Determinants of health-related quality of life among residents with and without COPD in a historically industrialised area.

PURPOSE: Chronic obstructive pulmonary disease (COPD) is associated with substantial morbidity, including impaired health-related quality of life (HRQoL). Despite the prominent role of occupational factors in the aetiology of COPD, the relationship between these exposures and HRQoL has not been well elucidated. METHODS: A subpopulation from an epidemiological study, designed to assess the workplace contribution to COPD, was administered the EQ5D HRQoL tool. Demographics, an index of economic deprivation, health endpoints including the presence of COPD and lung function were also recorded. Workplace exposures were categorised using both self-reported exposures and also by the use of an established job exposure matrix (JEM). RESULTS: A total of 623 individuals participated (mean age 67.1 years). One hundred and forty-eight (24%) reported having received a physician diagnosis of COPD, 355 (57%) were male, and 386 (62%) were ever smokers. As anticipated, the presence of COPD was associated with a poorer HRQoL. Additionally, however, HRQoL was significantly lower in the presence of both self-reported vapours, gases, dusts and fumes exposure and JEM-based exposure irrespective of the presence of COPD. Regression analysis, adjusting for a variety of covariates including the presence of COPD, confirmed a persisting higher likelihood of occupational exposure categorised by JEM being associated with poorer HRQoL scores (ß estimate: -0.069; p < 0.05). CONCLUSIONS: Our findings suggest that work may have an important link to HRQoL and that this effect can persist even among those who have retired. In those with COPD, HRQoL is worse than among those without this condition, but the work-associated decrement appears to be similar across both groups.

Assessing the impact of selective migration and care homes on geographical inequalities in health--a total population cohort study in Sheffield.

Selective migration and moves to care homes may potentially contribute to observed socioeconomic gradients in mortality across cities and regions. Sheffield has striking socioeconomic gradients in area-level mortality across the city. We examined for evidence of selective migration and assessed the contribution of migration to observed mortality gradients. We used a total population cohort (539737 in 2001), linked mortality data (2001-2010) and linked data from a health survey carried out in 2000 (66% response rate yielding 10185 responses). We used lower super-output areas and electoral wards as the spatial units of analysis. We found clear evidence of selective migration. In the 25-44 age band, relative risks of mortality were 1.71 (95% CI 1.37-2.12) in migrants from low to high deprivation areas compared with people remaining in low deprivation areas, and 0.53 (0.42-0.65) in migrants from high to low deprivation areas compared with people remaining in high deprivation areas. Relative risks shrank towards unity with increasing age. Characteristics of migrants and non-migrants (illness prevalence, indicators of socioeconomic status, smoking prevalence) ascertained before migration were largely consistent with the relative risks for mortality and indicated that people carried their risks with them. There was also a clear care homes effect, with higher mortality in electoral wards with higher care home bed provision rates. Overall, however, adjustment for selective migration, which included moves to care homes, made little difference to gradients in inequality across the city. Our results suggest that selective migration, including moves to care homes, do not explain existing socioeconomic gradients in area level mortality across Sheffield.

Chronic obstructive pulmonary disease among residents of an historically industrialised area.

OBJECTIVE: To assess the contribution of workplace exposures to chronic obstructive pulmonary disease (COPD) risk in a community with a heavy burden of past industrial employment. METHODS: A random population sample of Sheffield, U.K. residents aged over 55 years (n=4000), enriched with a hospital-based supplemental sample (n=209), was approached for study. A comprehensive self-completed questionnaire elicited physician-made diagnoses, current symptoms, and past workplace exposures. The latter were defined in three ways: self-reported exposure to vapours, gases, dusts and fumes (VGDF); response to a specific exposure checklist; and through a job exposure matrix (JEM) assigning exposure risk likelihood based on job history independent of respondent-reported exposure. A subset of the study group underwent lung function testing. Population attributable risk fractions (PAR%), adjusted for age, sex and smoking, were calculated for association between workplace exposure and COPD. RESULTS: 2001 (50%) questionnaires were returned from the general population sample and 60 (29%) by the hospital supplement. Among 1754 with complete occupational data, any past occupational exposure to VGDF carried an adjusted excess risk for report of a physician's diagnosis of COPD, emphysema, or chronic bronchitis (ORs 3.9; 95% CI 2.7 to 5.8), with a corresponding PAR% value of 58.7% (95% CI 45.6% to 68.7%). The PAR% estimate based on JEM exposure was 31%. From within the subgroup of 571 that underwent lung function testing, VGDF exposure was associated with a PAR% of 20.0% (95% CI -7.2 to 40.3%) for Global initiative for chronic obstructive lung disease (GOLD) 1 (or greater) level of COPD. CONCLUSION: This heavy industrial community-based population study has confirmed significant associations between reported COPD and both generic VGDF and JEM-defined exposures. This study supports the predominantly international evidence-based notion that workplace conditions are important when considering the current and future respiratory health of the workforce.

Psychosocial impact of the summer 2007 floods in England.

BACKGROUND: The summer of 2007 was the wettest in the UK since records began in 1914 and resulted in severe flooding in several regions. We carried out a health impact assessment using population-based surveys to assess the prevalence of and risk factors for the psychosocial consequences of this flooding in the United Kingdom. METHODS: Surveys were conducted in two regions using postal, online, telephone questionnaires and face-to-face interviews. Exposure variables included the presence of flood water in the home, evacuation and disruption to essential services (incident management variables), perceived impact of the floods on finances, house values and perceived health concerns. Validated tools were used to assess psychosocial outcome (mental health symptoms): psychological distress (GHQ-12), anxiety (GAD-7), depression (PHQ-9) and probable post-traumatic stress disorder (PTSD checklist-shortform). Multivariable logistic regression was used to describe the association between water level in the home, psychological exposure variables and incident management variables, and each mental health symptom, adjusted for age, sex, presence of an existing medical condition, employment status, area and data collection method. RESULTS: The prevalence of all mental health symptoms was two to five-fold higher among individuals affected by flood water in the home. People who perceived negative impact on finances were more likely to report psychological distress (OR 2.5, 1.8-3.4), probable anxiety (OR 1.8, 1.3-2.7) probable depression (OR 2.0, 1.3-2.9) and probable PTSD (OR 3.2, 2.0-5.2). Disruption to essential services increased adverse psychological outcomes by two to three-fold. Evacuation was associated with some increase in psychological distress but not significantly for the other three measures. CONCLUSION: The psychosocial and mental health impact of flooding is a growing public health concern and improved strategies for minimising disruption to essential services and financial worries need to be built in to emergency preparedness and response systems. Public Health Agencies should address the underlying predictors of adverse psychosocial and mental health when providing information and advice to people who are or are likely to be affected by flooding.

The Kidney Evaluation and Awareness Program in Sheffield (KEAPS): a community-based screening for microalbuminuria in a British population.

BACKGROUND/OBJECTIVES: Microalbuminuria (MA) detects subjects at risk for cardiovascular disease (CVD) and chronic kidney disease (CKD) among diabetics, hypertensives and the general population. There is still a paucity of data on prevalence and risk factors for MA in the UK. We examined in a cross-sectional study, the prevalence and risk factors for MA in the general population of Sheffield, UK. METHODS: The study was conducted among participants of the Kidney Evaluation and Awareness Program in Sheffield (KEAPS), a population-based screening program for MA. The screening tools included a questionnaire collating information on demographics, lifestyle, medical and family history of diabetes mellitus, hypertension and CKD. MA measurements were obtained by immunonephelometry, and MA thresholds were defined using the albumin-creatinine ratio. RESULTS: The prevalence of MA was 7.1% in a random sample of a Sheffield-based population screened only once. The prevalence was 6.2% in the non-diabetic and non-hypertensive subjects. The prevalence of MA was only 1.3% in the subjects without any known risk factor, such as old age, diabetes, hypertension, obesity or CVD. The prevalence of MA could be overestimated as it was based on a single albumin-creatinine ratio testing. The independent predictor variables associated with the presence of MA in a mutually adjusted logistic regression model were: age (OR = 1.012, 95% CI: 1.00-1.02), diabetes (OR = 3.25, 95% CI: 1.30-8.13), obesity (OR = 4.09, 95% CI: 1.71-9.80) and family history of hypertension (OR = 1.87, 95% CI: 1.00-3.47). CONCLUSIONS: The main determinants of MA were increased age, diabetes, obesity and family history of hypertension. On the population level, obesity as a risk factor for MA is less well documented; in this study obesity had greater odds for MA than diabetes and hypertension.

Evaluation of methodologies for exposure assessment to atmospheric pollutants from a landfill site.

Epidemiological studies around landfill sites are limited by several factors, particularly a lack of accurate exposure assessment. Traditionally, exposure estimates are based on distance between place of residence and the landfill site. However, this measure of exposure ignores the effects that environmental factors may have upon exposure. A previous epidemiological study at a landfill site in the United Kingdom provided the basis for a case study to investigate exposure assessment methodologies that could support ongoing and future epidemiological work. Estimation of relative exposure to atmospheric pollutants near the site was refined using the Atmospheric Dispersion Modeling System (ADMS) 3.1. Annual average concentrations were calculated around the landfill site, which was modeled as an area source with a steady release rate over its entire active surface. Local meteorological and terrain data were used in the assessment. A geographical information system (GIS) was then used to link the results of the modeling to population and other data. Sensitivity studies were included to examine the variation of predicted exposure with several modeling assumptions and hence set other uncertainties in context. No simple relationship existed between the relative individual exposure measured by distance from the site and by dispersion modeling. A reassessment of exposure assessment in epidemiological studies around landfill sites was then undertaken with the refined estimates of exposure. This concluded that use of distance from the site as a proxy for exposure could lead to significant exposure misclassification in comparison with exposure assessment using atmospheric dispersion modeling and GIS. The study also indicated that assessment of peak exposure rates (i.e., extreme concentration levels) might be necessary in some epidemiological work. Optimum strategies for increasing the probability of observing effects in the more highly exposed population can be derived by combining the results of dispersion modeling with population data and, where feasible, knowledge of the toxicology of the substances of interest.

A population-based screening for microalbuminuria among relatives of CKD patients: the Kidney Evaluation and Awareness Program in Sheffield (KEAPS).

BACKGROUND: Microalbuminuria has been used to detect subjects at risk of cardiovascular disease and chronic kidney disease (CKD) in patients with diabetes, those with hypertension, and the general population. However, relatives of patients with CKD have not been investigated for microalbuminuria in the United Kingdom. STUDY DESIGN: A cross-sectional study evaluating the prevalence of microalbuminuria in relatives of patients with CKD compared with the general population of Sheffield, England. SETTING & PARTICIPANTS: Participants in the Kidney Evaluation and Awareness Program in Sheffield, a population-based screening program for microalbuminuria. 274 relatives of patients with CKD were studied and compared with an age- and sex-matched control group from the general population. PREDICTOR: Family history of CKD. MEASUREMENT & OUTCOMES: Screening tools included a questionnaire collating information for demographics, lifestyle, and medical and family history of diabetes, hypertension, and CKD. Urine samples were collected for microalbuminuria estimation. Microalbuminuria measurements were obtained by using immunonephelometry. Microalbuminuria thresholds were defined using albumin-creatinine ratio. RESULTS: The prevalence of microalbuminuria was 9.5% in those with a family history of CKD. This was significantly greater than the prevalence of 1.4% in the age- and sex-matched control group with no family history of CKD (P = 0.001). Independent determinants of microalbuminuria in the study population in an adjusted logistic regression model were family history of diabetes (odds ratio [OR], 2.88; 95% confidence interval, 1.17 to 7.04), obesity (OR, 3.29; 95% confidence interval, 1.61 to 6.69), and family history of CKD (OR, 6.96; 95% confidence interval, 3.48 to 13.92). LIMITATIONS: Cross-sectional snapshot analysis, microalbuminuria measured once. CONCLUSIONS: The prevalence of microalbuminuria in relatives of patients with CKD is greater than in an age- and sex-matched control group from the general population. The prognostic value of microalbuminuria in this category of at-risk population remains to be determined in longitudinal studies.

The economics of routine antenatal anti-D prophylaxis for pregnant women who are rhesus negative.

OBJECTIVE: To investigate the economics of routine antenatal anti-D prophylaxis in the prevention of haemolytic disease of the newborn, in support of the NICE appraisals process. DESIGN: Cost effectiveness analysis. SETTING: UK NHS. POPULATION/SAMPLE: Pregnant women who are RhD-negative. METHODS: A model was constructed to estimate the incremental cost effectiveness and cost utility of: (1) offering routine antenatal anti-D prophylaxis to all pregnant women who are RhD-negative; (2) offering routine antenatal anti-D prophylaxis to RhD-negative primigravidae, compared with conventional management alone. Effectiveness estimates were derived from a meta-analysis of two UK community-based studies. Costs were derived from published sources and NHS product lists. Threshold analysis was conducted to reflect the social value of routine antenatal anti-D prophylaxis through incorporating valuations of parental grief and fetal/neonatal loss. MAIN OUTCOME MEASURES: Cost per life year gained and cost per quality adjusted life year (QALY) gained. RESULTS: The cost per life year gained is in the range pound 5,000- pound 15,000. The inclusion of long term neurodevelopmental problems results in a cost utility ranging between pound 11,000 and pound 52,000 per QALY gained. Threshold analysis suggests that if fetal loss, parental grief and subsequent high intervention pregnancy are valued at greater than 9 QALYs, the comprehensive policy would be more attractive than the primigravidae policy, assuming a maximum acceptable threshold of pound 30,000 per QALY. CONCLUSION: Routine antenatal anti-D prophylaxis provides a cost effective intervention for preventing haemolytic disease of the newborn in the pregnancies of women who are RhD-negative.

Variation in cadaveric organ donor rates in the UK.

BACKGROUND: Considerable variation exists in the organ donation rate between kidney retrieval areas (KRAs) within the UK. The causes for this are unknown. This study examines whether or not observed variations are correlated with various possible explanatory factors. METHODS: A geographical study involving Poisson regression analysis was carried out of all 21 KRAs in the UK in 1999 and 2000, with donor rate as dependent variable, and the following independent variables: road traffic accident, intracerebral haemorrhage and other trauma death rates; intensive care unit (ICU) bed numbers; co-location of transplant and neurosurgical units; population ethnicity; proportion of the population on the organ donor register; transplant coordinator numbers; and transplant unit numbers. Main outcome measures were: donor rate in each KRA; strength of association between independent and dependent variables; and magnitude of changes in the donor rate associated with changes in independent variables. RESULTS: The donor rate varied between eight and 27.4 donors per million population per year. There was an association between donor rate and general ICU bed numbers (more beds associated with a higher donor rate), but this was of borderline statistical significance (P = 0.065). However, the donor rate was negatively associated (P = 0.02) with neurosurgical ICU bed numbers (more beds, fewer donors) and the proportion of the population from minority ethnic communities. There was no statistically significant association with the other independent variables. CONCLUSIONS: There is significant variation in the organ donor rate between different parts of the UK. More research is needed to explore the counter-intuitive association between neurosurgical ICU beds and donations, and to determine the remaining causes of the observed variation.

Pulsatile machine perfusion vs. cold storage of kidneys for transplantation: a rapid and systematic review.

OBJECTIVE: To identify and prioritize key areas for further research in kidney preservation systems. MATERIALS AND METHODS: We conducted a systematic review and meta-analysis of the effectiveness of machine perfusion and cold storage techniques in reducing delayed graft function (DGF) and improving graft survival in recipients of kidneys from beating and non-heart-beating donors. Literature quantifying the link between DGF and graft survival was used to evaluate the potential long-term impact of machine perfusion and cold storage systems. Cox proportional hazards modelling was used to predict graft survival and graft years gained over 10 yr. Monte Carlo sensitivity analysis was conducted to evaluate stochastic uncertainties within the model. RESULTS: Machine perfusion leads to a relative risk of DGF of approximately 80% (67%, 96%) compared with cold storage, although the evidence base is limited in quality and study size. Direct evidence on graft survival at 1 yr demonstrates no statistically significant difference between machine perfusion and cold storage. Predictions based upon quantifying the link between DGF and graft survival suggest potential improvements of between 0 and 6% at 10 yr. DISCUSSION: Studies of high methodological quality and sufficient size are required to determine whether machine preservation leads to reduce rates of DGF. Predicted impact on graft survival implies that direct evidence would require a large population followed up over a long period of time. Registry database analysis supported by validation of the link between DGF and graft survival may be preferable and more feasible than randomized controlled trials.

Very high cost treatment for a single individual--a case report.

A Health Authority was requested to fund immune tolerance induction for a young haemophiliac at a potential cost of up to 2 million pounds sterling over a year. The decision-making process adopted included an external review of the case, literature review to establish the evidence base for treatment, and extensive discussions with the clinicians involved. The Health Authority agreed to fund treatment, but with continuous review of the case and explicit criteria for abandoning treatment if it was not working. After 11 months these criteria were met, and the treatment was abandoned. The decision-making process and ethical issues involved in deciding whether or not to fund extremely high cost treatment for an individual patient are discussed. Cases such as this present a stark contrast between rights-based and utilitarian ethical approaches. Primary Care Trusts (PCTs) are more vulnerable (because of their smaller populations and budgets) than Health Authorities were to the financial destabilization that high-cost cases can cause. PCTs are advised to make arrangements to enter risk-sharing arrangements to spread the cost of such high-cost treatments.