Gill M Price

Blood levels of vitamin C, carotenoids and retinol are inversely associated with cataract in a north Indian population

PURPOSE To examine the association of blood antioxidants with cataract. METHODS Cross-sectional study of people aged >or=50 years identified from a household enumeration of 11 randomly sampled villages in North India. Participants were interviewed for putative risk factors (tobacco, alcohol, biomass fuel use, sunlight exposure, and socioeconomic status) and underwent lens photography and blood sampling. Lens photographs (nuclear, cortical, and posterior subcapsular) were graded according to the Lens Opacities Classification System (LOCS II). Cataract was defined as LOCS II grade >or=2 for any opacity or ungradable, because of dense opacification or history of cataract surgery. People without cataract were defined as LOCS II <2 on all three types of opacity, with absence of previous surgery. RESULTS Of 1443 people aged >or=50 years, 94% were interviewed, 87% attended an eye examination, and 78% gave a blood sample; 1112 (77%) were included in the analyses. Compared with levels in Western populations, antioxidants were low, especially vitamin C. Vitamin C was inversely associated with cataract. Odds ratios (OR) for the highest (>or=15 micromol/L) compared with the lowest (<or=6.3 micromol/L) tertile were 0.64, (95% confidence interval [CI] 0.48-0.85; P < 0.01). Tertiles of zeaxanthin (P < 0.03), alpha-carotene (P < 0.05), and retinol (P < 0.02) were associated with decreased odds of cataract. In analysis of continuous data, significant inverse associations were found for vitamin C, zeaxanthin, lutein, lycopene, alpha- and beta-carotene, and beta-cryptoxanthin, but not for alpha- or gamma-tocopherol. CONCLUSIONS Inverse associations were found between cataract and blood antioxidants in an antioxidant-depleted study sample.

Are older people dying of depression? Findings from the medical research council trial of the assessment and management of older people in the community

Objectives: To examine the relationship between symptoms of depression and mortality in older people.

Trends in influenza vaccination uptake among people aged over 74 years, 1997-2000: survey of 73 general practices in Britain.

BackgroundInfluenza vaccination policy for elderly people in Britain has changed twice since 1997 to increase protection against influenza but there is no information available on how this has affected vaccine uptake, and socioeconomic variation therein, among people aged over 74 years.MethodsVaccination information for 1997–2000 was collected directly from general practices taking part in a MRC-funded Trial of the Assessment and Management of Older People in the Community. This was linked to information collected during assessments carried out as part of the Trial. Regression modelling was used to assess relative probabilities (as relative risks, RR) of having vaccination according to year, gender, age, area and individual socioeconomic characteristics.ResultsOut of 106 potential practices, 73 provided sufficient information to be included in the analysis. Uptake was 48% (95% CI 45%, 55%) in 1997 and did not increase substantially until 2000 when the uptake was a third higher at 63% (50%, 66%). Vaccination uptake was lower among women than men (RR 0.9), people aged 85 or more compared to people aged under 80 (RR 0.9), those in the most deprived areas (RR 0.8) compared to the least deprived, and was relatively high for those in owner-occupied homes with central heating compared to other non-supported housing (RR for remainder = 0.9). This pattern did not change over the years studied.ConclusionsIncreased uptake in 2000 may have resulted from the additional financial resources given to practices; it was not at the expense of more disadvantaged socioeconomic groups but nor did they benefit disproportionately.

A novel imaging technique as an adjunct to the in vivo diagnosis of nonmelanoma skin cancer

Background  Spectrophotometric intracutaneous analysis (SIAscopy) is a light‐based imaging system capable of producing rapid images of melanin, blood and collagen of the skin. Although the SIAscope has been investigated for melanoma diagnosis, no formal study has been conducted to determine its use in the diagnosis of nonmelanoma skin cancer (NMSC).

A prospective comparison of spectrophotometric intracutaneous analysis to clinical judgment in the diagnosis of nonmelanoma skin cancer

Introduction:Research indicates that spectrophotometric intracutaneous analysis (SIAscopy) may be a useful adjunct in nonmelanoma skin cancer (NMSC) diagnosis. A study was performed to prospectively assess the accuracy of NMSC diagnosis by the SIAscope as compared with a clinician. Methods:Prior to excision, 323 consecutive lesions were examined and diagnosed by a clinician. SIAgraphs were then taken of the lesions and examined blindly at a later date. Diagnostic accuracy for the clinician and SIAscope was compared between the clinician and SIAscope and to histology. Results:Sensitivity, specificity, positive and negative predictive values for clinical diagnoses were 95.6%, 75.8%, 0.79, and 0.95, respectively. Results for SIA diagnoses were 97.5%, 86.7%, 0.88, and 0.97. Statistical comparison revealed comparable sensitivities for the 2 groups but significantly better specificity for the SIAscope at the 95% confidence level. Conclusion:This study indicates that the SIAscope may be useful in NMSC diagnosis, with accuracies comparable to a clinician.

Evaluation of stroke services in Anglia stroke clinical network to examine the variation in acute services and stroke outcomes

BackgroundStroke is the third leading cause of death in developed countries and the leading cause of long-term disability worldwide. A series of national stroke audits in the UK highlighted the differences in stroke care between hospitals. The study aims to describe variation in outcomes following stroke and to identify the characteristics of services that are associated with better outcomes, after accounting for case mix differences and individual prognostic factors.Methods/DesignWe will conduct a cohort study in eight acute NHS trusts within East of England, with at least one year of follow-up after stroke. The study population will be a systematically selected representative sample of patients admitted with stroke during the study period, recruited within each hospital. We will collect individual patient data on prognostic characteristics, health care received, outcomes and costs of care and we will also record relevant characteristics of each provider organisation. The determinants of one year outcome including patient reported outcome will be assessed statistically with proportional hazards regression models. Self (or proxy) completed EuroQol (EQ-5D) questionnaires will measure quality of life at baseline and follow-up for cost utility analyses.DiscussionThis study will provide observational data about health service factors associated with variations in patient outcomes and health care costs following hospital admission for acute stroke. This will form the basis for future RCTs by identifying promising health service interventions, assessing the feasibility of recruiting and following up trial patients, and provide evidence about frequency and variances in outcomes, and intra-cluster correlation of outcomes, for sample size calculations. The results will inform clinicians, public, service providers, commissioners and policy makers to drive further improvement in health services which will bring direct benefit to the patients.

A potentially useful distribution model for dietary intake data

BACKGROUND Conventional mixed models for the analysis of diet diary data have introduced several simplifying assumptions, such as that of a single standard deviation for within-person day-to-day variation which is common to all individuals. OBJECTIVE We developed a model in which the within-person standard deviation was allowed to differ from person to person. DESIGN The model was demonstrated using data on daily retinol intake from the Dietary and Nutritional Survey of British Adults. The data were from 7-day weighed dietary diaries. Estimation was performed by Markov chain Monte Carlo. Reliability of the model was assessed from the accuracy of estimation of the percentage of days on which various intakes were exceeded. For levels above the median retinol intake, estimation of percentages of days with excessive intakes was most accurate using the model with varying within-person standard deviation. SETTING A survey of British adults aged 16-64 years. SUBJECTS In total 2197 adults living in the UK, 1087 males and 1110 females. RESULTS Under the traditional model, estimated daily intake ranged from 716.4 to 1421.8 microg depending on age and sex, with a within-person standard deviation of 4298.9 microg. Under the new model, estimated average daily intake ranged from 388.9 to 518.3 microg depending on age and sex, but with a within-person standard deviation varying between subjects with a 95% range of 29 to 8384 microg. The new model was shown to predict the percentage of days of exceeding large intakes more successfully than the traditional model. For example, the percentage of days of exceeding the maximum recommended intake (9000 microg for men and 7500 microg for women) was 2.4%. The traditional model predicted no excessive intakes, whereas the new model predicted 2.9%. CONCLUSIONS This model is potentially useful in dietary research in general and for analysis of data on chemical contaminants in foods, in particular.

A Depression Recognition and Treatment package for families living with Stroke (DepReT-Stroke): study protocol for a randomised controlled trial

AbstractBackgroundDepression occurs in up to 50% of patients after stroke and limits rehabilitation and recovery. Mood disorders are also highly prevalent in carers; their mental health intertwined with the physical and mental wellbeing of the person they are caring for. We argue that working with families, rather than patients alone may improve the treatment of depression in both patients and their carers enhancing the mental wellbeing and quality of life of both.MethodsA single blind cluster randomised controlled trial to evaluate whether families after stroke who are treated with the Depression Recognition and Treatment package (DepReT-Stroke) in addition to treatment as usual (TAU) show improved mental well being compared to those families who receive only TAU. We aim to recruit one hundred and twenty-six families (63 in each group). The DepReT-Stroke intervention will help families to consider the various treatment options for depression, make choices about which are likely to fit best with their lives and support them in the use of self-help therapies (e.g. computerised Cognitive Behavioural Therapy or exercise). An essential component of the DepReT-Stroke package will be to help people adhere to their chosen treatment(s). The primary outcome will be the Mental Component Subscale of the SF-36 assessed at baseline and again six months post intervention. Effectiveness of the intervention will be determined using analysis of co-variance; comparing the mean change in MCS scores from baseline to six months follow-up adjusting for the clustering effects of baseline scores and family. An economic evaluation of the intervention will help us determine whether the intervention represents a cost-effective use of resources.DiscussionDepression both for patients and their carers is common after stroke. Our Dep ression Re cognition and T reatment package (DepReT-stroke) may help clinicians be more effective at detecting and managing a common co-morbidity that limits rehabilitation and recovery.Trial RegistrationISRCTN: ISRCTN32451749 Research Ethics Committee Reference Number: 10/H0310/23Grant Reference Number: (NIHR) PB-PG-0808-17056

Similarity of patient characteristics and outcomes in consecutive data collection on stroke admissions over one month compared to longer periods

BackgroundThe usefulness of time-limited consecutive data collection compared to continuous consecutive data collection in conditions which show seasonal variations is unclear. The objective of this study is to assess whether one month of admission data can be representative of data collected over two years in the same hospitals.MethodsWe compared the baseline characteristics and discharge outcomes of stroke patients admitted in the first month (October 2009) of the Anglia Stroke Clinical Network Evaluation Study (ASCNES) with the routinely collected data over 2 years between September 2008 and April 2011 from the same 8 hospital trusts in the Anglia Stroke & Heart Clinical Network (AS&HCN) as well as seasonal cohorts from the same period.ResultsWe included a total of 8715 stroke patients (October 2009 cohort of ASCNES (n = 308), full AS&HCN cohort (n = 8407 excluding October 2009)) as well as cohorts from different seasons. All cohorts had a similar median age. No significant differences were observed for pre-stroke residence, pre-stroke modified Rankin, weekend vs. weekday admission, time of admission, patients with atrial fibrillation, type of stroke, admission systolic blood pressure, use of thrombolysis (rTPA), in-patient mortality and discharge destination. There were statistically significant differences between cohorts with regard to Oxfordshire Community Stroke Project Classification.ConclusionsStroke patients admitted in one month had largely indistinguishable characteristics and discharge outcomes to those admitted to the same trusts in three separate seasons and also over two years in this cohort.

Important factors in predicting mortality outcome from stroke: findings from the Anglia Stroke Clinical Network Evaluation Study

Abstract Background although variation in stroke service provision and outcomes have been previously investigated, it is less well known what service characteristics are associated with reduced short- and medium-term mortality. Methods data from a prospective multicentre study (2009–12) in eight acute regional NHS trusts with a catchment population of about 2.6 million were used to examine the prognostic value of patient-related factors and service characteristics on stroke mortality outcome at 7, 30 and 365 days post stroke, and time to death within 1 year. Results a total of 2,388 acute stroke patients (mean (standard deviation) 76.9 (12.7) years; 47.3% men, 87% ischaemic stroke) were included in the study. Among patients characteristics examined increasing age, haemorrhagic stroke, total anterior circulation stroke type, higher prestroke frailty, history of hypertension and ischaemic heart disease and admission hyperglycaemia predicted 1-year mortality. Additional inclusion of stroke service characteristics controlling for patient and service level characteristics showed varying prognostic impact of service characteristics on stroke mortality over the disease course during first year after stroke at different time points. The most consistent finding was the benefit of higher nursing levels; an increase in one trained nurses per 10 beds was associated with reductions in 30-day mortality of 11–28% (P < 0.0001) and in 1-year mortality of 8–12% (P < 0.001). Conclusions there appears to be consistent and robust evidence of direct clinical benefit on mortality up to 1 year after acute stroke of higher numbers of trained nursing staff over and above that of other recognised mortality risk factors.