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Atmospheric particulate matter (PM) causes 3.7 million annual deaths worldwide and potentially damages every organ in the body. The cancer-causing potential of fine particulates (PM2.5) highlights the inextricable link between air quality and human health. With over half of the world's population living in cities, PM2.5 emissions are a major concern, however, our understanding of exposure to urban PM is restricted to relatively recent (post-1990) air quality monitoring programmes. To investigate how the composition and toxicity of PM has varied within an urban region, over timescales encompassing changing patterns of industrialisation and urbanisation, we reconstructed air pollution records spanning 200 years from the sediments of urban ponds in Merseyside (NW England), a heartland of urbanisation since the Industrial Revolution. These archives of urban environmental change across the region demonstrate a key shift in PM emissions from coarse carbonaceous 'soot' that peaked during the mid-twentieth century, to finer combustion-derived PM2.5 post-1980, mirroring changes in urban infrastructure. The evolution of urban pollution to a recent enhanced PM2.5 signal has important implications for understanding lifetime pollution exposures for urban populations over generational timescales. [ABSTRACT FROM AUTHOR]

Background: During the first wave of the COVID-19 pandemic, the United Kingdom experienced one of the highest per-capita death tolls worldwide. It is debated whether this may partly be explained by the relatively late initiation of voluntary social distancing and mandatory lockdown measures. In this study, we used simulations to estimate the number of cases and deaths that would have occurred in England by 1 June 2020 if these interventions had been implemented one or two weeks earlier, and the impact on the required duration of lockdown. Methods: Using official reported data on the number of Pillar 1 lab-confirmed cases of COVID-19 and associated deaths occurring in England from 3 March to 1 June, we modelled: the natural (i.e. observed) growth of cases, and the counterfactual (i.e. hypothetical) growth of cases that would have occurred had measures been implemented one or two weeks earlier. Under each counterfactual condition, we estimated the expected number of deaths and the time required to reach the incidence observed under natural growth on 1 June. Results: Introducing measures one week earlier would have reduced by 74% the number of confirmed COVID-19 cases in England by 1 June, resulting in approximately 21,000 fewer hospital deaths and 34,000 fewer total deaths; the required time spent in full lockdown could also have been halved, from 69 to 35 days. Acting two weeks earlier would have reduced cases by 93%, resulting in between 26,000 and 43,000 fewer deaths. Conclusions: Our modelling supports the claim that the relatively late introduction of social distancing and lockdown measures likely increased the scale, severity, and duration of the first wave of COVID-19 in England. Our results highlight the importance of acting swiftly to minimise the spread of an infectious disease when case numbers are increasing exponentially. [ABSTRACT FROM AUTHOR]

Background and Objectives A 2008 European consensus on research outcome measures in dementia care concluded that measurement of carer quality of life (QoL) was limited. Three systematic reviews (2012, 2017, and 2018) of dementia carer outcome measures found existing instruments wanting. In 2017, recommendations were published for developing reliable measurement tools of carers' needs for research and clinical application. The aim of this study was to develop a new instrument to measure the QoL of dementia carers (family/friends). Methods Items were generated directly from carers following an inductive needs-led approach. Carers (n = 566) from 22 English and Welsh locations then completed the items and comparator measures at three time points. Rasch, factor, and psychometric (reliability, validity, responsiveness, and minimally important differences [MIDs]) analyses were undertaken. Results Following factor analysis, the pool of 70 items was refined to three independent scales: primary SIDECAR-D (direct impact of caring upon carer QOL, 18 items), secondary SIDECAR-I (indirect impact, 10 items), and SIDECAR-S (support and information, 11 items). All three scales satisfy Rasch model assumptions. SIDECAR-D, I, S psychometrics: reliability (internal ≥.70; test–retest ≥.85); convergent validity (as hypothesized); responsiveness (effect sizes: D: moderate; I and S: small); MIDs (D = 9/100, I = 10/100, S = 11/100). Discussion and Implications SIDECAR scales demonstrate robust measurement properties, meeting COSMIN quality standards for study design and psychometrics. SIDECAR provides a theoretically based needs-led QoL profile specifically for dementia carers. SIDECAR is free for use in public health, social care, and voluntary sector services, and not-for-profit organizations. [ABSTRACT FROM AUTHOR]

Objective: To explore the separate effects of being 'at risk' of gestational diabetes mellitus (GDM) and screening for GDM, and of raised fasting plasma glucose (FPG) and clinical diagnosis of GDM, on the risk of late stillbirth.Design: Prospective case-control study.Setting: Forty-one maternity units in the UK.Population: Women who had a stillbirth ≥28 weeks of gestation (n = 291) and women with an ongoing pregnancy at the time of interview (n = 733).Methods: Causal mediation analysis explored the joint effects of (i) 'at risk' of GDM and screening for GDM and (ii) raised FPG (≥5.6 mmol/l) and clinical diagnosis of GDM on the risks of late stillbirth. Adjusted odds ratios (aOR) were estimated by logistic regression adjusted for confounders identified by directed acyclic graphs.Main Outcome Measures: Screening for GDM and FPG levels RESULTS: Women 'at risk' of GDM, but not screened, experienced 44% greater risk of late stillbirth than those not 'at risk' (aOR 1.44, 95% CI 1.01-2.06). Women 'at risk' of GDM who were screened experienced no such increase (aOR 0.98, 95% CI 0.70-1.36). Women with raised FPG not diagnosed with GDM experienced four-fold greater risk of late stillbirth than women with normal FPG (aOR 4.22, 95% CI 1.04-17.02). Women with raised FPG who were diagnosed with GDM experienced no such increase (aOR 1.10, 95% CI 0.31-3.91).Conclusions: Optimal screening and diagnosis of GDM mitigate the higher risks of late stillbirth in women 'at risk' of GDM and/or with raised FPG. Failure to diagnose GDM leaves women with raised FPG exposed to avoidable risk of late stillbirth.Tweetable Abstract: Risk of #stillbirth in gestational diabetes is mitigated by effective screening and diagnosis. [ABSTRACT FROM AUTHOR]

Aim To explore the provision and variations in care for children and young people with cerebral palsies ( CP) registered with the population-based North of England Collaborative Cerebral Palsy Survey ( NECCPS). Method This is a retrospective multicentre record audit of 389 children with CP (220 males, 148 females, 21 no data; median age at time of audit 12y 3mo), born between 1995 and 2002. Data were collected on cranial magnetic resonance imaging ( MRI), hip and spine surveillance and management, and pain presence and management. Variations over time and between the districts in the north of England (Northumberland, North and West Cumbria, North and South Tyneside, Newcastle-upon-Tyne, Gateshead, Sunderland, Durham, Darlington, Bishop Auckland, Hartlepool, Stockton-on-Tees, Middlesbrough, Redcar, and Cleveland), and by socio-economic status ( SES) (estimated from the Index of Multiple Deprivation [ IMD] 2004) were estimated by generalized estimating equations. Results There was significant variation between districts in access to MRI ( p<0.001), orthopaedic surgeons ( p=0.005), recording state of spine ( p<0.001), and discussions about pain ( p<0.001). Fifty-seven per cent (95% CI 52-62) had evidence of a reported MRI brain scan, the proportion of which increased over time ( p<0.001). Sixty-seven per cent (95% CI 62-71) had a discussion about pain recorded. Of those in pain, 87% (95% CI 80-93) had a pain management plan. The proportion with documented discussion about pain increased with increasing SES ( p=0.04). Interpretation The provision of care for children with CP in the north of England varies between districts. Internationally agreed, evidence-based standards are urgently needed to ensure more equitable health care and improved outcomes for all. [ABSTRACT FROM AUTHOR]

Background: Partial urorectal septum malformation (pURSM) sequence (or 'persistent cloaca') is a rare congenital anomaly characterised by a joining of the urethral, anal, and genital openings into a single common channel. This study describes the epidemiology of pURSM sequence in England and Wales including prevalence, additional anomalies, and pregnancy outcomes. Methods: All cases of pURSM sequence prospectively notified to seven congenital anomaly registers in England and Wales during 1985-2010, whether delivered as live births, spontaneous fetal deaths (>20 weeks' gestation), or elective terminations of pregnancy for fetal anomaly (TOPFA, any gestation), formed this population-based cohort. The risks of spontaneous fetal and infant death were examined by Kaplan-Meier analysis. Differences in prevalence over time, and between regions, were examined by multilevel Poisson regression. Results: 117 cases were recorded among 4 251 241 total births. Six (5%) pregnancies resulted in spontaneous fetal deaths, 53 (45%) in TOPFA, and 58 (50%) in live births. The prevalence was 2.8 (95% CI 2.3 to 3.4) per 100 000 total births, increasing significantly over time (p=0.002) and differing significantly between regions (p=0.005). 77 cases (66%) had at least one additional major congenital anomaly outside the perineum, including 67 (57%) renal, 29 (25%) musculoskeletal, 26 (23%) digestive system, and 24 (21%) cardiovascular anomalies. The risks of spontaneous fetal and infant death were estimated as 8.9% (95% CI 4.1 to 18.8) and 26.3% (95% CI 15.1 to 43.4) respectively. Conclusions: This is the largest study of the epidemiology of pURSM sequence. The information will be valuable for families and health professionals whenever a case of pURSM sequence is diagnosed. [ABSTRACT FROM AUTHOR]

Background: The Epworth Sleepiness Scale (ESS-8) is frequently used in stroke but has never been validated for this condition. There is concern regarding the suitability of the driving item (item 8). A summed raw score of 10 or more (from a maximum of 24) signifies pathological sleepiness. Objective: To determine the construct validity of the ESS-8 by Rasch analysis and in particular to determine whether omission of item 8 confounds the scale. Method: A pack containing the ESS-8 and questions regarding sleep and demographics was sent to 999 patients who had experienced a stroke within the past 4 years. Data were assessed for fit to the Rasch model. Results: Analysis of 269 records revealed a unidimensional scale that was free from differential item functioning by age and sex with good overall fit to the Rasch model. Item 4 had disordered thresholds. Analysis of the ESS without item 8 (ESS-7) also revealed a valid scale. Equating person locations between the ESS-8 and ESS-7 showed no differences below a summed raw score of 18. Conclusion: The ESS-8 has good construct validity for use in stroke and is reliable at the cutpoint of 10. Summed raw scores below 18 will be unaffected if nondrivers either score as zero or simply omit item 8. The scale is therefore robust for detecting cases of pathological sleepiness in stroke but may not be suitable for measuring high levels of sleepiness in a sample containing both drivers and nondrivers. Instead, the ESS-7 could be used for this purpose. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate in a pilot study the usefulness of measures of health and psychosocial status for use with young people with physical and complex disability. Also to test empirically a conceptual model of the factors determining key outcomes in young disabled adults, in particular, participation (handicap). Design: A cross-sectional study involving face-to-face interviews with young adults aged 16–28 years (n = 45) with physical and complex disabilities. A group of nondisabled college students completed the same set of questions to provide normative scores for some psychosocial measures. Setting: Young people with physical disabilities were recruited from the area of North and North East Lincolnshire, and nondisabled young people from the Leeds area. Methods: Standardized measures of impairment, disability and handicap, together with various psychosocial scales were incorporated into a structured face-to-face interview. Standardized measures included the Nottingham Health Profile (NHP), the Barthel Index, the London Handicap Scale, Rosenberg’s Self-esteem Scale and the Proactive Scale. Results: Regression analysis showed the most important predictors of participation were energy and pain (NHP), disability (Barthel) and self-efficacy. Most of the health status measures were able to discriminate between disabled and nondisabled young people, but some measures lacked face validity for the ‘nonwalking’ disabled group. Conclusions: Both health status and psychosocial factors were found to impact on the participation of young people. Impairment and disability however, did not impact adversely on self-ratings of health or quality of life and it is clear from these results that having a disability may limit participation, but is not necessarily synonymous with a poorer quality of life. [ABSTRACT FROM AUTHOR]

A survey of rheumatic disablement in the population has enabled the comparative impact of self reported causes of disability to be studied. One in three households in Calderdale, West Yorkshire, United Kingdom was screened in 1986 with a postal questionnaire (87% response rate), followed by in depth interviews with a sample of subjects reporting disability in conjunction with a rheumatic disorder (608 interviews). Severity of disablement was assessed using the physical independence handicap classification. The estimated prevalence of disability in conjunction with reported rheumatic disorders is 82/1000 population aged at least 16 years (95% confidence interval (CI) 77 to 87). Arthritis (mainly osteoarthritis) is the most commonly reported cause (47/1000 population; 95% CI 43 to 51), followed by back or neck disorders (25/1000; 95% CI 23 to 28), soft tissue disorders (18/1000; 95% CI 15 to 20), and rheumatoid arthritis (RA) (4/1000; 95% CI 3 to 5). A total of 30% reported more than one category of rheumatic disorder (mean number 1.3) and 63% reported non-rheumatic comorbidity. Current joint symptoms were reported by 98%, current antirheumatic drugs (including analgesics) by 70%, and severe pain by 62%. Overall 82% of subjects had seen their general practitioner in the past year, and 71% reported having attended an outpatient clinic; 26% reported current outpatient clinic attendance, and 15% a hospital inpatient stay during the previous year. Forty six per cent reported some dependence, with 12% reporting being dependent on a daily basis. Rheumatoid arthritis was the most disabling disorder with 73% dependent. Taking into account prevalence, osteoarthritis and back disorders are the most, and RA the least, common causes of dependence and incapacitating pain in the population. This challenges stereotypes and raises questions about the organisation and priorities for specialist services and for research. [ABSTRACT FROM PUBLISHER]

Problem To reduce hospital inpatient mortality and thus increase public confidence in the quality of patient care in an urban acute hospital trust after adverse media coverage. Design Eight care bundles of treatments known to be effective in reducing in-hospital mortality were used in the intervention year; adjusted mortality (from hospital episode statistics) was compared to the preceding year for the 13 diagnoses targeted by the intervention care bundles, 43 non-targeted diagnoses, and overall mortality for the 56 hospital standardised mortality ratio (HSMR) diagnoses covering 80% of hospital deaths. Setting Acute hospital trust in north west London. Strategies for change Use of clinical guidelines in care bundles in eight targeted clinical areas. Interventions Use of care bundles in treatment areas for the diagnoses leading to most deaths in the trust in 2006-7. Key measures for improvement Change in adjusted mortality in targeted and non-targeted diagnostic groups; hospital standardised mortality ratio (HSMR) during the intervention year compared with the preceding year. Effect of the change The standardised mortality ratio (SMR) of the targeted diagnoses and the HSMR both showed significant reductions, and the non-targeted diagnoses showed a slight reduction. Cumulative sum charts showed significant reductions of SMRs in 11 of the 13 diagnoses targeted in the year of the quality improvements, compared with the preceding year. The HSMR of the trust fell from 89.6 in 2006-7 to 71.1 in 2007-8 to become the lowest among acute trusts in England. 255 fewer deaths occurred in the trust (174 of these in the targeted diagnoses) in 2007-8 for the HSMR diagnoses than if the 2006-7 HSMR had been applicable. From 2006-7 to 2007-8 there was a 5.7% increase in admissions, 7.9% increase in expected deaths, and 14.5% decrease in actual deaths. Lessons learnt Implementing care bundles can lead to reductions in death rates in the clinical diagnostic areas targeted and in the overall hospital mortality rate. [ABSTRACT FROM AUTHOR]

Investigates the prevalence of knee problems in people aged 55 years and over among residents of North Yorkshire Health Authority in Great Britain. Identification of those who should be considered for knee arthroplasty; Age and sex specific rates in men who might benefit from arthroplasty; Reliability of knee replacement techniques.

The article offers information on challenges of optimising screening and diagnosis of gestational diabetes (GDM). Topics discussed the average effect of GDM in observational data contains both the harmful effect of the raised glucose and the beneficial effect of diagnosis; provide a unique estimate of the total causal effect of GDM; and treatment of GDM which reduce adverse outcomes including macrosomia.

The article focuses on the veterinary medicine research about thelazia species found in a wild deer in southern England. The research assessed that 41.9 percent of the animals are prevalence of infection with the thelazia gulosa and thelazia skrjabini. The Department of Pathology and Infectious Diseases of the Royal Veterinary College stresses that through the introduction of macrocyclic lactone endectocides like ivermectin, the percentage of infected animals decreases in 2004.

Describes a study designed to establish whether there had been a change in prevalence of Thelazia species infection in cattle slaughtered in the abattoir in Surrey, England. Application of digital pressure to the Harderian and orbital lachrymal glands to express any parasites present; Recovery of Thelazia species from the eyes of three cattle out of 195 being slaughtered; Number of Thelazia nematodes during the investigation.

Objective To investigate the influences of survival in children born with Down Syndrome. Design Population-based case-series derived from the Northern Congenital Abnormality Survey. Setting A geographically distinct area of Northeast England, incorporating North Cumbria, Northumberland, Tyne and Wear, Country Durham, and the Tees Valley. Participants 1101 individuals with Down Syndrome delivered between 01 January 1985 and 31 December 2003, of whom 697 were live born and 664 (95%) were traced for their survival status on 28 January 2008. Main outcome measures Overall prevalence of Down Syndrome. Frequency of additional structural anomalies among cases of Down Syndrome. 10-year survival for all cases of Down Syndrome, by time-period, and by presence, and type, of additional structural anomalies. Independent influence of year of birth, sex, plurality, gestational age, birthweight (standardised for sex, plurality, and gestational age), maternal age, index of multiple deprivation, prenatal diagnosis, and presence, and type, of additional structural anomalies on survival. Results Overall prevalence of Down Syndrome was 16.7 per 10 000 registered births (95% CI 15.6 to 17.6). 697 (63%) cases had no additional structural anomalies, 320 (29%) had isolated cardiovascular anomalies, 27 (2%) had isolated digestive system anomalies, 26 (2%) had both cardiovascular and digestive system anomalies, and 31 (3%) had at least one other structural congenital anomaly. 10-year survival among children born with Down syndrome was 83.9% (95% CI 80.9 to 86.5). Survival increased significantly with time (p<0.001), from a 10-year survival of 78.2% (95% CI 72.4 to 83.0) in 1985–1990 to 91.1% (86.7 to 94.1) in 1997–2003. Presence of an additional structural anomaly significantly reduced survival (p<0.001) from a 10-year survival of 94.1% (95% CI 90.9 to 96.1) among those with no additional anomaly to 75.2% (69.5 to 80.0), 68.4% (42.8 to 84.4), 54.2% (32.7 to 71.4), and 76.9% (44.2 to 91.9) among those with cardiovascular anomalies, digestive system anomalies, both cardiovascular and digestive system anomalies, and at least one other structural anomaly respectively. Of the other factors examined, only gestational age (p<0.001) and standardised birthweight (p=0.008) also independently predicted survival. Conclusion Independent of significant improvement over time, survival of children born with Down syndrome is influenced by gestational age, birthweight, and the presence of additional structural anomalies. This information will be valuable for families and health care professionals when Down Syndrome is detected, and will assist in planning, assessing, and aiding, the future care needs of those affected. [ABSTRACT FROM PUBLISHER]

Objective To investigate the association between maternal obesity and the prevalence of fetal and infant death. Design Cohort study using prospectively collected data matched to a high-quality population-based registry data of fetal and infant death. Setting Five maternity units in the North of England. Participants 40 932 singleton pregnancies delivered between 2003 and 2005, excluding 1092 pregnancies associated with a congenital anomaly and/or maternal pre-gestational diabetes, and 9998 pregnancies with missing maternal body mass index (BMI). Main Outcome Measures Prevalence, among singleton pregnancies, of late miscarriage (20–23 weeks gestation), termination of pregnancy for fetal anomaly (≥20 weeks gestation), stillbirth (≥24 weeks gestation), fetal death (miscarriage or antepartum stillbirth), perinatal mortality, neonatal mortality, post-neonatal mortality, and all infant mortality. Crude and adjusted (for maternal age, gestational age, where appropriate, birth weight, standardised for sex and gestational age, ethnicity, cigarette smoking status, index of multiple deprivation, and sex of infant/fetus) ORs of each outcome among maternal obese (BMI ≥30 kg/m) compared to maternal recommended BMI (BMI 18.5–24.9 kg/m). Results Compared to women of recommended BMI, obese women were at significantly greater risk of a fetal death (adjusted odds ratio (aOR) 2.94 (95% CI 2.02 to 4.27), p<0.001), including late miscarriage (aOR 3.27 (95% CI 1.43 to 7.44), p=0.005) and antepartum stillbirth (aOR 2.86 (95% CI 1.88 to 4.35), p<0.001), perinatal death (aOR 2.54 (95% CI 1.70 to 3.79), p<0.001), including stillbirth (aOR 2.77 (95% CI 1.86 to 4.13), p<0.001) and early neonatal death (aOR 3.00 (95% CI 1.12 to 8.03), p=0.03), and infant death (aOR 2.49 (95% CI 1.34 to 4.62), p=0.004), including neonatal death (aOR 2.57 (95% CI 1.13 to 5.88), p=0.03). There was no significant association between maternal obesity and post-neonatal death (aOR 2.27 (95% CI 0.89 to 5.80), p=0.09). The effect of obesity on risk of stillbirth was greater among small-for-gestational-age fetuses, but less among current smokers. Except for higher rates of pre-eclampsia among stillbirths, no specific cause of death could explain the increased odds of fetal and infant death among the obese. Conclusion Early-pregnancy obesity is significantly associated with fetal and infant death, independent of the known relationship with congenital anomalies. Further studies are required to investigate the specific mechanisms involved. In the meantime, women should be made aware of these risks and supported to optimise their weight before pregnancy. [ABSTRACT FROM PUBLISHER]

Background: While the prevalence and impact of musculoskeletal problems are high, most attention has been directed towards the back, knee and hip disorders. Foot pain is known to be common in older adults and accounts for a significant burden on health services. The aim of this study was to assess the impact of foot and ankle joint pain, considering age, presence of co-morbidities and other site joint pain, in a large community sample., Methods: In the North Yorkshire Health study, 16,222 people over 55 years participated in a detailed survey of the prevalence and impact of lower limb joint problems. Self-assessment of overall body pain and functional activities of daily living were assessed. Participants indicated the presence of joint pain, stiffness or swelling during the last 3 months which had lasted for more than 6 weeks on a manikin: data were captured on the foot and the ankle., Results: The prevalence of self-reported foot and ankle joint pain was substantial: 184.33 per 1000, second only to knee problems. While foot pain was common, it was mostly associated with joint pain at other sites; only 1 in 11 of those with foot and ankle pain reported it only in the foot. Logistic regression modeling revealed while established factors such as co-morbidities, knee and hip problems contributed to functional impairment, foot and ankle problems contributed to an additional increased risk of having difficulty standing and walking by two fold (OR = 2.314, 95%CI 2.061-2.598), going up and down stairs by 71% (OR = 1.711, 95%CI 1.478-1.980) and getting up from a seated position by 44% (OR = 1.438, 95%CI 1.197-1.729)., Conclusion: These results suggest that not only are foot problems in the over 55 age group extremely prevalent, they have a considerable impact on functional abilities., Competing Interests: Competing interestsThe authors declare they have no competing interests., (© The Author(s). 2019.)

Objective: To compare disease activity and disability over 2 years in early rheumatoid arthritis (RA) before and after implementation of treat-to-target therapy and identify predictors of adverse outcome., Methods: The Yorkshire Early Arthritis Register (YEAR) recruited 725 patients with early RA between 2002 and 2009, treated with a step-up approach. The Inflammatory Arthritis Continuum study (IACON) recruited cases between 2010 and 2014 and treated to target. A total of 384 IACON cases met 2010 American College of Rheumatology/European League Against Rheumatism criteria. Latent growth curves of change in Disease Activity Score in 28 joints (DAS28) and the Health Assessment Questionnaire (HAQ) were compared between YEAR and IACON. Latent class growth analysis identified trajectories of change. Baseline predictors of trajectories were identified using logistic regression., Results: The mean DAS28 over 2 years was lower in IACON than in YEAR. Latent trajectories of HAQ change in YEAR were high stable (21% of cohort), moderate reducing (35%), and low reducing (44%). Only moderate reducing (66%) and low reducing (34%) were seen in IACON. In both cohorts, female sex and fatigue predicted adverse HAQ trajectories (high stable and moderate reducing). Odds ratios (ORs) for moderate reducing compared to low reducing for women were 2.58 (95% confidence interval [95% CI] 1.69, 4.49) in YEAR and 5.81 (95% CI 2.44, 14.29) in IACON. ORs per centimeter fatigue visual analog score were 1.13 (95% CI 1.07, 1.20) in YEAR and 1.16 (95% CI 1.12, 1.20) in IACON., Conclusion: Treat-to-target therapy gave more favorable trajectories of change in DAS28 and HAQ, but adverse HAQ trajectory was more likely in women with greater fatigue, suggesting such patients would benefit from interventions to improve function as well as reduce inflammation., (© 2017, American College of Rheumatology.)

Background: Self-harm is common among prisoners, particularly female prisoners. In 2007, concerned about the rising incidence, the prison service introduced a care-planning system called Assessment, Care in Custody, and Teamwork (ACCT). To date, it does not incorporate a standardised diagnostic test to estimate the risk of future self-harm., Objective: To identify potential screening instruments, or items from those instruments, to predict the risk of self-harm among prisoners., Participants: Prisoners who had been assigned to an ACCT during the recruitment period., Design: A multistage prospective cohort study. Following a pilot study, instruments were administered to prisoners by interview at baseline, and followed up for 6 months (or until point of release if this was sooner) to ascertain self-harm status. Instruments were assessed for unidimensionality, scalability (Mokken) and quantitative structure (Rasch). Area under the curve (AUC) analysis was used to examine the ability of instruments and/or their items to predict future self-harm. Cox proportional hazards regression models were used to examine the multivariate predictive ability of the scales and various sociodemographic and sentencing factors., Setting: Three prisons (including one women's prison) in northern England., Main Outcome Measures: A set of standardised questionnaires, including the Prison Screening Questionnaire (PriSnQuest), Revised Borderline Symptom List-23 (frequency-based responses) (BSL-23-F), Self-Harm Inventory (SHI), Patient Health Questionnaire (PHQ-9) and the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), together with sociodemographic and sentencing data., Results: In total, 450 prisoners consented to participate in the study, of whom 26% were female. The mean age of participants was 31.2 years. Over half of male prisoners recruited were on remand, compared with just over one-fifth (22.6%) of female prisoners. The average tariff of those sentenced was 41 months, of which 14.7 months, on average, had been served. Just over one-third of ACCTs had been initiated because of a known self-harm event, and over one-quarter (27.8%) of participants self-harmed during the follow-up period. Thus, almost half (46.7%) of those entered into the study were reported to have self-harmed, either from their index ACCT, or subsequently, or both. Cutting was the most frequent behaviour (51%). All screening instruments showed some evidence of unidimensionality, and four out of five showed scaling criteria consistent with ordinal scaling, so verifying the validity of the cut points. However, many showed gender bias and failure to fit the Rasch measurement model. While a resolution was made in most cases, both ordinal raw scores and latent interval scale estimates failed to show predictive value when applied within AUC analysis (0.491-0.566) or adjusted Cox proportional hazards models. However, good predictive values were shown for gender-specific sets of items, thus providing easily applied screening indexes., Conclusions: While four out of five potential screening instruments were found to have acceptable psychometric properties within this setting, their predictive validity of all instruments was poor under AUC analysis. Gender-specific item sets were put together to form two screening indexes with formative indicators which gave reasonable AUC values, particularly so for females. The indexes provide identification of low-medium-high risk of self-harm, and so may help to inform potential care pathways and decisions to sign prisoners off from the ACCT. Future work should concentrate on refining a set of predictive screening items among different offender populations and investigating the time point at which this set of items should be administered. Future work may also look at the different magnitudes of risk as indicators for care pathways., Funding: The National Institute for Health Research Health Technology Assessment programme.

Background: Self-efficacy concerns the individual's belief that he or she is capable of performing a certain task and producing a desired effect, i.e. it reflects the person's perceptions of their capability for specific tasks, as distinct from their actual ability. Self-efficacy has been shown to influence motivation, psychological well-being, adherence with treatment regimes and quality of life in multiple sclerosis and other conditions., Objective: To develop a unidimensional scale of MS self-efficacy with robust psychometric properties, suitable for patient self report., Methods: A questionnaire pack covering three MS self-efficacy scales, the Dispositional Resilience Scale and demographic data was posted to MS patients from two MS databases. Data underwent Rasch analysis., Results: Response rate was 309/600 (51.5%). None of the existing MS self-efficacy scales were unidimensional. A new 12-item scale, created by combining items from our two scales, was shown to fit the Rasch model, was unidimensional, and invariant for gender, education and disease duration., Conclusion: The Unidimensional Self-Efficacy scale for MS (USE-MS) provides a simple summated scale for an ordinal estimate of a persons' self efficacy. A transformation to interval scaling is available for use in the calculation of change scores and effect sizes.

Background: Multiple sclerosis (MS) mainly presents amongst those of working age. Depending upon the type of MS, many people embark upon a long period of managing their day-to-day work-related needs in the face of intermittent and sometimes persistent disabling symptoms. The objective of this study was to explore the concept of work instability (WI) following the onset of MS and develop a Work Instability Scale (WIS) specific to this population., Method: WI amongst those with MS in work was explored through qualitative interviews which were then used to generate items for a WIS. Rasch analysis was used to refine the scaling properties of the MS-WIS, which was then validated against expert vocational assessment by occupational health physiotherapists and ergonomists., Results: The resulting measure is a 22-item, self-administered scale which can be scored in three bands indicating low, medium and high risk of WI (job retention) problems. The scale meets modern psychometric requirements for measurement, indicated by adequate fit to the Rasch model with absence of local dependency and differential item functioning (DIF) by age, gender and hours worked., Conclusions: The scale presents an opportunity in routine clinical practice to take positive action to reduce sickness absence and prevent job loss.

Objective: To establish the prevalence and patterns of self-reported musculoskeletal symptoms in community-dwelling stroke survivors and their impact on common activities of daily living., Methods: Analysis of data from two consecutive postal surveys in northern England. Data on overall joint pain, swelling or stiffness and difficulties with daily living tasks were obtained from 16,222 individuals aged ≥ 55 years (a response rate of 86%). Information on stroke-specific impairments was obtained from the 415 individuals who reported a stroke., Results: Forty-seven percent of stroke survivors reported musculoskeletal symptoms. There was a greater prevalence of reported symptoms in the smaller peripheral joints: 23.4% of stroke survivors reported symptoms in the ankle joint compared with 12.3% in the general population aged ≥ 55 years. Although both stroke-specific impairments and musculoskeletal pain contributed to difficulty in functional tasks, the effect of both was more than additive (for example, left hip symptoms increased the risk of having difficulty with standing and walking by 10.3 times (95% confidence interval 1.0, 106.3); stroke affecting the right leg increased the odds by 4.8 times (95% confidence interval 2.5, 9.2). Having both impairments increased the odds by 49.1 times (95% confidence interval 10.7, 225.4))., Conclusion: Musculoskeletal symptoms are common in people with stroke and can have a significant additional effect on disability.

Objectives: Anti-tumour necrosis factor (anti-TNF) therapy is effective in the treatment of ankylosing spondylitis (AS), but guidelines are needed because of the cost. The primary aim of this study was to evaluate the proportion of patients with AS who meet the criteria for anti-TNF therapy as well as to explore the relationship between disease activity, health status and quality of life in patients with AS who would potentially meet the criteria compared with those who would not., Methods: All patients with a confirmed diagnosis of AS were identified via a search through the clinic correspondence database and sent postal questionnaires. Data captured included demographics, disease activity, aspects of functional impairment, activity limitation and quality of life using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), pain scores (using a visual analogue scale), the Bath Ankylosing Spondylitis Functional Index (BASFI), Health Assessment Questionnaire (HAQ), short-form 36 (SF-36) and the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire. The unpaired Student's t-test, chi(2) test and Mann-Whitney U-test were performed for comparisons of groups where appropriate., Results: Out of 325 mailed questionnaires, 246 (76%) were returned. The mean age of the patients who replied to the questionnaire was 52 yr (+/-12 yr) and 25% (62) were females. Mean BASDAI was 49 (+/-24) and 64% had a BASDAI > or = 40. There were significant differences between the groups with a BASDAI above and below 40 in pain by VAS, functional ability (BASFI, HAQ), health status (SF-36) and quality of life (ASQoL). Almost two-thirds (64%) of patients would meet the criteria for anti-TNF therapy under recommended guidelines., Conclusion: Patients with AS demonstrated poor functional status and poor quality of life. There is a large unmet need for effective therapy in AS, with almost two-thirds of patients meeting the proposed criteria for biological therapy. Patients with a BASDAI > or = 40 had a worse functional status and quality of life than those who have a BASDAI of <40. These results indicate that the need for effective intervention for AS is a priority area.

Purpose: This paper describes the application of the handicap dimension of the International Classification of Impairments, Disabilities and Handicaps., Method: A method of assessing four of the six roles (or areas of expected competency) was developed and applied to an in-patient population, aged 16 to 65 years, receiving specialist rehabilitation following neurological damage. Handicap assessment was a collaborative process by a multidisciplinary team. Difficulties were experienced in measuring inter-rate reliability in the busy, clinical setting., Results: We conclude that handicap assessment in an in-patient rehabilitation unit which uses a multidisciplinary approach to treating patients with complex physical, sensory and cognitive problems is both feasible and useful., Conclusion: The developed scale, The Leeds Assessment Scale of Handicap, provides a valid and valuable summary of human disadvantage, complementing the common disability assessments.

Objective: To investigate the psychosocial factors associated with consultation for low back pain., Design: Two phase cross sectional postal survey., Setting: Bradford Metropolitan Health District., Subjects: 1813 adults responding to the phase 1 questionnaire. 540 of the 782 with an episode of low back pain in the past 12 months completed the second questionnaire., Main Outcome Measures: Six psychosocial constructs., Results: 406 (52%) of the respondents reporting back pain in the past 12 months had not consulted a health professional. Logistic regression showed that consultation was associated with externalised beliefs regarding pain management (odds ratio 3.6; 95% confidence interval 2.1 to 6.0). Duration of pain affected the factors associated with consultation. Consultation for episodes lasting less than two weeks (n=290) was associated with greater than median pain (3.0; 1.7 to 5.5), consultation for episodes over two weeks (n=243) was associated with increased disability (3.7; 1.5 to 9.0), and consultation for episodes over three months (n=143) with increased depression (3.9; 1.3 to 11.8)., Conclusions: The results support a role for psychosocial factors in consultation for low back pain and suggest that the reasons for consultation vary with duration of pain. Duration of the episode may be a useful guide to management of non-specific low back pain.

The extent of mood disorders following traumatic brain injury (TBI), and the possible risk factors, are investigated. New data are presented from a prospective study of consecutive hospital admissions. Six months post-TBI, 99 adults completed a standardized assessment of emotional state, the Wimbledon Self-Report Scale. Cognitive performance and the impact of the injury on everyday functioning were also assessed. The rate of clinically significant mood disorders (caseness) was 38%. Of the demographic or injury characteristics, only pre-injury occupational status predicted post-injury caseness. Those unoccupied pre-injury were more likely to report mood disturbance post-injury. In contrast, post-injury occupational status was not related to caseness either for the whole group or the subgroup of those previously occupied, despite the adverse effects on occupational functioning for a significant proportion of subjects. Associations were found between emotional state and cognitive and everyday functioning 6 months post-injury. Psychosocial disabilities appeared more strongly associated to mood disorders than did physical disabilities. A significant level of unmet need has been highlighted, and possible risk factors identified, which may inform the purchase and provision of TBI rehabilitation services. Follow-up data on these subjects are available and will be reported separately.

Study Objective: To assist a purchasing district in the planning of services for low back pain by assessing the prevalence of symptoms and the current involvement of primary, secondary, and complementary care in the treatment of low back pain. In the light of these findings, to assess further the potential impact of a new system of open access to physical therapy, as recommended by the British Clinical Standards Advisory Group (CSAG)., Design: A two-stage cross sectional survey approach using postal questionnaires., Subjects: Altogether 1437 men and 1747 women aged 25-64 years, randomly selected from the family health services association register in Bradford., Main Results: An annual incidence of 4.7% for low back pain was found, with lifetime, 12 month period, and point prevalences of 59%, 39%, and 19% respectively. Over a one year period, 50.3% of episodes were acute (< 2 weeks), 21% were subacute (2 weeks-3 months), and 26% were chronic (over 3 months) in duration. Altogether 17.8% of the population in this age range experienced referred pain, numbness, or tingling, and 6.4% took time off work as a result of low back pain. In the same year, 20% of the population in the same age range consulted no-one about their pain, 13.7% were treated at the primary care level, 4% received secondary care, and 3% visited a complementary therapist. One fifth of those who did not consult a professional experienced severe pain during episodes. Prevalence estimates indicate that an emphasis on early intervention and primary care management of simple low back pain as recommended by the CSAG could generate a 131% surge in demand for physical therapy., Conclusions: Local prevalence estimates may allow purchasers to estimate the potential effects of a shift in management policy for low back pain and to highlight areas of unmet need in terms of resources and patient education.

Study Objective: The aim of this study was to determine the prevalence of stroke survivors in a health district population aged 55 years and over., Design: This was a point prevalence study using two-stage postal questionnaires sent to an age stratified random sample of the population., Setting: A district health authority in northern England with a resident population of 723,000., Subjects: Altogether 18,827 residents aged 55 years or over., Main Results: Prevalence was found to increase with age and, apart from the very elderly, males had a higher prevalence than females. Overall prevalence was found to be 46.8/1,000 (95% CI 42.5, 51.6). 23% of respondents reported full recovery from stroke. Cognitive impairments (33%), problems with lower limbs (33% for right leg; 27% for left leg) and speech difficulties (27%) were the most common residual impairments., Conclusions: Current guidelines to purchasers on the provision of services to those who have had a stroke may under-estimate prevalence rates by as much as 50%. This could lead to a shortfall in provision of services designed to support people in the months and years following their stroke.

As most of those experiencing traumatic brain injury tend to be young, disabled survivors will be gradually accruing in each locality as each year passes. How many need continuing care a decade after injury? How many need day care, or need help with finding work, or continuing support for carers? 190 patients who had been admitted to two UK regional neurosurgical units on average some 7 years earlier were followed up. With an average age of 29 years these patients stayed in hospital for an average 33 days. At follow-up 23% were classified as having moderate disability or worse on the Glasgow Outcome Scale, including 7.4% who had died subsequent to discharge. Survivors were given a neuropsychological assessment and a socioeconomic interview. Of the survivors, 17% had failed to make a good recovery, but 36% were failing to occupy their time in a meaningful way. Age over 30 at time of injury, not occupied before injury, and above-average length of stay were some of the predictors for failing to occupy time. Quality of life was severely curtailed for those who could not occupy their time, as was the case for their carers. Appropriate counselling, vocational evaluation and family support in the early years following injury may help to improve quality of life for both the head-injured person and their carers.

Research on disablement highlights a wide variability in the impact of disabling conditions on individuals' lives. However, in most of this work, the relationships between impairment/disability and features of individuals' social and physical environments are not specified conceptually. Recent conceptual work in the context of the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) suggests that the impact of impairment/disability on individuals' lives is contingent on levels of resources and other aspects of social context. The research question addressed in this paper is whether selected social factors affect the impact of impairment/disability on mobility handicap, defined as 'the individual's ability to move about effectively in his/her surroundings'. Two types of social factors are considered: resources such as help from others or having a car available; and social role obligations such as having a job or visiting relatives. Data are derived from a 1986 probability sample of 570 individuals with disabilities living in communities in Calderdale, Yorkshire, England. Multiple-regression models indicate that the impact of walking disability on mobility handicap was reduced by availability of a car in the household and school or job obligations. Other impairments/disabilities, resources and social role demands examined did not act on mobility outcomes in this manner. Implications for conceptualizing and testing relationships between impairment, disability, handicap and social and physical environments are discussed. A critical task for future research is the investigation of personal and social resources and barriers that may moderate the impact of disability on individuals' lives.

Study Objective: The aim was to determine whether or not there was a measurable risk of ill health associated with contact with sea water for children between the ages of 6 and 11 years old., Design and Setting: This was a prospective survey carried out on Blackpool beach. Parents of children between the ages of 6 and 11 years were interviewed over a seven week period during July, August, and September, 1990. Respondents were followed up 10-14 d after the original interview by either telephone or post. Water samples were collected on each day of the survey., Participants: 939 interviews with parents or guardians were completed on the beach; 857 (91.9%) of these persons agreed to a follow up interview. The results of this study are based on 703 cases of matched data, of good quality, collected for each child on the beach and during a follow up interview., Main Results: Non-compliance with the European Community microbiological imperative standards for recreational waters at Blackpool Tower and South Pier sampling sites, respectively, ranged between: 6% and 7% for total coliforms; 13% and 25% for faecal coliforms; 69% and 80% for faecal streptococci (Guide standard); 50% and 67% for salmonellae and 73% and 88% for enteroviruses. There was a significant overall increase in the mean number of symptoms reported for each child (p < 0.001). However, the prevalence of certain symptoms increased significantly only in those children who had been in contact with the water on the day of the beach interview. These symptoms included vomiting (p < 0.0009), diarrhoea (p < 0.0001), itchy skin (p < 0.0009), fever (p < 0.0013), lack of energy (p < 0.0007), and loss of appetite (p < 0.0227). None of the other variables investigated could account for the significant increase in the reported symptom experience of those children in contact with sea water contaminated with sewage., Conclusions: Children who come into contact with contaminated sea water are likely to develop symptoms as a result.

A survey of the age-sex specific prevalence of joint problems in a population and associated features such as disablement and use of treatment was carried out in 1986 in Calderdale, West Yorkshire, United Kingdom. A postal questionnaire was sent to 25,168 households; 87% were returned, representing households containing 42,826 people aged 16 years and over. Positive answers to a question about pain, swelling, or stiffness in the joints, neck, or back were given by 10,246 subjects, 24% of the population aged 16 years and older, of whom 6181 (60.3%) were women. The rate of reporting of joint problems increased markedly with age, from 5% for subjects aged 16-24 years to 54% for those aged 85 years and older. The joint sites most often reported as affected were the knee and the back, with a frequency in the population of about 10%. The increase in joint problems with age was accompanied by an increase in reported morning stiffness of more than half an hour, taking drugs, and disability, but not in reporting seeing a specialist for these conditions. Of those aged 85 years and older who reported joint problems, most also had difficulty or dependence in activities of daily living. The increasing prevalence of joint problems with age has implications for the provision of care, both in the community and in hospitals, especially in view of the aging of the population as a whole. The planning of health services for those with rheumatic disorders needs to take into account the high incidence of joint problems in the population.

A population survey with the aim of obtaining information to facilitate the planning of services for younger physically disabled people provided the opportunity to explore the use of physical independence handicap in this context. A Phase 1 sift questionnaire was sent to one in three (25,167) occupied households in Calderdale, a district in Yorkshire, England, with a final 87% response rate. A Phase 2 in-depth interview was carried out on a stratified random sample of those identified as disabled in Phase 1. Interviews were obtained with 570 individuals aged 16-64 years, 93% of those available. The measure of physical independence handicap was derived from data obtained in the interview indicating need for help at infrequent or short intervals and immediate-needs dependence. The estimated prevalence of dependent people aged 16-64 in Calderdale is 26.6 per 1000 population (95% CI: 24.9-28.3). Rates were higher in females, and both prevalence and level of dependence increased with age. Disability in activities of daily living and locomotion was linked to the level of physical independence handicap. Problems with housework and collecting (including shopping) were most frequent for those who needed help on an infrequent basis, while self-care needs were substantial for the short and immediate-needs dependence groups. Only a small proportion reported receiving services in their home during the previous 12 months; 20% received services from a nurse and 10% the services of a local authority home help. Overall, 91% reported contact with the primary health care team within the previous 12 months and 68% with hospital and rehabilitation services.(ABSTRACT TRUNCATED AT 250 WORDS)

Two approaches to the ascertainment of physical independence handicap have been explored using data from a survey of disablement in the population. The survey used a two-stage methodology with an initial postal shift to ascertain those with selected disabilities, a stratified random sample of whom were followed-up with an in-depth interview. The first approach to handicap was direct ascertainment of the scale categories by means of a question in the interview schedule. The second approach was to synthesize the scale categories from the answers to interview questions about disabilities in activities of daily living and other relevant factors. The final synthesized algorithm gave a 75% match within one scale point with the direct question and 85% agreement with receipt of attendance allowance, a state benefit paid to those meeting certain criteria for dependence on others. The lessons learned from the work have been incorporated in a revised and expanded scale, which is suggested as a starting point for revision of physical independence dimension of handicap.