct association between the amounts of child and non-child DNA observed. There was no relationship between the amount of DNA recovered and the demographic and biographic variables analysed. These background data have the potential to assist the analysis of DNA from the skin of children during criminal investigation. Electronic supplementary material The online version of this article (doi:10.1007/s00414-013-0906-8) contains supplementary material, which is available to authorized users.

Background Eczema is common in infancy; however, there is little evidence about its natural history to adulthood. Objectives To study the natural history of eczema from birth to young adult life with particular reference to its relation to atopy. Methods A birth cohort of children with atopic family histories was followed for 23 years. Clinical examinations were conducted until the age of 7 years, skin-prick tests and serum total IgE were recorded in infancy and at ages 7 and 23 years, and questionnaires about eczema symptoms were completed at 15 and 23 years. Results Information was obtained on 497 subjects at birth, 482 at 1 year, 440 at 7 years, 363 at 15 years and 304 at 23 years. Eczema usually remitted from age 1 to 7 years but became more persistent from the age of 15 years, especially in those who were atopic. The prevalence of eczema rose in women from age 15 to 23 years but declined in men. Adults with eczema had higher IgE than those without at 3 months (geometric mean 3·0 vs. 1·7 kU L-1; P = 0·01), 7 years (107·9 vs. 45·2 kU L-1; P = 0·01) and 23 years (123·4 vs. 42·3 kU L-1; P = 0·01), and were more likely to have had positive skin-prick tests at 1 year of age. Current eczema was associated with raised IgE in infancy and adulthood but not in childhood. Conclusions Predisposed infants and children with eczema usually grow out of the disease, but in adolescence it is more likely to persist. Adult eczema is related to atopy from the age of 3 months. What's already known about this topic? Eczema is associated with atopy, asthma and rhinoconjunctivitis. Eczema in infancy usually remits but is more likely to persist if the child is atopic. After puberty eczema often persists to adult life. What does this study add? Adult eczema is associated with atopy from the age of 3 months. Atopy increases the likelihood of persistence after adolescence.

Bruises in suspected abuse are routinely measured for clinical and forensic purposes. We aimed to determine the consistency of electronic and manual bruise measurements. Over two sessions, 45 observers recorded the greatest lengths of eight bruises in cross‐polarised images. Observers were presented with six images in each session; four were common to both sessions. Manual measurements were achieved using a paper tape‐measure on hard‐copy images; electronic measurements used ImageJ software for digital on‐screen images. Differences in mean measurements between methods were tested using paired t‐tests; within‐ and between‐observer variations were computed. On average, manual measurements were smaller than electronic measurements. Observers were prone to rounding bias in manual measurements. Overall standard deviations of measurements (0.39–0.63 cm) did not differ greatly between methods. Measuring electronically, observers showed more consistency between sessions than measuring manually. Electronic measurements had greater variation between observers than manual measurements. Overall, 95 per cent of measurements for a given bruise lay within a range of 2 cm. We conclude that measurement of a bruise by either method varied. In clinical practice, we recommend that a right‐angled linear scale is included in any photographic image of a bruise, such that clinicians can standardise the estimate of bruise size.

Summary Clinical diagnosis is often a complex task of decision making in the face of uncertainty. Diagnosis of child abuse is a particular example where misdiagnosis in either direction is very serious. We have developed a formal Bayesian methodology to quantify the intrinsic uncertainty in complex clinical diagnostic problems. The motivating case-study was the diagnosis of abuse in an infant presenting with an acute life threatening event and oronasal haemorrhage (nosebleed). Since no direct evidence was available on the probability of abuse given an acute life threatening event and nosebleed, we used Bayes theorem to formulate the diagnosis in terms of prior and inverse conditional probabilities and adapted systematic review methodology and Bayesian evidence synthesis to estimate these and to propagate the associated uncertainty. The estimated probability of abuse was far more uncertain than might be supposed from either expert advice or an informal reading of the literature, and estimates depended crucially on assumptions that were made about the conditional independence of multiple signs of abuse. This highlights the importance of having a formal statistical methodology such as this to assist clinicians in reaching a diagnosis. The process that we worked through is likely to have wider application to other problems of complex clinical diagnosis.

Background National housing quality standards are now being applied throughout the UK. The Welsh Government has introduced the Welsh Housing Quality Standards. A housing improvement programme in Wales has been delivered through one local authority to bring 9500 homes up to standard. Homes received multiple elements, including new kitchens, bathrooms, windows and doors, boilers, insulation, and wiring, through an 8 year rolling work programme. The study aimed to determine the impacts of the different housing improvements on hospital emergency admissions for residents over 60 years of age. Methods Intervention homes (council homes that received at least one element of work) were data linked to individual health records of residents. Counts of admissions for respiratory and cardiovascular conditions, and for falls and burns, were obtained retrospectively for each individual in a dynamic housing cohort (Jan 1, 2005, to March 31, 2015). The criterion for the intervention cohort was for someone to have lived in any one of the 9500 intervention homes for at least 3 months within the intervention period. Counts were captured for up to 123 consecutive months for 7054 individuals in the intervention cohort and analysed in a multilevel approach to account for repeated observations for individuals, nested within geographical areas. Negative binomial regression models were constructed to determine the effect on emergency admissions for those living in homes compliant for each element of work compared with those living in homes that were non-compliant at that time. We adjusted for background trends in the regional general population, and for other confounding factors. Findings For residents 60 years old and over there was a reduction in admissions for people with compliant boilers (rate ratio 0·71, 95% CI 0·67–0·76), loft insulation (0·87, 0·80–0·95), wall insulation (0·74, 0·69–0·80), and windows and doors (0·56, 0·52–0·61) compared with those living in homes that were non-compliant for those work elements. Interpretation Improving housing to national standards reduces the number of emergency admissions to hospital for older residents. Strengths of the data-linkage approach included the retrospective collection of complete baseline and follow-up data using routine data for a long-term intervention, and large scale regional adjustment. Funding National Institute for Health Research (NIHR) Public Health Research programme (project number 09/3006/02).

OBJECTIVES:To investigate the association between moving home in the first year of life and subsequent emergency admissions for potentially preventable hospitalizations.METHODS:We undertook a cohort analysis of linked anonymized data on 237 842 children in the Welsh Electronic Cohort for Children. We included children born in Wales between April 1, 1999 and December 31, 2008. The exposure was the number of residential moves from birth up to 1 year. The main outcome was emergency admissions for potentially preventable hospitalizations (PPH) between the age of 1 and 5 years.RESULTS:After adjustment for confounders, we identified that moving home frequently in the first year of life was associated with an increased risk of emergency PPH between the ages of 1 and 5 when compared with not moving. We found significant differences associated with ≥2 moves for the following: ear, nose, and throat infections (incidence risk ratio [IRR], 1.44; 95% confidence interval [CI], 1.29–1.61); convulsions/epilepsy (IRR, 1.58; 95% CI, 1.23–2.04); injuries (IRR, 1.33; 95% CI, 1.18–1.51); dehydration/gastroenteritis (IRR, 1.51; 95% CI, 1.21–1.88); asthma (IRR, 1.61; 95% CI, 1.19–2.16); influenza/pneumonia (IRR, 1.15; 95% CI, 1.00–1.32); and dental conditions (IRR, 1.30; 95% CI, 1.03–1.64) for ≥1 moves.CONCLUSIONS:Children who move home in the first year of life are at substantially increased risk of emergency admissions for PPH in early childhood. Additional research that focuses on enhancing health and social support services for highly mobile families, educating parents about safety risks, and improving housing quality is warranted.

BackgroundExcess alcohol consumption has serious adverse effects on health and results in violence-related harm.ObjectiveThis study investigated the impact of change in community alcohol availability on alcohol consumption and alcohol-related harms to health, assessing the effect of population migration and small-area deprivation.DesignA natural experiment of change in alcohol outlet density between 2006 and 2011 measured at census Lower Layer Super Output Area level using observational record-linked data.SettingWales, UK; population of 2.5 million aged ≥ 16 years.Outcome measuresAlcohol consumption, alcohol-related hospital admissions, accident and emergency (A&E) department attendances from midnight to 06.00 and violent crime against the person.Data sourcesLicensing Act 2003 [Great Britain.Licensing Act 2003. London: The Stationery Office; 2003. URL:www.legislation.gov.uk/ukpga/2003/17/contents(accessed 8 June 2015)] data on alcohol outlets held by the 22 local authorities in Wales, alcohol consumption data from annual Welsh Health Surveys 2008–12, hospital admission data 2006–11 from the Patient Episode Database for Wales (PEDW) and A&E attendance data 2009–11 were anonymously record linked to the Welsh Demographic Service age–sex register within the Secure Anonymised Information Linkage Databank. A final data source was recorded crime 2008–11 from the four police forces in Wales.MethodsOutlet density was estimated (1) as the number of outlets per capita for the 2006 static population and the per quarterly updated population to assess the impact of population migration and (2) using new methods of network analysis of distances between each household and alcohol outlets within 10 minutes of walking and driving. Alcohol availability was measured by three variables: (1) the previous quarterly value; (2) positive and negative change over the preceding five quarters; and (3) volatility, a measure of absolute quarterly changes during the preceding five quarters. Longitudinal statistical analysis used multilevel Poisson models of consumption and Geographically Weighted Regression (GWR) spatial models of binge drinking, Cox regression models of hospital admissions and A&E attendance and GWR models of violent crime against the person, each as a function of alcohol availability adjusting for confounding variables. The impact on health inequalities was investigated by stratifying models within quintiles of the Welsh Index of Multiple Deprivation.ResultsThe main finding was that change in walking outlet density was associated with alcohol-related harms: consumption, hospital admissions and violent crime against the person each tracked the quarterly changes in outlet density. Alcohol-related A&E attendances were not clinically coded and the association was less conclusive. In general, social deprivation was strongly associated with the outcome measures but did not substantially modify the associations between the outcomes and alcohol availability. We found no evidence for an important effect of population migration.LimitationsLimitations included the absence of any standardised methods of alcohol outlet data collation, processing and validation, and incomplete data on on-sales and off-sales. We were dependent on the quality of clinical coding and administrative records and could not identify alcohol-related attendances in the A&E data set.ConclusionThis complex interdisciplinary study found that important alcohol-related harms were associated with change in alcohol outlet density. Future work recommendations include defining a research standard for recording outlet data and classification of outlet type, the methodological development of residence-based density measures and a health economic analysis of model-predicted harms.FundingThe National Institute for Health Research Public Health Research programme. Additional technical and computing support was provided by the Farr Institute at Swansea University, made possible by the following grant:Centre for the Improvement of Population Health through E-records Research (CIPHER) and Farr Institute capital enhancement. CIPHER and the Farr Institute are funded by Arthritis Research UK, the British Heart Foundation, Cancer Research UK, the Chief Scientist Office (Scottish Government Health Directorates), the Economic and Social Research Council, the Engineering and Physical Sciences Research Council, the Medical Research Council, the National Institute for Health Research, the National Institute for Social Care and Health Research (Welsh Government) and the Wellcome Trust (grant reference MR/K006525/1).

Background Aortic dilatation is the main therapeutic target in patients with Marfan syndrome. Standard treatment with a β-blocker may not lower central pulse pressure – the major objective – because it does not do so in hypertension, unlike angiotensin-converting enzyme inhibitors and calcium-channel blockers. We therefore performed a prospective, randomised, double-blind, crossover trial to compare the effects of these three agents on large artery function and central aortic pressure in patients with Marfan syndrome. Methods and Results Eighteen patients had applanation tonometry, pulse wave analysis and echocardiography, before and after atenolol 75 mg, perindopril 4 mg and verapamil 240 mg, each given for 4 weeks, in a random order, with 2 weeks between medications. Fourteen patients completed the study. Within-drug comparisons demonstrated that perindopril (−10·3 mmHg, P = 0·002), verapamil (−9·2 mmHg, P = 0·003) and atenolol (−7·1 mmHg, P = 0·01) all reduced central systolic pressure and brachial pressure; central changes were least, and peripheral changes greatest with atenolol but between-drug comparisons (analysis of covariance) were not significant. There was a trend for augmentation to be reduced by perindopril (−6·3%, P = 0·05), verapamil (−5·5%, P = 0·07) and atenolol (−3·2%, P = 0·09). Only atenolol reduced heart rate (by 16%) and delayed expansion in the arch and abdominal aorta (by 8% and 11%) (P < 0·001, P < 0·01 and P < 0·05, respectively, for between-drug comparisons). Conclusions Perindopril, verapamil and atenolol all reduced peripheral and central systolic pressure. As atenolol slowed heart rate and delayed aortic wave travel, β-blockade may have a continuing role in the treatment of patients with Marfan syndrome.

In recent years, the rate of preterm births has risen in many industrialised countries with late preterm births forming a substantial proportion of the preterm births. Late preterm infants are delivered at the immature saccular stage of lung development when surfactant and antioxidant systems are still developing. It is now increasingly recognised that late preterm infants have increased respiratory morbidity in the neonatal period. In addition, late preterm infants are at an increased risk of lower respiratory tract infections in infancy from respiratory viruses such as respiratory syncytial virus. There is a paucity of data reporting lung function in infancy and childhood in late preterm born children. The available data suggest that children born late preterm may be at risk of decreased lung function in later life. However, further studies are required to assess the medium and long term respiratory consequences of late preterm birth.

Perceptions that rural populations are inevitably healthier and live longer than urban populations are increasingly being challenged. But very few publications have investigated the extent to which these putative differences can be explained by variation in area composition. Existing publications have tended to use conventional deprivation measures, often thought to mask rural deprivation by favourable averages. Further, they have typically been based on large and variably-sized geographical units, or confined to studies of a single region or cause of death. This study examines differences in mortality between rural and urban areas in the entire population of England and Wales for 2002–2004. It uses the most up-to-date small geographical units of similar size and homogeneity of population together with the recently-introduced Rural and Urban Area Classification, and adjusts for five different deprivation measures (including modern composite indices). The causes of death investigated were all-cause mortality, cancer, lung cancer, respiratory disease, circulatory disease, suicide and accidents. Particular points of focus for the study were the potential for interaction between deprivation and rurality, and the importance of choice of deprivation measure in quantifying the relationships between mortality, rurality and deprivation. Choice of deprivation measure was not found to alter the substantive conclusions of any analysis, and little evidence for differential effects of deprivation in rural and urban areas was uncovered. Differences between rural and urban areas in all-cause, circulatory disease and cancer mortality could largely be accounted for by adjusting for deprivation. For these causes of death, therefore, rural populations were not found to be inherently healthier than their urban counterparts. However, substantial residual differences between rural and urban areas were found in comparisons of mortality from lung cancer and respiratory disease, mortality being lower in rural areas. Stronger relationships between rurality and mortality were found in ‘village and dispersed’ settlements.

Images of bruises serve as a clinical record and may facilitate forensic analysis in the assessment of suspected physical child abuse. Currently, only conventional imaging techniques are employed; however, alternative imaging modalities using visible and non-visible light may provide additional information. We sought to determine the image modality preferences of paediatricians and the between-observer agreement therein. Nine paediatricians who work in child protection independently compared five image modalities (conventional colour, conventional grey-scale, cross-Polarised, ultraviolet, and infrared) of four bruises, with a compliance rate of 95%. All images were taken using a standardised set of protocols with Nikon D90 cameras and 105-mm macro-lenses. The paediatricians almost unanimously chose cross-Polarised as their preferred modality for all four bruises when assessing boundary, shape, colour, size, and absence of light reflectance. Conventional colour and grey-scale imaging were typically ranked second and third. Ultraviolet and infrared were consistently ranked in the least two favourable positions. Between-observer agreement on ranking order was high, with coefficients of concordance ranging from 0.76 to 0.96. Combinations of imaging modalities chosen to give the most complete picture of the bruise predominantly consisted of cross-Polarised and conventional (colour and grey-scale). This pilot study demonstrated that clinicians collectively favoured cross-Polarised in addition to conventional imaging. Further studies are required to determine the value of ultraviolet and infrared imaging in the assessment of childhood bruises.

Rationale: Few studies have investigated childhood respiratory outcomes of intrauterine growth retardation (IUGR), and it is unclear if catch-up growth in these children influences lung function. Objectives: We determined if lung function differed in 8- to 9-year-old children born at term with or without growth retardation, and, in the growth-retarded group, if lung function differed between those who did and those who did not show weight catch up. Methods: Caucasian singleton births of 37 weeks or longer gestation from the Avon Longitudinal Study of Parents and Children (n = 14,062) who had lung spirometry at 8–9 years of age were included (n = 5,770). Measurements and Main Results: Infants with gestation-appropriate birthweight (n = 3,462) had significantly better lung function at 8–9 years of age than those with IUGR (i.e., birthweight

BACKGROUND:Coronary heart disease (CHD) mortality in England fell by 36% between 2000 and 2007 and it is estimated that approximately 50% of the fall was due to improved treatment uptake. Marked socio-economic inequalities in CHD mortality in the United Kingdom (UK) remain, with higher age-adjusted rates in more deprived groups. Inequalities in the persistence of medication for primary and secondary prevention of CHD may contribute to the observed social gradient and we investigated this possibility in the population of Wales (UK). METHODS AND FINDINGS:An electronic cohort of individuals aged over 20 (n = 1,199,342) in Wales (UK) was formed using linked data from primary and secondary care and followed for six years (2004-2010). We identified indications for medication (statins, aspirin, ACE inhibitors, clopidogrel) recommended in UK National Institute for Clinical Excellence (NICE) guidance for CHD (high risk, stable angina, stable angina plus diabetes, unstable angina, and myocardial infarction) and measured the persistence of indicated medication (time from initiation to discontinuation) across quintiles of the Welsh Index of Multiple Deprivation, an area-based measure of socio-economic inequality, using Cox regression frailty models. In models adjusted for demographic factors, CHD risk and comorbidities across 15 comparisons for persistence of the medications, none favoured the least deprived quintile, two favoured the most deprived quintile and 13 showed no significant differences. CONCLUSIONS:During our study period (2004-2010) we found no significant evidence of socio-economic inequality in the persistence of recommended medication for primary and secondary prevention of CHD.

Objective— Hemostasis and inflammation have been implicated in dementia. This study investigates the role of specific hemostatic and inflammatory pathways with incident vascular and nonvascular dementia. Methods and Results— This was a prospective study of a population sample of men aged 65 to 84 years, with baseline assessment of hemostatic and inflammatory factors and cognition measured 17 years later. The sample included 865 men (59 had dementia and 112 had cognitive impairment, not dementia), free of vascular disease at baseline and for whom hemostatic and inflammatory marker data were available and cognitive status was known. A total of 15 hemostatic and 6 inflammatory markers were assessed. Factor analysis was used to identify hemostatic subsystems. The National Institute of Neurological Disorders and Stroke–Association Internationale pour la Recherche et l’Enseignement en Neurologie criteria were used to identify vascular dementia. By using standardized ( z ) scores for hemostatic and inflammatory markers, and after adjustment for age and risk factors, vascular dementia was associated with fibrinogen (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.02–2.76), factor VIII (HR, 1.79; 95% CI, 1.09–3.00), and plasminogen activator inhibitor 1 (HR, 3.13; 95% CI, 1.73–5.70). For vascular dementia, the HR risk from high levels of all three hemostatic variables (fibrinogen, factor VIII, and plasminogen activator inhibitor 1) was 2.97 ( P Conclusion— The associations of these hemostatic markers with vascular dementia may implicate clot formation as the primary mechanism and are consistent with a microinfarct model of vascular dementia.

The association between cognitive function and mortality is of increasing interest. We followed 1870 men aged 55–69 years at cognitive assessment for 16 years to establish associations with all case and cause specific mortality. Cognitive assessment included AH4, 4 choice reaction time (used as estimates of mid-life cognition) and the National Adult Reading Test (used as an estimate of early-life cognition). Causal models were tested for the effects of a) early-life cognition, b) confounding through mid-life disease, and c) the effects of sociodemographic and lifestyle factors. A fully adjusted model was also tested. Age adjusted associations with mid-life cognitive function were found with mortality from circulatory, coronary, respiratory and digestive disease but not from cancer mortality. Age adjusted associations were attenuated and in some cases nullified by further adjustment for each of early-life cognition, mid-life disease risk and sociodemographic and lifestyle factors. These associations cannot be assumed to be unbiased estimates of effect due to the complex confounding structures that exist in these data. Future studies should explore natural experiments, use different populations where the confounding structures may be different and evaluate more complex methods that may be able to deal with the inherent complexities of a life course perspective.

Objective: To estimate the incidence and describe the aetiology of epistaxis in infants. Design: Population-based study including a retrospective hospital admission database analysis and a postal questionnaire to clinicians. Setting: Wales, United Kingdom. Methods: Cases of epistaxis over a 6-year period (1999–2004) were identified from the Patient Episode Dataset for Wales (PEDW) and validated using clinical information to calculate the population-based incidence and ascertain the causes of epistaxis in infants in Wales. Results: 36 confirmed cases were identified over the 6-year period giving an estimated annual incidence of epistaxis of 19.3 (95% CI 14.0 to 26.7) per 100 000 infants. The median age at admission was 12 weeks (interquartile range 4–33) (min 1 week, max 49 weeks). 23 of the infants had a recognised cause for their epistaxis (trauma (five), coagulation disorder (four), congenital anomaly (two), acute rhinitis or coryza (11), abusive smothering event (one)). No cause for the epistaxis was identified for 13 cases. Coagulation disorder was excluded in seven of these 13 infants but in the other six no attempt was made to exclude this disorder. Child abuse was suspected but excluded in four of the 13 cases. Conclusion: Hospital admission for epistaxis is a rare event. In the majority of cases in this study a simple explanation was available and proven physical abuse was rare. A bleeding disorder should always be considered and, if additional evidence suggests physical abuse, this must be excluded.

Background Studies have found that health checking in primary care led to the identification of previously unrecognized morbidity among adults with intellectual disabilities. The aim here was to evaluate whether health checking stimulated increased consultation with the general practitioner or another member of the primary care team, increased health promotion actions undertaken outside the health check or increased contact with specialists. Method Data on the above three categories of activity were abstracted from the medical records of 77 adult participants with intellectual disabilities for eight 6-month periods before and seven 6 month periods after they had undergone a health check. Comparisons of access to care before and after the health check were made using non-parametric statistics. Results On average, participants had 5.4 and 1.8 primary care and specialist consultations per year respectively. There were no significant differences in either rate before and after the health check. The frequency of health promotion actions increased significantly after the health check from a mean of 1.2 to 2.2/year. Conclusions Comparison of the primary care and specialist consultations rates of people with intellectual disabilities with those for the general population might suggest that the former have greater access to these services. However, comparison to the general practitioner consultation rates of patients with other chronic conditions would seem to indicate that contact with primary care may not be commensurate with need. Attention to health promotion is inadequate. Further research is required to substantiate whether health checking increases health promotion and how increased health promotion activity would affect the health of this population.

Background An earlier study (Baxter et al. 2006) found that a structured health check conducted in primary care identified clinically significant previously unrecognized morbidity among adults with intellectual disabilities. The aim here was to examine whether follow-up health checks would identify equally significant newly identified morbidity and to investigate this as a function of the interval between health checks. Method Adults with intellectual disabilities who had had an initial health check (n = 108) participated: group 1 (n = 39) had a repeat health check an average of 28 months later, group 2 (n = 36) had a repeat health check an average of 44 months later and group 3 (n = 33) did not have a subsequent health check. Thirty participants in group 1 had a second repeat health check an average of 14 months after the first repeat. An audit of the results of the health check established whether morbidity was newly identified. Information was collected on each participant’s age, gender, place of residence, skills, challenging behaviour, social abilities, psychiatric status and perceived health. Comparisons within groups over time or between groups at a point in time were made using non-parametric statistics. Results A similar number of newly identified health problems were found at the repeat health check compared to the initial check. The nature of needs identified was also similar. There was no association between the number of new needs identified at the repeat health check and the interval between it and the initial check. The perceived health of participants receiving health checks tended to decline. Conclusions As the level of new need revealed by repeated checks at even the shortest interval since the previous check studied here (mean = 14 months) was as high as that found by the initial check, annual health checking could be a justifiable intervention for this population. Decline in perceived health may represent more accurate assessment by carers following feedback from the health checks.

Background. Social inequalities in health are well documented in the social epidemiology literature. However, less is known about the mechanisms linking individual and area-level socio-economic status to health. In this paper we examine whether health locus of control (HLC) beliefs can help to explain socio-economic differences in self-rated health using the multidimensional HLC scale. Methods. Data for this study come from the Caerphilly Health and Social Needs Survey (n = 10,892). Multilevel modelling was used to examine the variation in HLC beliefs across different socio-demographic groups and levels of neighbourhood socio-economic status, and to investigate whether HLC beliefs mediate the health effects of individual and neighbourhood socio-economic position. Results. This study found that the HLC scales were significantly associated with individual and neighbourhood socio-economic status, as well as with self-rated health. HLC beliefs appeared to mediate some of the health effects of individual socio-economic status and to a lesser extent the health effects of neighbourhood socio-economic status. Conclusions. Some evidence was found that HLC forms part of the pathway between individual and neighbourhood socio-economic status and health. Future research should further explore the psychological consequences of living in economically deprived conditions, alongside material, social and behavioural processes, and examine how this impacts upon people's health and well-being.

BackgroundThere is increasing interest in the proposition that residential environment can affect mental health.AimsTo study the degree to which common mental disorder clusters according to postcode units and households. To investigate whether contextual measures of residential environment quality and geographical accessibility are associated with symptoms of common mental disorder.MethodA total of 1058 individuals aged 16–75 years (response rate 66%) participated in a cross-sectional survey The 12-item General Health Questionnaire measured symptoms of common mental disorder.ResultsOnly 2% (95% CI 0–6) of the unexplained variation in symptoms existed at postcode unit level, whereas 37% (95% CI 27–49) existed at household-level, but the postcode unit variation was reduced to zero after adjustments. There was little evidence to suggest that residential quality or accessibility were associated with symptoms.ConclusionsThere was substantial unexplained variation at the household level but we could find no evidence of postcode unit variation and no association with residential environmental quality or geographical accessibility. It is likely that the psychosocial environment is more important than the physical environment in relation to common mental disorder.

BackgroundThe relationship between the Mental Illness Needs Index (MINI) and the common mental disorders is not known.AimsTo investigate associations between the small-area MINI score and common mental disorder at individual level.MethodMental health status was measured using the Mental Health Inventory of the Short Form 36 instrument (SF-36). Data from the Caerphilly Health and Social Needs population survey were analysed in multilevel models of 10 653 individuals aged 18–74 years nested within the 2001 UK census geographies of 110 lower super output areas and 33 wards.ResultsThe MINI score was significantly associated with common mental disorder after adjusting for individual risk factors. This association was stronger at the smaller spatial scale of the lower super output area and for individuals who were permanently sick or disabled.ConclusionsThe MINI is potentially useful for small-area needs assessment and service planning for common mental disorder in community settings.

This paper investigates multilevel associations between the common mental disorders of anxiety, depression and economic inactivity measured at the level of the individual and the UK 2001 census ward. The data set comes from the Caerphilly Health & Social Needs study, in which a representative survey of adults aged 18–74 years was carried out to collect a wide range of information which included mental health status (using the Mental Health Inventory (MHI-5) scale of the Short Form-36 health status questionnaire), and socio-economic status (including employment status, social class, household income, housing tenure and property value). Ward level economic inactivity was measured using non-means tested benefits data from the Department of Work and Pensions (DWP) on long-term Incapacity Benefit and Severe Disablement Allowance. Estimates from multilevel linear regression models of 10,653 individuals nested within 36 census wards showed that individual mental health status was significantly associated with ward-level economic inactivity, after adjusting for individual-level variables, with a moderate effect size of ?0.668 (standard error=0.258). There was a significant cross-level interaction between ward-level and individual economic inactivity from permanent sickness or disability, such that the effect of permanent sickness or disability on mental health was significantly greater for people living in wards with high levels of economic inactivity. This supports the hypothesis that living in a deprived neighbourhood has the most negative health effects on poorer individuals and is further evidence for a substantive effect of the place where you live on mental health.

Dual-energy X-ray absorptiometry (DEXA) is a rapid and precise technique for the assessment of bone mineralization in children. Interpretation of the results in growing children is complex as results are influenced by age, body size (height and weight) and puberty. Conventionally, bone mineral data derived from DEXA have been presented as an areal density [BMD; bone mineral content (BMC, g)/projected bone area (BA, cm2)], yet this fails to account for changes in BMC that result from changes in age, body size or pubertal development. Measurement of BMC and BA of the whole body, lumbar spine and left hip were made in 58 healthy boys and girls using DEXA. The relationship between BMC and BA was curvilinear, with the best fit being that of a power model (BMD = BMC/BAlambda, where lambda is the exponent to which BA is raised in order to remove its influence on BMC). The value of lambda changed when measures of body size and puberty were taken into account (e.g. for lumbar spine from 1.66 to 1.49). Predictive formulae for BMC were produced using regression analysis and based on the variables of age, body size and pubertal development. This provides a method for interpreting the measured BMC which is independent of such variables and a constant reference range for children aged 6-18 y.

Using data on 24,975 respondents to the Welsh Health Survey 1998 aged 17-74 years, we investigated associations between individual mental health status measured using the SF-36 instrument, social class, economic inactivity and the electoral division Townsend deprivation score. In a multilevel modelling analysis, we found mental health was significantly associated with the Townsend score after adjusting for composition, and this effect was strongest in respondents who were economically inactive. Further contextual effects were shown by significant random variability in the slopes of the relation between mental health and economic inactivity at the electoral division level. Our results suggest that the places in which people live affect their mental health, supporting NHS policy that multi-agency planning to reduce inequalities in mental health status should address the wider determinants of health, as well as services for individual patients.

OBJECTIVE: To assess the effect of educational outreach visits on antibiotic prescribing for acute dental pain in primary care. STUDY DESIGN: RCT. SETTING: General dental practices in four health authority areas in Wales. SUBJECTS AND METHODS: General dental practitioners were recruited to the study and randomly allocated to one of the three study groups (control group, guideline group or intervention group). Following the intervention, practitioners completed a standardised questionnaire for each patient that presented with acute dental pain. INTERVENTIONS: The control group received no intervention. The guideline group received educational material by post. The intervention group received educational material by post and an academic detailing visit by a trained pharmacist. The educational material included evidence-based guidelines on prescribing for acute dental pain and patient information leaflets. MAIN OUTCOME MEASURES: The number of antibiotic prescriptions issued to patients presenting with dental pain and the number of 'inappropriate' antibiotic prescriptions. Antibiotics were considered to be inappropriate if the patient did not have symptoms indicative of spreading infection. RESULTS: A total of 1,497 completed questionnaires were received from 23, 20 and 27 general dental practitioners in the control, guideline and intervention group respectively. Patients in the intervention group received significantly fewer antibiotic prescriptions than patients in the control group (OR (95% CI) 0.63 (0.41, 0.95)) and significantly fewer inappropriate antibiotic prescriptions (OR (95% CI) 0.33 (0.21, 0.54)). However, antibiotic and inappropriate antibiotic prescribing were not significantly different in the guideline group compared to the control group (OR (95% CI) 0.83 (0.55, 1.21) and OR (95% CI) 0.82 (0.53, 1.29) respectively).CONCLUSIONS: Strategies based upon educational outreach visits may be successfully employed to rationalise antibiotic prescribing by dental practitioners.

There has been much speculation about a possible association between the social and built environment and health, but the empirical evidence is still elusive. The social and built environments are best seen as contextual concepts but they are usually estimated as an aggregation of individual compositional measures, such as perceptions on trust or the desirability to live in an area. If these aggregated compositional measures were valid measures, one would expect that they would evince correlations at higher levels of data collection (e.g., neighbourhood). The aims of this paper are: (1) to investigate the factor structure of a self-administered questionnaire measuring individual perceptions of trust, social participation, social cohesion, social control, and the built environment; (2) to investigate variation in these factors at higher than the individual level (households and postcodes) in order to assess if these constructs reflect some contextual effect; and (3) to study the association between mental health, as measured by the General Health Questionnaire-12 (GHQ-12), and these derived factors. A cross-sectional household survey was undertaken during May-August 2001 in a district of South Wales with a population of 140,000. We found that factor analysis grouped our questions in factors similar to the theoretical ones we had previously envisaged. We also found that approximately one-third of the variance for neighbourhood quality and 10% for social control was explained at postcode (neighbourhood) level after adjusting for individual variables, thus suggesting that some of our compositional measures capture contextual characteristics of the built and social environment. After adjusting for individual variables, trust and social cohesion, two key social capital components were the only factors to show statistically significant associations with GHQ-12 scores. However, these factors also showed little variation at postcode levels, suggesting a stronger individual determination. We conclude that our results provide some evidence in support of an association between mental health (GHQ-12 scores) and perceptions of social capital, but less support for the contextual nature of social capital.

Background: A study was undertaken to see whether the prevalence of asthma has changed since a survey was conducted in 1988, using the same methods that showed an increase during the previous 15 years. Methods: A survey of 12 year old children was conducted in schools in South Wales where surveys had taken place in 1973 and 1988. The survey comprised a parentally completed questionnaire and an exercise challenge test, performed when no bronchodilator had been recently used. Results: In 1973, 1988, and 2003, questionnaires were obtained for 817, 965 and 1148 children, respectively; the exercise test was performed by 812, 960 and 1019 children, respectively. The prevalence of reported wheeze in the last year rose during each 15 year period (9.8%, 15.2%, 19.7%), with an even steeper rise in reported asthma ever (5.5%, 12.0%, 27.3%). There was a continued increase in wheeze attributed to running, in terms of all children (5.8%, 10.5%, 16.0%) and also as the proportion of those with a history of wheeze (34.1%, 47.0%, 57.3%). The use of inhaled corticosteroids (not available in 1973) increased fourfold between 1988 and 2003. The prevalence of exercise induced bronchoconstriction rose between 1973 and 1988 but had declined by 2003. Conclusions: The rise in the prevalence of asthmatic symptoms has continued since 1988. This appears to conflict with a reported recent decline, unless asthma prevalence peaked in the 1990s. The decline in exercise induced bronchoconstriction is probably attributable to better control of the disease as more children are now using inhaled corticosteroids as preventive treatment.

The effect of the built environment on the quality of life of its residents is of growing interest. To investigate this properly, a method for measuring the physical condition of residential areas is required and this paper describes the development of such a tool. The Residential Environment Assessment Tool (REAT) is designed as a survey instrument, to be completed by an independent observer, to produce a contextual measure of a neighbourhood, reflecting both physical aspects and also the extent to which residents have established territoriality over the area. The tool is based on 28 items which are aggregated to give a total score, ranging between 0 and 68, and subdivided into 5 different domains to reflect different aspects of the environment. Inter-observer comparisons show that the tool is reliable, with kappa coefficients for most of the item scores exceeding 0.9. To investigate its validity the results were compared with responses to a detailed survey of individual residents and significant positive associations were found between most relevant items. The tool is being used for studies involving common mental disorders in the community and should be valuable for local authorities in targeting interventions to improve the physical condition of their area.

Two successive randomized trials examined the effect of an increased intake of fatty fish, or the use of fish oil supplements, in reducing mortality in men with heart disease. The Diet and Reinfarction Trial (DART) was conducted in 2033 men who were recovering from acute myocardial infarction (MI). Those who were advised to eat fatty fish (or who opted to take fish oil capsules instead) had a 29% reduction in all-cause mortality over the following two years compared with those not so advised. The effect appeared in the first few months of the trial. The Diet and Angina Randomized Trial (DART 2) involved 3114 men with stable angina. Advice to eat fatty fish did not reduce mortality, and taking fish oil capsules was associated with a higher risk of cardiac and sudden death. The adverse effects of fish or fish oil were restricted to men not taking beta-blockers or dihydropyridine calcium-channel blockers, and were greater in those taking digoxin. Evidence from other sources strongly suggests an anti-arrhythmic action of fish oil, particularly after MI or in the presence of acute ischemia. The apparently conflicting results of the two trials may reflect different actions of n-3 fatty acids in acute and chronic conditions, together with different effects of eating fish and taking fish oil capsules. A mechanism is proposed that could account for these findings.

Objective: To investigate the effects of laboratory testing policies, particularly selective testing, rule-based reporting and isolate identification, on estimates of community antimicrobial resistance. Materials and methods: Antibiotic resistance estimates were analysed from an all-Wales dataset for approximately 300 000 community isolates of common pathogens. Results: Selective testing policies were often associated with markedly increased resistance, particularly for second-line testing. Site-specific testing tended to yield variant resistance estimates for eye and ear isolates. Estimates from rule-based reporting deviated markedly from test-result-based reporting. Urinary isolates reported as Escherichia coli showed greater susceptibility than those reported as undifferentiated urinary ‘coliforms’. The proportion of isolates tested for an antibiotic by a laboratory was a useful indicator of selective testing in this dataset. Selective testing policies had invariably been applied where the proportion of isolates of a species tested against an antibiotic was

Objective: To identify the most appropriate metric to determine the effectiveness of mobile speed cameras in reducing road traffic related injuries. Design: Controlled before and after study which compares two methods for examining the local effectiveness of mobile speed cameras—a circular zone around the camera and a route based method to define exposure at various distances from sites. Setting: South Wales, UK. Subjects: Persons injured by road traffic before and after intervention. Intervention: Use of mobile speed cameras at 101 sites. Main outcome measures: Rate ratio of injurious crashes at intervention and control sites. Results: Camera sites had lower than expected numbers of injurious crashes up to 300 metres using circles and up to 500 metres using routes. Routes methods indicated a larger effect than the circles method except in the 100 metres nearest sites. A 500 metre route method was used to investigate the effect within strata of time after intervention, time of day, speed limit, and type of road user injured. The number of injurious crashes after intervention was substantially reduced (rate ratio 0.49, 95% confidence interval 0.42 to 0.57) and sustained throughout two years after intervention. Significant decreases occurred in daytime and night time, on roads with speed limits of 30 and 60–70 miles/hour and for crashes that injured pedestrians, motorcycle users, and car occupants. Conclusions: The route based method is the better method of measure effectiveness at distances up to 500 metres. This method demonstrates a 51% reduction in injurious crashes.