Isla Gemmell

Psychosocial risk factors for hospital readmission in COPD patients on early discharge services: a cohort study

BackgroundHospital readmission for acute exacerbation of COPD (AECOPD) occurs in up to 30% of patients, leading to excess morbidity and poor survival. Physiological risk factors predict readmission, but the impact of modifiable psychosocial risk factors remains uncertain. We aimed to evaluate whether psychosocial risk factors independently predict readmission for AECOPD in patients referred to early discharge services (EDS).MethodsThis prospective cohort study included 79 patients with AECOPD cared for by nurse led EDS in the UK, and followed up for 12 months. Data on lung function, medical comorbidities, previous hospital admissions, medications, and sociodemographics were collected at baseline; St Georges Respiratory Questionnaire (SGRQ), Hospital Anxiety and Depression Scale (HADS), and social support were measured at baseline, 3 and 12-months. Exploratory multivariate models were fitted to identify psychosocial factors associated with readmission adjusted for known confounders.Results26 patients were readmitted within 90 days and 60 patients were readmitted at least once during follow-up. Depression at baseline predicted readmission adjusted for sociodemographics and forced expiratory volume in 1 second (odds ratio 1.30, 95% CI 1.06 to 1.60, p = 0.013). Perceived social support was not significantly associated with risk of readmission. Home ownership was associated with the total number of readmissions (B = 0.46, 95% CI -0.86 to -0.06, p = 0.024). Compared with those not readmitted, readmitted patients had worse SGRQ and HADS scores at 12 months.ConclusionDepressive symptoms and socioeconomic status, but not perceived social support, predict risk of readmission and readmission frequency for AECOPD in patients cared for by nurse-led EDS. Future work on reducing demand for unscheduled hospital admissions could include the design and evaluation of interventions aimed at optimising the psychosocial care of AECOPD patients managed at home.

The statistical pitfalls of the partially randomized preference design in non-blinded trials of psychological interventions

In a partially randomized preference trial (PRPT) patients with no treatment preference are allocated to groups at random, but those who express a preference receive the treatment of their choice. It has been suggested that the design can improve the external and internal validity of trials. We used computer simulation to illustrate the impact that an unmeasured confounder could have on the results and conclusions drawn from a PRPT. We generated 4000 observations (“patients”) that reflected the distribution of the Beck Depression Index (DBI) in trials of depression. Half were randomly assigned to a randomized controlled trial (RCT) design and half were assigned to a PRPT design. In the RCT, “patients” were evenly split between treatment and control groups; whereas in the preference arm, to reflect patient choice, 87.5% of patients were allocated to the experimental treatment and 12.5% to the control. Unadjusted analyses of the PRPT data consistently overestimated the treatment effect and its standard error. This lead to Type I errors when the true treatment effect was small and Type II errors when the confounder effect was large. The PRPT design is not recommended as a method of establishing an unbiased estimate of treatment effect due to the potential influence of unmeasured confounders. Copyright

Seasonal and socio-demographic predictors of suicide in Ireland: A 22 year study

BACKGROUND Seasonal influences on suicide have been studied for many years with inconclusive and contradictory findings. METHODS Data on suicide in Ireland from 1980 to 2002 was examined to ascertain the contribution of season and demographic variables to suicide. Using Poisson regression modelling and sinusoidal analysis a small seasonal effect (7% from peak to trough) was identified but age, gender, marital status and residence were much larger contributors. The seasonal contribution increased in the latter half of the period under study. There was also a small seasonal effect for method of suicide. The suicide rate was highest in the 40-44 age group after controlling for confounders. LIMITATIONS Because this was an ecological study, information on other possible contributors, such as mental illness was not available. CONCLUSIONS These findings are discussed in light of international studies. Continuing studies are required to confirm the trend in increasing seasonality in Ireland. Since suicide is highest in those who are middle aged, preventive strategies should be directed to this group.

Internationalisation in online distance learning postgraduate education: a case study on student views on learning alongside students from other countries

Internationalisation in higher education has been shown to provide both intellectual and cultural benefits to students which can help in their future employment. This case study describes student views on learning alongside students from different countries in an online distance learning environment. Seventy-three students undertaking the online Master of Public Health programme at Manchester University, UK completed the survey which explored student experiences, views and opinions on aspects of the course. Learning about other countries’ health systems and the experiences of public health professionals in other countries were identified as a key benefit of studying alongside students from other countries. Students were able to appreciate other perspectives, reconsider their own attitudes and improve their understanding of the context of public health issues. The benefits of learning alongside students from other countries can be enhanced within an online learning environment through the appropriate use of discussion boards and other online learning strategies.

The Impact of Malaria in Pregnancy on Changes in Blood Pressure in Children During Their First Year of Life

We established a maternal birth cohort in Ibadan, Nigeria, where malaria is hyperendemic, to assess how intrauterine exposure to malaria affected infant blood pressure (BP) development. In a local maternity hospital, healthy pregnant women had regular blood films for malaria parasites from booking to delivery. Growth and BP were measured on 318 babies, all followed from birth to 3 and 12 months. Main outcomes were standardized measures of anthropometry and change in BP to 1 year. Babies exposed to maternal malaria were globally smaller at birth, and boys remained smaller at 3 months and 1 year. Change in systolic BP (SBP) during the year was greater in boys than in girls (20.9 versus 15.7 mm Hg; P=0.002) but greater in girls exposed to maternal malaria (18.7 versus 12.7 mm Hg; 95% confidence interval, 1–11 mm Hg; P=0.02). Eleven percent of boys (greater than twice than expected) had a SBP ≥95th percentile (hypertensive, US criteria), of whom 68% had maternal malaria exposure. On regression analysis (&bgr; coefficients, mm Hg), sex (boys>girls; &bgr;=4.4; 95% confidence interval, 1.1–7.7; P=0.01), maternal malaria exposure (3.64; 0.3–6.9; P=0.03), and weight change (2.4; 0.98–3.8/1 standard deviation score; P=0.001) all independently increased SBP change to 1 year, whereas increase in length decreased SBP (−1.98; −3.6 to −0.40). In conclusion, malaria-exposed boys had excess hypertension, whereas malaria-exposed girls a greater increase in SBP. Intrauterine exposure to malaria had sex-dependent effects on BP, independent of infant growth. Because infant–child–adult BP tracking is powerful, a malarial effect may contribute to the African burden of hypertension.

Adiponectin and Lipid Profiles Compared with Insulins in Relation to Early Growth of British South Asian and European Children: The Manchester Children's Growth and Vascular Health Study

CONTEXT Adiponectin, high-density lipoprotein cholesterol (HDL-C) and insulin concentrations may be important in the pathophysiology of cardiovascular disease. OBJECTIVE We tested the hypothesis that serum adiponectin rather than insulin differs from early life, between South Asians and Europeans, with a potentially key role in excess cardiovascular risk characteristic of adult South Asians. DESIGN AND PARTICIPANTS We conducted a longitudinal study of 215 British-born children of European (n = 138) and South Asian (n = 77) origin, from birth to 3 yr. MAIN OUTCOME MEASURE Serum adiponectin, insulin, proinsulin and HDL-C concentrations were assessed in relation to ethnic group and growth in anthropometric variables from 0-3 yr of age. RESULTS Serum adiponectin was lower in South Asian children, despite their smaller size, notable at age 3-6 months (9.5 vs. 11.8 mg/liter; P = 0.04), with no ethnic differences in serum lipids or insulin or proinsulin. In mixed-effects longitudinal models for HDL-C, determinants were adiponectin (P = 0.034), age (P < 0.001), and body mass index (P < 0.001) but not ethnicity. None of these or growth variables affected either insulin or proinsulin. In a fully adjusted mixed-effects longitudinal model including age, sex, insulin, and proinsulin, the independent determinants of serum adiponectin were height [21.3 (95% confidence interval = 31.7-10.8 cm lower, for every 1 mmol/liter increase in adiponectin, P < 0.001], HDL-C [2.8 (1.3-4.2) mmol/liter higher, P < 0.0001], body mass index (lower, P = 0.03), and South Asian ethnicity (lower, P = 0.01). CONCLUSIONS These British South Asian-origin infants have lower serum adiponectin but no differences in HDL-C or insulin molecules. In South Asians, factors affecting adiponectin metabolism in early life, rather than insulin resistance, likely determine later excess cardiovascular risk.

Maternal Malaria, Birth Size and Blood Pressure in Nigerian Newborns: Insights into the Developmental Origins of Hypertension from the Ibadan Growth Cohort

Background Hypertension is an increasing health issue in sub-Saharan Africa where malaria remains common in pregnancy. We established a birth cohort in Nigeria to evaluate the early impact of maternal malaria on newborn blood pressure (BP). Methods Anthropometric measurements, BP, blood films for malaria parasites and haematocrit were obtained in 436 mother-baby pairs. Women were grouped to distinguish between the timing of malaria parasitaemia as ‘No Malaria’, ‘Malaria during pregnancy only’ or ‘Malaria at delivery’, and parasite density as low (<1000 parasites/µl of blood) and high (≥1000/µl). Results Prevalence of maternal malaria parasitaemia was 48%, associated with younger maternal age (p<0.001), being primigravid (p = 0.022), lower haematocrit (p = 0.028). High parasite density through pregnancy had the largest effect on mean birth indices so that weight, length, head and mid-upper arm circumferences were smaller by 300 g, 1.1 cm, 0.7 cm and 0.4 cm respectively compared with ‘No malaria’ (all p≤0.005). In babies of mothers who had ‘malaria at delivery’, their SBPs adjusted for other confounders were lower respectively by 4.3 and 5.7 mmHg/kg compared with ‘malaria during pregnancy only’ or ‘none’. In contrast the mean newborn systolic (SBP) and diastolic BPs (DBP) adjusted for birth weight were higher by 1.7 and 1.4 mmHg/kg respectively in babies whose mothers had high compared with low parasitaemia. Conclusions As expected, prenatal malarial exposure had a significant impact on fetal growth rates. Malaria at delivery was associated with the lowest newborn BPs while malaria through pregnancy, which may attenuate growth of the vascular network, generated higher newborn BPs adjusted for size. These neonatal findings have potential implications for cardiovascular health in sub-Saharan Africa.

Teaching science and technology via online distance learning: the experience of teaching biostatistics in an online Master of Public Health programme

This paper describes the development and teaching of a biostatistics module within a fully online distance learning Master of Public Health (MPH) programme at the University of Manchester. The MPH programme caters for students from over 40 countries worldwide and all materials are delivered via the Blackboard virtual learning environment. In this paper we describe how we have developed teaching materials according to the pedagogic approach and embraced new technologies to allow us to enhance the learning experience for our students. This has been carried out within a dedicated multi‐disciplinary team incorporating academics, e‐learning technologists and administrative staff.

Developing a European urban health indicator system: results of EURO-URHIS 1

Introduction More than half of the worlds population now live in cities, including over 70% in Europe. Cities bring opportunities but can be unhealthy places to live. The poorest urban dwellers live in the worst environments and are at the greatest risk of poor health outcomes. EURO-URHIS 1 set out to compile a cross-EU inventory of member states use of measures of urban health in order to support policymakers and improve public health policy. Following a literature review to define terms and find an appropriate model to guide urban health research, EURO-URHIS Urban Areas in all EU member states except Luxembourg, as well as Croatia, Turkey, Macedonia, Iceland and Norway, were defined and selected in collaboration with project partners. Following piloting of the survey tool, a the EURO-URHIS 45 data collection tool was sent out to contacts in all countries with identified EUAs, asking for data on 45 Urban Health Indicators (UHI) and 10 other indicators. 60 questionnaires were received from 30 countries, giving information on local health indicator availability, definitions and sources. Telephone interviews were also conducted with 14 respondents about their knowledge of sources of urban health data and barriers or problems experienced when collecting the data. Most participants had little problem identifying the sources of data, though some found that data was not always routinely recorded and was held by diverse sources or not at local level. Some participants found the data collection instrument to not be user-friendly and with UHI definitions that were sometimes unclear. However, the work has demonstrated that urban health and its measurement is of major relevance and importance for Public Health across Europe. The current study has constructed an initial system of European UHIs to meet the objectives of the project, but has also clearly demonstrated that further development work is required. The importance and value of examining UHIs has been confirmed, and the scene has been set for further studies on this topic.

The use of epidemiological measures to estimate the impact of primary prevention interventions on CHD, stroke and cancer outcomes: Experiences from Herefordshire, UK

Background: CHD, stroke and cancers are the major causes of mortality in the UK and are responsible for significant amounts of morbidity and healthcare costs. This study examines the proportion of CHD, stroke and cancer owing to specific risk factors in Herefordshire, UK. It estimates the population impact of a number of interventions being implemented to reduce these risk factors, through the NHS Health Check program and the Herefordshire Health Improvement Plan. The present study also aims to demonstrate the value of epidemiological measures in providing evidence-based public health information in policy-making to aid decision makers when prioritizing investments and optimal use of resources. Methods: The epidemiological measures–‘Population Attributable Risk’ and ‘Population Impact Measures’–were used to assess the impact of interventions to reduce the burden of CHD, stroke and cancer. Results: Implementation of the NHS Health Check program will prevent 63 CHD events, 90 MI events and 125 stroke events, and one lung cancer over a period of 5 years. Reducing specific risk factors by 5% annually through the Health Improvement Plan will prevent 65 CHD events, 25 MI events, 140 stroke events, four lung cancer, one breast cancer and four colorectal cancer cases in Herefordshire if targets are met over a period of 5 years. Conclusion: Physical inactivity and obesity are the major causes of CHD and stroke events (incidence and mortality) in Herefordshire. Their impact is greater than the combined effect of hypercholesterolemia and hypertension. Epidemiological measures used in this study proved to be excellent tools in providing evidence-based public health information. Their use is strongly recommended to support prioritization of primary prevention interventions.