Tom Fowler

Excess Winter Deaths in Europe: a multi-country descriptive analysis

BACKGROUND Winter deaths are a known health and social care challenge for many countries. A previous international comparison showed significant differences in excess winter deaths across Europe in the 1990s, with the northern countries having lower excess winter mortality than those in southern Europe. METHODS The Excess Winter Deaths Index (EWDI) is the ratio of deaths in the winter period (December to March) compared with deaths in the non-winter period. Data from the Eurostat database and national registries were used to calculate the EWDI for 31 countries in Europe across the time period 2002/2003 to 2010/2011. RESULTS National EWDI values show heterogeneity, with a broad pattern of increasing EWDI values from northern to southern Europe and increasing mean winter temperature (r(2) = 0.50, P > 0.0001). Malta, Portugal, Spain, Cyprus and Belgium all had an EWDI that was statistically significantly higher than the average EWDI for the other 30 European countries. There was no clear association between country-level EWDI and the level of inter-annual variability in winter temperature across Europe. DISCUSSION This article demonstrates the differences in EWDI that exist between European countries with implications for both research and policy. Many deaths may be avoidable as environmental, social and personal factors are known to contribute to winter mortality. We now need to work to better understand the causes of inter-country differences.

Tackling the threat of antimicrobial resistance: from policy to sustainable action.

Antibiotics underpin all of modern medicine, from routine major surgery through to caesarean sections and modern cancer therapies. These drugs have revolutionized how we practice medicine, but we are in a constant evolutionary battle to evade microbial resistance and this has become a major global public health problem. We have overused and misused these essential medicines both in the human and animal health sectors and this threatens the effectiveness of antimicrobials for future generations. We can only address the threat of antimicrobial resistance (AMR) through international collaboration across human and animal health sectors integrating social, economic and behavioural factors. Our global organizations are rising to the challenge with the recent World Health Assembly resolution on AMR and development of the Global Action plan but we must act now to avoid a return to a pre-antibiotic era.

For debate: a new wave in public health improvement

The rising burden of chronic disease poses a challenge for all public health systems and requires innovative approaches to effectively improve population health. Persisting inequalities in health are of particular concern. Disadvantage because of education, income, or social position is associated with a larger burden of disease and, in particular, multimorbidity. Although much has been achieved to enhance population health, challenges remain, and approaches need to be revisited. In this paper, we join the debate about how a new wave of public health improvement might look. We start from the premise that population health improvement is conditional on a health-promoting societal context. It is characterised by a culture in which healthy behaviours are the norm, and in which the institutional, social, and physical environment support this mindset. Achievement of this ambition will require a positive, holistic, eclectic, and collaborative effort, involving a broad range of stakeholders. We emphasise three mechanisms: maximisation of the value of health and incentives for healthy behaviour; promotion of healthy choices as default; and minimisation of factors that create a culture and environment which promote unhealthy behaviour. We give examples of how these mechanisms might be achieved.

The risk/benefit of predicting a post‐antibiotic era: Is the alarm working?

There have been concerns about antimicrobial resistance since the first widespread use of antibiotics in humans. More recently, this concern has grown and become the focus of clinical, scientific, and political activity. In part, the political interest is a consequence of publicizing a bleak picture of a post‐antibiotic world. There are, however, dangers in using a discourse of fear. In this article, we discuss whether the evidence base is available to justify such claims and, more importantly, put this in the policy context with which it is used. Many governments now use a risk assessment approach to identify security concerns, based on reasonable worst‐case scenarios. There is no doubt that for effective policy‐based action to occur, antimicrobial resistance needs to be seen as a national and international security priority, particularly as the major cost of inaction will mostly be felt in the future. We conclude that presenting the evidence in a manner that is used to encourage prioritization of security policy is not only justified, it is essential to drive action in this area.

Maternal pre-pregnancy weight and externalising behaviour problems in preschool children: a UK-based twin study

Objective To estimate the heritability of child behaviour problems and investigate the association between maternal pre-pregnancy overweight and child behaviour problems in a genetically sensitive design. Design Observational cross-sectional study. Setting The Twins and Multiple Births Association Heritability Study (TAMBAHS) is an online UK-wide volunteer-based study investigating the development of twins from birth until 5 years of age. Participants A total of 443 (16% of the initial registered members) mothers answered questions on pre-pregnancy weight and their twins’ internalising and externalising problems using the Child Behavior Checklist and correcting for important covariates including gestational age, twins’ birth weight, age and sex, mothers educational level and smoking (before, during and after pregnancy). Primary outcomes The heritability of behaviour problems and their association with maternal pre-pregnancy weight. Results The genetic analysis suggested that genetic and common environmental factors account for most of the variation in externalising disorders (an ACE model was the most parsimonious with genetic factors (A) explaining 46% (95% CI 33% to 60%) of the variance, common environment (C) explaining 42% (95% CI 27% to 54%) and non-shared environmental factors (E) explaining 13% (95% CI 10% to 16%) of the variance. For internalising problems, a CE model was the most parsimonious model with the common environment explaining 51% (95% CI 44% to 58%) of the variance and non-shared environment explaining 49% (95% CI 42% to 56%) of the variance. Moreover, the regression analysis results suggested that children of overweight mothers showed a trend (OR=1.10, 95% CI 0.58% to 2.06) towards being more aggressive and exhibit externalising behaviours compared to children of normal weight mothers. Conclusions Maternal pre-pregnancy weight may play a role in childrens aggressive behaviour.

The Influence of Genetic and Environmental Factors on the Etiology of the Human Umbilical Cord: The East Flanders Prospective Twin Survey

The umbilical cord is vulnerable to a number of insults that may alter cord morphology, diminish cord flow, and ultimately compromise fetal nutrition. Thus, an investigation of the underlying mechanisms of the development of cord morphology and possible pathologies associated with it may provide insight regarding fetal growth in the intrauterine environment and have an impact on later development of the child. To our knowledge, this study, which included 11 980 twins, is the first to report the relative contribution of genes and environment in the development of the cord. Umbilical cord length, insertion, knots, twisting, and number of vessels were examined by trained midwives at birth. Means and percentages of cord characteristics by twin zygosity/chorionicity and gender were calculated. ANOVA and chi-square tests were performed to calculate discordance in cord morphology between dizygotic (DZ), monozygotic monochorionic (MZMC), and monozygotic dichorionic (MZDC) twins. Univariate genetic models were fit to the umbilical cord characteristics to investigate the genetic and environmental influences on umbilical cord morphology. Mainly nonshared environmental but also genetic factors influence umbilical cord morphology. In MZMC male and female twins, a peripheral/marginal cord insertion was significantly (P < 0.01) more prevalent compared to MZDC and DZ male and female twins, respectively. In MZMC male twins, clockwise twisting was significantly (P = 0.02) less frequent compared to DZ twins. Environmental and genetic factors influence cord morphology and pathology. Twin members can experience environmental influences that are not shared between them even in that very early stage of in utero life.

Suicide prevention: is more demographic information the answer?

Suicide is an important health issue and its prevention is prioritized in government targets. PCTs in England and Wales are also required to carry out audits of suicide deaths by the Healthcare Commission (HCC). We present findings of a 6-year analysis of suicide deaths between 2002 and 2008 in Birmingham and Solihull, the second largest urban conurbation in the UK. After extensive analysis, no demographic group was shown to have a significantly greater risk of suicide and no geographical area had significantly higher rates than another. Despite the large population examined (c.1.3 million), these findings are likely to be due to the rarity of suicides as an outcome. We discuss the practical implications of these findings for local health organizations charged with reducing suicide rates, the value to local suicide audits and the use of a new suicide audit tool developed for use by PCTs. We conclude that ever increasing collection of information surrounding suicide deaths is unlikely to result in the discovery of local groups amenable to targeted suicide prevention interventions and that the HCC may want to reconsider its performance indicator around suicide audits to allow valuable resources to be used more effectively elsewhere.

Changes in genetic and environmental effects on growth during infancy.

BACKGROUND Accelerated infant growth is a possible explanation for the relation between birth weight and adult diseases. OBJECTIVE The aim of this study was to estimate the heritability of infant growth and to examine whether the genetic contribution changes with increasing or decreasing birth weight and gestational age. DESIGN Growth (change in weight z score) was analyzed in 522 infants from the East Flanders Prospective Twin Survey for age windows of 0-1, 1-6, 6-12, and 12-24 mo. Structural equation modeling was performed to estimate the relative importance of additive genetic, shared environmental, and unique environmental sources of variance. RESULTS We showed no genetic contribution to growth in the 0-1-mo growth period. However, at later ages, the heritability of growth was high at 94% (95% CI: 90%, 96%) from 1 to 6 mo, 85% (95% CI: 80%, 89%) from 6 to 12 mo, and 86% (95% CI: 77%, 91%) in the 12-24-mo growth period. Nevertheless, in the last age window, a model without genetic factors was also statistically plausible. From 0 to 1 mo, the genetic contribution to growth was low in the average birth weight range but higher at both extremes of birth weight. The genetic contribution from 0 to 1 mo increased with increasing gestational age from 36 wk of gestation onward. CONCLUSIONS This study shows that genetic factors are not important in early infant growth (0-1 mo), whereas heritability is high after 1 mo. Because many (nutritional) interventions are aimed at influencing early postnatal growth, to target long-term health, these interventions may be most successful if implemented in the first month of postnatal growth.

A Risk Assessment of Antibiotic Pan-Drug-Resistance in the UK: Bayesian Analysis of an Expert Elicitation Study

To inform the UK antimicrobial resistance strategy, a risk assessment was undertaken of the likelihood, over a five-year time-frame, of the emergence and widespread dissemination of pan-drug-resistant (PDR) Gram-negative bacteria that would pose a major public health threat by compromising effective healthcare delivery. Subsequent impact over five- and 20-year time-frames was assessed in terms of morbidity and mortality attributable to PDR Gram-negative bacteraemia. A Bayesian approach, combining available data with expert prior opinion, was used to determine the probability of the emergence, persistence and spread of PDR bacteria. Overall probability was modelled using Monte Carlo simulation. Estimates of impact were also obtained using Bayesian methods. The estimated probability of widespread occurrence of PDR pathogens within five years was 0.2 (95% credibility interval (CrI): 0.07–0.37). Estimated annual numbers of PDR Gram-negative bacteraemias at five and 20 years were 6800 (95% CrI: 400–58,600) and 22,800 (95% CrI: 1500–160,000), respectively; corresponding estimates of excess deaths were 1900 (95% CrI: 0–23,000) and 6400 (95% CrI: 0–64,000). Over 20 years, cumulative estimates indicate 284,000 (95% CrI: 17,000–1,990,000) cases of PDR Gram-negative bacteraemia, leading to an estimated 79,000 (95% CrI: 0–821,000) deaths. This risk assessment reinforces the need for urgent national and international action to tackle antibiotic resistance.

Estimating the positive predictive value of opportunistic population testing for gonorrhoea as part of the English Chlamydia Screening Programme

Advances in technology have raised the possibility of including gonorrhoea testing as part of chlamydia screening. In England this is recommended only where the positive predictive value (PPV) of the test is >90%. This study assessed the PPV for gonorrhoea testing using routine testing data. Routine data (including gonorrhoea testing) from the Greater Manchester Chlamydia Screening Programme (GMCSP) in 2009/2010, were used to estimate the PPV for gonorrhoea testing. Of those screened, 0.3% (59/18044) of men and 0.4% (174/41873) of women tested positive for gonorrhoea. The PPV was 82.3% in women and 73.6% in men, in those who also tested positive for chlamydia. For women and men testing negative for chlamydia the PPV for a positive gonorrhoea test was incalculable. The low PPV observed in most groups suggests that where population testing for gonorrhoea occurs there is a need for further confirmatory testing of positive results before treatment decisions are made. Clinicians should be aware of screening test result limitations in this context.