Bustamante-Zamora D.,Public Health |
Maizlish N.,Public Health
BMJ Open | Year: 2017
Objective To study the magnitude and direction of city-level racial and ethnic differences in poverty and education to characterise health equity and social determinants of health in California cities. Design We used data from the American Community Survey, United States Census Bureau, 2006-2010, and calculated differences in the prevalence of poverty and low educational attainment in adults by race/ethnicity and by census tracts within California cities. For race/ethnicity comparisons, when the referent group (p 2) to calculate the difference (p 1-p 2) was the non-Hispanic White population (considered a historically advantaged group), a positive difference was considered a health inequity. Differences with a non-White reference group were considered health disparities. Setting Cities of the State of California, USA. Results Within-city differences in the prevalence of poverty and low educational attainment disfavoured Black and Latinos compared with Whites in over 78% of the cities. Compared with Whites, the median within-city poverty difference was 7.0% for Latinos and 6.2% for Blacks. For education, median within-city difference was 26.6% for Latinos compared with Whites. In a small, but not negligible proportion of cities, historically disadvantaged race/ethnicity groups had better social determinants of health outcomes than Whites. The median difference between the highest and lowest census tracts within cities was 14.3% for poverty and 15.7% for low educational attainment. Overall city poverty rate was weakly, but positively correlated with within-city racial/ethnic differences. Conclusions Disparities and inequities are widespread in California. Local health departments can use these findings to partner with cities in their jurisdiction and design strategies to reduce racial, ethnic and geographic differences in economic and educational outcomes. These analytic methods could be used in an ongoing surveillance system to monitor these determinants of health. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved.
Gadsby R.,University of Warwick |
Barker P.,Public Health |
Sindair A.,The Institute of Diabetes for Older People IDOP
Diabetic Medicine | Year: 2011
Aims To describe the degree of disability and nursing need of people living with diabetes resident in nursing homes in one Primary Care Trust in the UK. Methods A retrospective case notes review of 75 people with known diabetes who were resident in the 11 nursing homes in Coventry Teaching Primary Care Trust. Results Very significant levels of disability and nursing need were documented in areas of continence, feeding, mobility and communication. Each individual had a mean of four co-morbidities (range 1-8), excluding diabetes. Using the definition of terminal illness based on a negative answer to the question 'would I be surprised if my patient were to die in the next 12months' it is likely that the majority of individuals described in this study would be classified as being terminally ill. Conclusion Using four practical clinical measures, this study has shown very significant levels of disability and nursing care need in this population of mainly elderly people resident in nursing homes in Coventry. In addition, it has demonstrated that a large proportion of nursing home residents with diabetes can be considered to be in the terminal phase of life, a period where many other factors interplay in how care should be delivered and what outcomes are appropriate. In fact, residents in this category may well be candidates for a considered withdrawal of treatments, but not of care. © 2011 The Authors. Diabetic Medicine © 2011 Diabetes UK.
Athey V.L.,Royal Infirmary |
Athey V.L.,Academic Unit of Respiratory Medicine |
Suckling R.J.,Public Health |
Tod A.M.,Sheffield Hallam University |
And 2 more authors.
Thorax | Year: 2012
Background: Poor UK lung cancer survival rates may, in part, be due to late diagnosis. Objectives: To evaluate the effectiveness of a mixed-method community-based social marketing intervention on lung cancer diagnoses. Methods: A public awareness campaign in conjunction with brief intervention training in general practices was piloted in six localities with a high lung cancer incidence. End points were self-reported awareness of lung cancer symptoms; intention to seek healthcare; chest x-ray referral rates in primary care; secular trends in the incidence of lung cancer and stage at diagnosis, compared before and after the intervention. Results: 21% (128/600) (95% CI 18% to 25%) of the targeted population recalled something about the campaign. Compared with a responder in the control area, the odds of a responder in the intervention area saying that they would visit their general practitioner and request a chest x-ray for a cough was 1.97 times (95% CI 1.18 to 3.31, p=0.01). Primary care chest x-ray referral rates increased by 20% in the targeted practices in the year following the intervention compared with a 2% fall in the control practices. The difference was highly significant, with an incidence rate ratio of 1.22 (95% CI 1.12 to 1.33, p=0.001). There was a 27% increase in lung cancer diagnoses in the intervention area compared with a fall in the control area. The incidence rate ratio was 1.42 (95% CI 0.83 to 2.44 p=0.199). Conclusion: This is encouraging early evidence that an awareness and early recognition initiative may facilitate lung cancer diagnosis.
Ahmed S.,University of Leeds |
Bryant L.D.,University of Leeds |
Cole P.,Public Health
Midwifery | Year: 2013
Objective: to explore midwives' perceptions of their role as facilitators of informed choice in antenatal screening. Design: qualitative. Setting: community midwives, Yorkshire and Humber region, UK. Participants: community midwives offering antenatal screening (n=15). Method: semi-structured interviews analysed using Thematic Analysis. Findings: to facilitate informed choice, midwives highlighted both the importance and challenges of engaging in discussion with women, remaining non-directive, within tight timeframes, sometimes with women unable to communicate in English or with complex social needs. Conclusion: midwives varied in the degree to which they believed it was their role to (1) discuss rather than just provide information and (2) to check women's understanding of the information provided. Midwives were concerned about the constraints imposed by first trimester combined screening in terms of the limited time in which they had to facilitate informed choice and the women had to make a decision about screening. To ensure that women understand the options available to them and are able to exercise an informed choice, clinical guidelines are needed that set out how midwives can actively facilitate informed screening choices without compromising patient autonomy. This is especially important given the small 'window of opportunity' within which combined first trimester screening is a viable option. © 2012 Elsevier Ltd.
Barbee L.A.,University of Washington |
Barbee L.A.,Public Health
Current Opinion in Infectious Diseases | Year: 2014
PURPOSE OF REVIEW: The proportion of Neisseria gonorrhoeae isolates with reduced susceptibility to extended-spectrum cephalosporins (ESCs) has increased rapidly since 2006. Clinicians, researchers, and public health officials need to be prepared for the possibility of an era of untreatable gonorrhea. This review focuses on the evidence for current gonorrhea treatment recommendations, potential future treatment options, and other methods to control gonorrhea. RECENT FINDINGS: In addition to an increase in isolates with decreased susceptibility to ESCs, there have been reported treatment failures to both cefixime and ceftriaxone. In response, some countries have increased the recommended cephalosporin dose, and most now recommend dual therapy with an ESC and azithromycin. The pharynx has been implicated as a site for acquiring resistance through transformation with commensal Neisseria species or induced resistance through subtherapeutic antimicrobial levels. Thus, appropriate screening of the pharynx and treatment with a regimen that eradicates gonorrhea from the pharynx is necessary. At present, several studies are evaluating various novel treatment regimens in preparation for an era of untreatable gonorrhea. SUMMARY: Screening for asymptomatic infections, maintaining culture capacity to monitor antimicrobial resistance, treating with ceftriaxone and azithromycin, and ensuring that all sexual partners are treated are among the best strategies to control gonorrhea in the current clime. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Douglas-Pannett L.,Public Health |
Gnani S.,Imperial College London
Journal of Ambulatory Care Management | Year: 2015
In England, theDepartment ofHealth's planned introduction of a named and accountable family doctor (general practitioner) for patients older than 75 years is aimed at reducing the increasing number of unplanned hospital admissions observed in this group and driving down the associated health care costs. In this article, we explore the debate surrounding the plans and the potential impact of the contractual change on patients and health care practitioners, both intended and unintended.
Toon C.D.,Public Health
The Cochrane database of systematic reviews | Year: 2013
Most surgical procedures involve a cut in the skin that allows the surgeon to gain access to the deeper tissues or organs. Most surgical wounds are closed fully at the end of the procedure (primary closure). The surgeon covers the closed surgical wound with either a dressing or adhesive tape. The dressing can act as a physical barrier to protect the wound until the continuity of the skin is restored (within about 48 hours) and to absorb exudate from the wound, keeping it dry and clean, and preventing bacterial contamination from the external environment. Some studies have found that the moist environment created by some dressings accelerates wound healing, although others believe that the moist environment can be a disadvantage, as excessive exudate can cause maceration (softening and deterioration) of the wound and the surrounding healthy tissue. The utility of dressing surgical wounds beyond 48 hours of surgery is, therefore, controversial. To evaluate the benefits and risks of removing a dressing covering a closed surgical incision site within 48 hours permanently (early dressing removal) or beyond 48 hours of surgery permanently with interim dressing changes allowed (delayed dressing removal), on surgical site infection. In July 2013 we searched the following electronic databases: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We also searched the references of included trials to identify further potentially-relevant trials. Two review authors independently identified studies for inclusion. We included all randomised clinical trials (RCTs) conducted with people of any age and sex, undergoing a surgical procedure, who had their wound closed and a dressing applied. We included only trials that compared early versus delayed dressing removal. We excluded trials that included people with contaminated or dirty wounds. We also excluded quasi-randomised studies, and other study designs. Two review authors independently extracted data on the characteristics of the trial participants, risk of bias in the trials and outcomes for each trial. We calculated risk ratios (RR) with 95% confidence intervals (CI) for binary outcomes and mean difference (MD) with 95% CI for continuous outcomes. We used RevMan 5 software to perform these calculations. Four trials were identified for inclusion in this review. All the trials were at high risk of bias. Three trials provided information for this review. Overall, this review included 280 people undergoing planned surgery. Participants were randomised to early dressing removal (removal of the wound dressing within the 48 hours following surgery) (n = 140) or delayed dressing removal (continued dressing of the wound beyond 48 hours) (n = 140) in the three trials. There were no statistically significant differences between the early dressing removal group and delayed dressing removal group in the proportion of people who developed superficial surgical site infection within 30 days (RR 0.64; 95% CI 0.32 to 1.28), superficial wound dehiscence within 30 days (RR 2.00; 95% CI 0.19 to 21.16) or serious adverse events within 30 days (RR 0.83; 95% CI 0.28 to 2.51). No deep wound infection or deep wound dehiscence occurred in any of the participants in the trials that reported this outcome. None of the trials reported quality of life. The hospital stay was significantly shorter (MD -2.00 days; 95% CI -2.82 to -1.18) and the total cost of treatment significantly less (MD EUR -36.00; 95% CI -59.81 to -12.19) in the early dressing removal group than in the delayed dressing removal group in the only trial that reported these outcomes. The early removal of dressings from clean or clean contaminated surgical wounds appears to have no detrimental effect on outcomes. However, it should be noted that the point estimate supporting this statement is based on very low quality evidence from three small randomised controlled trials, and the confidence intervals around this estimate were wide. Early dressing removal may result in a significantly shorter hospital stay, and significantly reduced costs, than covering the surgical wound with wound dressings beyond the first 48 hours after surgery, according to very low quality evidence from one small randomised controlled trial. Further randomised controlled trials of low risk of bias are necessary to investigate whether dressings are necessary after 48 hours in different types of surgery and levels of contamination and investigate whether antibiotic therapy influences the outcome.
Toon C.D.,Public Health
The Cochrane database of systematic reviews | Year: 2013
Many people undergo surgical operations during their life-time, which result in surgical wounds. After an operation the incision is closed using stiches, staples, steri-strips or an adhesive glue. Usually, towards the end of the surgical procedure and before the patient leaves the operating theatre, the surgeon covers the closed surgical wound using gauze and adhesive tape or an adhesive tape containing a pad (a wound dressing) that covers the surgical wound. There is currently no guidance about when the wound can be made wet by post-operative bathing or showering. Early bathing may encourage early mobilisation of the patient, which is good after most types of operation. Avoiding post-operative bathing or showering for two to three days may result in accumulation of sweat and dirt on the body. Conversely, early washing of the surgical wound may have an adverse effect on healing, for example by irritating or macerating the wound, and disturbing the healing environment. To compare the benefits (such as potential improvements to quality of life) and harms (potentially increased wound-related morbidity) of early post-operative bathing or showering (i.e. within 48 hours after surgery, the period during which epithelialisation of the wound occurs) compared with delayed post-operative bathing or showering (i.e. no bathing or showering for over 48 hours after surgery) in patients with closed surgical wounds. We searched The Cochrane Wounds Group Specialised Register;The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); The Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; the metaRegister of Controlled Trials (mRCT) and the International Clinical Trials Registry Platform (ICTRP). We considered all randomised trials conducted in patients who had undergone any surgical procedure and had surgical closure of their wounds, irrespective of the location of the wound and whether or not the wound was dressed. We excluded trials if they included patients with contaminated, dirty or infected wounds and those that included open wounds. We also excluded quasi-randomised trials, cohort studies and case-control studies. We extracted data on the characteristics of the patients included in the trials, risk of bias in the trials and outcomes from each trial. For binary outcomes, we calculated the risk ratio (RR) with 95% confidence interval (CI). For continuous variables we planned to calculate the mean difference (MD), or standardised mean difference (SMD) with 95% CI. For count data outcomes, we planned to calculate the rate ratio (RaR) with 95% CI. We used RevMan 5 software for performing these calculations. Only one trial was identified for inclusion in this review. This trial was at a high risk of bias. This trial included 857 patients undergoing minor skin excision surgery in the primary care setting. The wounds were sutured after the excision. Patients were randomised to early post-operative bathing (dressing to be removed after 12 hours and normal bathing resumed) (n = 415) or delayed post-operative bathing (dressing to be retained for at least 48 hours before removal and resumption of normal bathing) (n = 442). The only outcome of interest reported in this trial was surgical site infection (SSI). There was no statistically significant difference in the proportion of patients who developed SSIs between the two groups (857 patients; RR 0.96; 95% CI 0.62 to 1.48). The proportions of patients who developed SSIs were 8.5% in the early bathing group and 8.8% in the delayed bathing group. There is currently no conclusive evidence available from randomised trials regarding the benefits or harms of early versus delayed post-operative showering or bathing for the prevention of wound complications, as the confidence intervals around the point estimate are wide, and, therefore, a clinically significant increase or decrease in SSI by early post-operative bathing cannot be ruled out. We recommend running further randomised controlled trials to compare early versus delayed post-operative showering or bathing.
Satizabal C.L.,Boston University |
Beiser A.S.,Boston University |
Beiser A.S.,Public Health |
Chouraki V.,Boston University |
And 3 more authors.
New England Journal of Medicine | Year: 2016
BACKGROUND The prevalence of dementia is expected to soar as the average life expectancy increases, but recent estimates suggest that the age-specific incidence of dementia is declining in high-income countries. Temporal trends are best derived through continuous monitoring of a population over a long period with the use of consistent diagnostic criteria. We describe temporal trends in the incidence of dementia over three decades among participants in the Framingham Heart Study. METHODS Participants in the Framingham Heart Study have been under surveillance for incident dementia since 1975. In this analysis, which included 5205 persons 60 years of age or older, we used Cox proportional-hazards models adjusted for age and sex to determine the 5-year incidence of dementia during each of four epochs. We also explored the interactions between epoch and age, sex, apolipoprotein E e4 status, and educational level, and we examined the effects of these interactions, as well as the effects of vascular risk factors and cardiovascular disease, on temporal trends. RESULTS The 5-year age-and sex-adjusted cumulative hazard rates for dementia were 3.6 per 100 persons during the first epoch (late 1970s and early 1980s), 2.8 per 100 persons during the second epoch (late 1980s and early 1990s), 2.2 per 100 persons during the third epoch (late 1990s and early 2000s), and 2.0 per 100 persons during the fourth epoch (late 2000s and early 2010s). Relative to the incidence during the first epoch, the incidence declined by 22%, 38%, and 44% during the second, third, and fourth epochs, respectively. This risk reduction was observed only among persons who had at least a high school diploma (hazard ratio, 0.77; 95% confidence interval, 0.67 to 0.88). The prevalence of most vascular risk factors (except obesity and diabetes) and the risk of dementia associated with stroke, atrial fibrillation, or heart failure have decreased over time, but none of these trends completely explain the decrease in the incidence of dementia. CONCLUSIONS Among participants in the Framingham Heart Study, the incidence of dementia has declined over the course of three decades. The factors contributing to this decline have not been completely identified. © Copyright 2016 Massachusetts Medical Society.
News Article | February 23, 2017
HARRISBURG, Pa., Feb. 23, 2017 /PRNewswire-USNewswire/ -- Secretary of Health Dr. Karen Murphy today stressed the importance of improving health outcomes and access to quality health care at a meeting with community and business leaders from Dauphin, Perry, and Cumberland counties....