Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies.

OBJECTIVES: There is little consensus regarding the burden of pain in the UK. The purpose of this review was to synthesise existing data on the prevalence of various chronic pain phenotypes in order to produce accurate and contemporary national estimates. DESIGN: Major electronic databases were searched for articles published after 1990, reporting population-based prevalence estimates of chronic pain (pain lasting >3 months), chronic widespread pain, fibromyalgia and chronic neuropathic pain. Pooled prevalence estimates were calculated for chronic pain and chronic widespread pain. RESULTS: Of the 1737 articles generated through our searches, 19 studies matched our inclusion criteria, presenting data from 139 933 adult residents of the UK. The prevalence of chronic pain, derived from 7 studies, ranged from 35.0% to 51.3% (pooled estimate 43.5%, 95% CIs 38.4% to 48.6%). The prevalence of moderate-severely disabling chronic pain (Von Korff grades III/IV), based on 4 studies, ranged from 10.4% to 14.3%. 12 studies stratified chronic pain prevalence by age group, demonstrating a trend towards increasing prevalence with increasing age from 14.3% in 18-25 years old, to 62% in the over 75 age group, although the prevalence of chronic pain in young people (18-39 years old) may be as high as 30%. Reported prevalence estimates were summarised for chronic widespread pain (pooled estimate 14.2%, 95% CI 12.3% to 16.1%; 5 studies), chronic neuropathic pain (8.2% to 8.9%; 2 studies) and fibromyalgia (5.4%; 1 study). Chronic pain was more common in female than male participants, across all measured phenotypes. CONCLUSIONS: Chronic pain affects between one-third and one-half of the population of the UK, corresponding to just under 28 million adults, based on data from the best available published studies. This figure is likely to increase further in line with an ageing population.

Influenza A(H1N1)pdm09 in England, 2009 to 2011: a greater burden of severe illness in the year after the pandemic than in the pandemic year.

Influenza pandemics are often perceived as single-year events, but the burden of previous influenza pandemics has in reality been spread over a number of years. The aim of this paper is to compare the burden of influenza in the pandemic year 2009/10 with that in the year immediately after (2010/11) in England. We compared four measures of disease. There was a greater burden of severe illness in 2010/11 compared with 2009/10: more deaths (474 vs 361), more critical care admissions (2,200 vs 1,700), and more hospital admissions (8,797 vs 7,879). In contrast, there were fewer general practice consultations in 2010/11 compared with 2009/10 (370,000 vs 580,000). There was also much less public interest in influenza, as assessed by number of Google searches. This is a worrying finding, as by the time of the second influenza season, much had been learnt about the potential impact of the influenza A(H1N1)pdm09 virus and an effective vaccine developed. We suggest that a widespread assumption of 'mildness' led to insufficient ongoing action to prevent influenza and hence to avoidable influenza-related deaths. This offers a lesson to all countries, both for future influenza seasons and for pandemic preparedness planning.

Alcohol skin preparation causes surgical fires.

INTRODUCTION: Surgical fires are a rare but serious preventable safety risk in modern hospitals. Data from the US show that up to 650 surgical fires occur each year, with up to 5% causing death or serious harm. This study used the National Reporting and Learning Service (NRLS) database at the National Patient Safety Agency to explore whether spirit-based surgical skin preparation fluid contributes to the cause of surgical fires. METHODS: The NRLS database was interrogated for all incidents of surgical fires reported between 1 March 2004 and 1 March 2011. Each report was scrutinised manually to discover the cause of the fire. RESULTS: Thirteen surgical fires were reported during the study period. Of these, 11 were found to be directly related to spirit-based surgical skin preparation or preparation soaked swabs and drapes. CONCLUSIONS: Despite manufacturer's instructions and warnings, surgical fires continue to occur. Guidance published in the UK and US states that spirit-based skin preparation solutions should continue to be used but sets out some precautions. It may be that fire risk should be included in pre-surgical World Health Organization checklists or in the surgical training curriculum. Surgical staff should be aware of the risk that spirit-based skin preparation fluids pose and should take action to minimise the chance of fire occurring.

Mortality due to pandemic (H1N1) 2009 influenza in England: a comparison of the first and second waves.

Deaths in England attributable to pandemic (H1N1) 2009 deaths were investigated through a mandatory reporting system. The pandemic came in two waves. The second caused greater population mortality than the first (5·4 vs. 1·6 deaths per million, P<0·001). Mortality was particularly high in those with chronic neurological disease, chronic heart disease and immune suppression (450, 100, and 94 deaths per million, respectively); significantly higher than in those with chronic respiratory disease (39 per million) and those with no risk factors (2·4 per million). Greater mortality in the second wave has been observed in all previous influenza pandemics. This time, the explanation appears to be behavioural. This emphasizes the importance of maintaining public and clinical awareness of risks associated with pandemic influenza beyond the initial high-profile period.

Hospitalization in two waves of pandemic influenza A(H1N1) in England.

Uncertainties exist regarding the population risks of hospitalization due to pandemic influenza A(H1N1). Understanding these risks is important for patients, clinicians and policy makers. This study aimed to clarify these uncertainties. A national surveillance system was established for patients hospitalized with laboratory-confirmed pandemic influenza A(H1N1) in England. Information was captured on demographics, pre-existing conditions, treatment and outcomes. The relative risks of hospitalization associated with pre-existing conditions were estimated by combining the captured data with population prevalence estimates. A total of 2416 hospitalizations were reported up to 6 January 2010. Within the population, 4·7 people/100,000 were hospitalized with pandemic influenza A(H1N1). The estimated hospitalization rate of cases showed a U-shaped distribution with age. Chronic kidney disease, chronic neurological disease, chronic respiratory disease and immunosuppression were each associated with a 10- to 20-fold increased risk of hospitalization. Patients who received antiviral medication within 48 h of symptom onset were less likely to be admitted to critical care than those who received them after this time (adjusted odds ratio 0·64, 95% confidence interval 0·44-0·94, P=0·024). In England the risk of hospitalization with pandemic influenza A(H1N1) has been concentrated in the young and those with pre-existing conditions. By quantifying these risks, this study will prove useful in planning for the next winter in the northern and southern hemispheres, and for future pandemics.

Surgical fires, a clear and present danger.

BACKGROUND: A surgical fire is potentially devastating for a patient. Fire has been recognised as a potential complication of surgery for many years. Surgical fires continue to happen with alarming frequency. We present a review of the literature and an examination of possible solutions to this problem. METHODS: The PubMed and Medline databases from 1948 onwards were searched using the subject headings "operating rooms", "fire", "safety" and "safety management". "Surgical fire" was also searched as a keyword. Relevant references from articles were obtained. RESULTS: Fire occurs when the three elements of the fire triad, fuel, oxidiser and ignition coincide. Surgical fires are unusual in the absence of an oxygen-enriched atmosphere. The ignition source is most commonly diathermy but lasers carry a relatively greater risk. The majority of fires occur during head and neck surgery. This is due to the presence of oxygen and the extensive use of lasers. The risk of fire can be reduced with an awareness of the risk and good communication. CONCLUSIONS: Surgery will always carry a risk of fire. Reducing this risk requires a concerted effort from all team members.

The epidemiology of fractures in England.

INTRODUCTION: Fractures are a considerable public health burden in the United Kingdom but information on their epidemiology is limited. OBJECTIVE: This study aims to estimate the true annual incidence and lifetime prevalence of fractures in England, within both the general population and specific groups, using a self-report methodology. METHODS: A self-report survey of a nationally representative general population sample of 45,293 individuals in England, plus a special boost sample of 10,111 drawn from the ethnic minority population. RESULTS: The calculated fracture incidence is 3.6 fractures per 100 people per year. Lifetime fracture prevalence exceeds 50% in middle-aged men, and 40% in women over the age of 75 years. Fractures occur with reduced frequency in the non-white population: this effect is seen across most black and minority ethnic groups. CONCLUSIONS: This study suggests that fractures in England may be more common than previously estimated, with an overall annual fracture incidence of 3.6%. Age-standardised lifetime fracture prevalence is estimated to be 38.2%. Fractures are more commonplace in the white population.

1969 revisited: reflections on Tomorrow's community physician.

This lecture focuses on a paper that Jerry Morris published in the Lancet of Saturday 18 October 1969 entitled Tomorrow's Community Physician. It was a seminal paper in which a vision of the role and potential of a new breed of public health practitioner was set out. The themes raised in the original paper which examined population health and health service issues, are revisited, by assessing how things have changed, and in particular examining the extent to which the vision set out in the paper has become reality over the last 30 years.

Safe high quality health care: investing in tomorrow's leaders.

The agenda for health care in developed countries in the 21st century will be dominated by a vision of quality which seeks to address the deep seated problems of the past. The ability to deliver safe, effective, high quality care within organisations with the right cultures, the best systems, and the most highly skilled and motivated work forces will be the key to meeting this challenge. This is an issue which should be a priority for education and training bodies. The need for health services to give priority to developing health professionals equipped to practise in a new way and thrive in new organisational environments requires a rapid response to reshape curricula and training programmes. Developing leadership and management skills will be essential in achieving this transformation in the quality of care delivered to patients.

125 years of public health in the UK.

This paper examines four themes in public health theory and practice: all are important for the future and are illuminated by the last 125 years. First, while definitions of public health may be stable, the rationale of public health practice--'why bother?'--has altered considerably over time. A second theme revolves around personal autonomy--can we compel individuals to take health promoting measures? Third, public health practice today pays attention as never before to the use of research-based evidence, helping to answer three questions: What are the problems? What are their causes? What are the solutions? The fourth theme is the changing character, locus and focus of public health. From being predominantly locally focused within Borough Councils, albeit operating within frameworks of national legislation and one eye on global threats, it has become much more complex with emerging levels of action which encompass the neighbourhood, the strategic district, the region, nation state, Europe and finally the ever more pressing globalisation agenda as it affects the human condition. Public health has been medically dominated for the last 125 years and this is now changing. Its ties with local government are being strengthened after a break of nearly 30 years. The focus of public health has recently been strongly on health services. This reached its apogee a few years ago but is also now rapidly changing. Looking back over the last 125 years can help us identify some of the mistakes to be avoided and opportunities to be seized at this time of change.

Impact of clinical practice guidelines on clinicians' behaviour: tonsillectomy in children.

OBJECTIVE: This study was conducted to assess the extent to which developing and implementing clinical practice guidelines for listing children for tonsillectomy (with or without adenoidectomy) influenced the behaviour of participating ENT surgeons. METHOD: A before and after study in which the intervention (the development and dissemination of local practice guidelines) was introduced sequentially into different hospitals and surgical practice. The study was conducted in four ear, nose, and throat surgical services in the North of England, with 16 consultant ENT surgeons and their junior staff on 1190 children aged 0 to 14 years who were judged, prior to consultation with an ENT surgeon, to have been referred for throat-related problems for which tonsillectomy was one possible treatment option were included in the study. Decision reached by surgeons and proportion of decisions that complied with new guidelines. RESULTS: Of the clinical decisions to list children for tonsillectomy taken before introduction of locally agreed guidelines, 73% (486/660) conformed to the criteria in the subsequent guidelines, 15% (97/660) did not, and in 12% (77/660), it was impossible to judge. After the intervention, the corresponding figures were 73% (386/530), 14% (73/53), and 13% (71/530), respectively. When decisions were taken to break the guidelines, this was more often to list for tonsillectomy when it was not indicated--83% (141/170)--than to withhold tonsillectomy when it was indicated--17% (29/170). The aspects of guidelines that were breached in decisions to carry out tonsillectomy were: the age of the child was younger than the guidelines recommended--54% (75/141); there had been fever attacks of tonsillitis than the guidelines recommended--22% (32/141); and there were "significant" symptoms not included in the guidelines--20% (29/141). CONCLUSIONS: In spite of strong evidence to the contrary, local guidelines were formulated at a level that the majority of surgeons already attained. Guideline development and implementation, therefore, had very little impact on clinical practice. The process of local formulation of guidelines was not sufficient to achieve change toward evidence-based practice; clinical preference proved to be quite intractable. There is a need to enhance the ability of clinicians in the assessment and interpretation of research evidence. Previous work has emphasized the need to explore factors that influence clinical behaviour toward evidence-based practice. Our study suggests the need for more research into why clinicians continue to follow clinical preference even when invited to base agreed local clinical policies on evidence.