Case-control study of hospital admission with asthma in children aged 5-14 years: relation with road traffic in north west London

BACKGROUND: Evidence for an association between road traffic pollution and asthma is inconclusive. We report a case-control study of hospital admissions for asthma and respiratory illness among children aged 5-14 in relation to proxy markers of traffic related pollution. METHODS: The study was based on routine hospital admissions data in 1992/3 and 1993/4 for North Thames (West) health region within the M25 motorway. Cases were defined as emergency admissions for asthma (n = 1380) or all respiratory illness including asthma (n = 2131), and controls (n = 5703) were other emergency admissions excluding accidents. Cases and controls were compared with respect to distance of residence from nearest main road or roads with peak hour traffic >1000 vehicles and traffic volume within 150 m of residence, obtained by Geographical Information System techniques. Statistical analysis included adjustment for age, sex, admitting hospital, and a deprivation score for the census enumeration district of residence. RESULTS: Adjusted odds ratios of hospital admission for asthma and respiratory illness for children living within 150 m of a main road compared with those living further away were, respectively, 0.93 (95% CI 0.82 to 1.06) and 1.02 (95% CI 0.92 to 1.14). CONCLUSIONS: This study showed no association between risk of hospital admission for asthma or respiratory illness among children aged 5-14 and proxy markers of road traffic pollution.     

Temporal association between hospital admissions for asthma in Birmingham and ambient levels of sulphur dioxide and smoke.

BACKGROUND--A study was performed to determine whether daily and weekly variations in the levels of smoke and sulphur dioxide (SO2) in Birmingham are related to hospital admissions for asthma and acute respiratory diseases. METHODS--Daily numbers of hospital admissions for asthma (ICD code 493) and acute respiratory conditions (ICD 466, 480-486, 490-496) for residents of Birmingham between 1988 and 1990 were obtained from West Midlands RHA Körner inpatient data. Average daily levels of sulphur dioxide and smoke were obtained from Birmingham City Council for the same period, together with daily meteorological summaries from the Department of Geography, University of Birmingham. With the exception of one day, all air pollution measurements remained within current EC guide levels. Data were divided into seasons and the relation between hospital admissions and pollutant levels were explored by stepwise least squares regression models. Meteorological variables (temperature, pressure, humidity) were entered into the model if they showed significant association with hospital admissions during the season in question. Analysis was undertaken for daily (same day and lagged by two days) and weekly pollutant levels. Admissions were lagged behind pollution levels to allow for delayed effects of pollutants. RESULTS--The mean daily level of smoke was 12.7 micrograms/m3 and of SO2 was 39.1 micrograms/m3, with maxima of 188.3 micrograms/m3 and 126.3 micrograms/m3, respectively. Significant associations were found between hospital admissions for respiratory disease lagged by two days, and smoke and SO2 levels during winter. Associations between admissions for asthma and smoke and SO2 levels were significant at the 5% level. These were independent of temperature, pressure, and humidity. Stepwise regression including both pollutants showed that smoke, but not SO2, was a significant independent predictor of hospital admissions for both asthma and all respiratory conditions. During winter a rise of 100 micrograms/m3 smoke might result in five (95% CI 0.6 to 9) more asthma admissions and 21.5 (95% CI 10 to 33) more acute respiratory admissions each day in Birmingham. A 100 micrograms/m3 rise in SO2 might result in four (0 to 7) more asthma admissions and 15.5 (6 to 25) more respiratory admissions each day. Independent associations were also found between weekly mean smoke and SO2 levels and all respiratory admissions during autumn and winter. During summer, daily mean smoke and SO2 levels were significantly associated with non-lagged daily admissions for all respiratory diseases (p < 0.02). There was no association between air pollution and hospital admissions during spring. CONCLUSIONS--Daily variations in smoke and SO2 levels are significantly associated with hospital admissions for asthma and respiratory disease during winter in Birmingham at levels of air pollutants within the EC guide levels. This association was independent of potential confounding effects of weather (temperature, pressure, humidity) and suggests that current levels of air pollution can still produce significant health effects.     

Diagnostic and treatment behaviour in children with chronic respiratory symptoms: relationship with socioeconomic factors

BACKGROUND: The prevalence and severity of asthma is believed to increase with increasing socioeconomic deprivation. The relationship between asthma diagnosis, symptoms, diagnostic accuracy, and socioeconomic deprivation as determined by Townsend scores was determined in Sheffield schoolchildren. METHODS: All 6021 schoolchildren aged 8-9 years in one school year in Sheffield were given a parent respondent survey based on International Survey of Asthma and Allergies in Childhood (ISAAC) questions. RESULTS: 5011/6021 (83.2%) questionnaires were returned. Postcode data were available in 4131 replies (82.4%) and were used to assign a composite deprivation score (Townsend score). Scores were divided into five quintiles, with group 1 being least and group 5 being most deprived. A positive trend was observed from group 1 to group 5 for the prevalence of wheeze in the previous 12 months, wheeze attacks >or=4/year, nocturnal wheeze and cough (all p<0.001), cough and/or wheeze "most times" with exertion (p<0.03), current asthma (p<0.001), and significant asthma symptoms (p<0.001). No significant trend was observed for lifetime wheeze or attacks of speech limiting wheeze. There were no significant trends in the prevalence of current asthmatic children without significant symptoms (overdiagnosis) or children with significant asthma symptoms but no current asthma diagnosis (underdiagnosis) across the social groups. There was a significant negative trend in the ratio of asthma medication to asthma diagnosis from least to most deprived groups (p<0.001). CONCLUSIONS: Asthma morbidity and severity increase according to the level of socioeconomic deprivation. This may be due to differences in environment, asthma management, and/or symptom reporting. Diagnostic accuracy does not vary significantly across deprivation groups but children living in areas of least deprivation and taking asthma medication are less likely to be labelled as having asthma, suggesting diagnostic labelling bias.     

Geographical and socioeconomic variation in the prevalence of asthma symptoms in English and Scottish children.

BACKGROUND: There has been controversy over the relation between poverty and asthma in the community. The aim of this analysis was to disentangle geographical and socioeconomic variation in asthma symptoms. METHODS: The analysis is based on parental reports of symptoms from data collected in 1990 and 1991. Children aged 5-11 years from three populations (English representative sample, Scottish representative sample, and an English inner city sample) were included. Of 17 677 eligible children, between 14 490 (82.0%) and 15 562 (88.0%) children were available for analysis according to symptom group. RESULTS: Wheezy symptoms were less prevalent in the Scottish sample than in the English samples and asthma attacks were most prevalent in the English representative sample. Asthma attacks were less prevalent in inner city areas than in the English representative sample (OR 0.79, 95% CI 0.66 to 0.95), but persistent wheeze and other respiratory symptoms were more prevalent (OR 1.95, 95% CI 1.65 to 2.32 and OR 1.67, 95% CI 1.52 to 1.84, respectively). The prevalence of persistent wheeze was higher in children whose father's social class was low and in those living in areas with a high Townsend score (an index of poverty) than in other children (p<0.001). Of the 14 areas with the highest Townsend score, 13 had an OR above 1 and six had an OR significantly higher than the reference area. CONCLUSIONS: Persistent wheeze is more prevalent in poor areas than in less deprived areas. This may indicate that poverty is associated with severe asthma or that a high percentage of persistent asthma symptoms in inner city areas are unrecognised and untreated.     

Parental education and guided self-management of asthma and wheezing in the pre-school child: a randomised controlled trial

BACKGROUND: The effects on morbidity were examined of providing an educational intervention and a written guided self-management plan to the parents of pre-school children following a recent attendance at hospital for asthma or wheeze. METHODS: A prospective, randomised, partially blinded, controlled trial was designed at two secondary care centres. Over a 13 month period 200 children aged 18 months to 5 years at the time of admission to a children's ward or attendance at an accident and emergency department or children's (emergency) assessment unit (A&E/CAU) with a primary diagnosis of acute severe asthma or wheezing were recruited. 101 children were randomised into the control group and received usual care and 99 were assigned to the intervention group and received: (1) a pre-school asthma booklet; (2) a written guided self-management plan; and (3) two 20 minute structured educational sessions between a specialist respiratory nurse and the parent(s) and child. Subjects were assessed at 3, 6, and 12 months. The main outcomes were GP consultation rates, hospital re-admissions, and attendances at A&E/CAU. Secondary outcomes included disability score, caregivers' quality of life, and parental knowledge of asthma. RESULTS: There were no statistically significant differences between the two groups during the 12 month follow up period for any of the main or secondary outcome measures. CONCLUSIONS: These results do not support the hypothesis that the introduction of an educational package and a written guided self-management plan to the parents of pre-school children with asthma who had recently attended hospital for troublesome asthma or wheeze reduces morbidity over the subsequent 12 months.     

Effect of readmissions on increasing hospital admissions for asthma in children.

BACKGROUND--Previous studies have reported increases in the number of hospital admissions for asthma in children. The aim of the present study was to examine the effect of readmissions on these increased hospital admissions and to investigate gender differences in asthma readmissions. METHODS--The Provincial Government of Saskatchewan provides universal health care to its residents. Hospital admissions data for asthma were obtained from the Saskatchewan Health Department for all 134 hospitals in the province between 1980 and 1989. Age-specific and sex-specific hospital admission rates for asthma were calculated for each calendar year using first admissions and all admissions. The ratio between the number of readmissions and all admissions in a year was defined as the readmission rate for that year. RESULTS--Although rates based on all admissions for asthma were greater than rates based on first admissions, trends and sex differences were similar for the two rates. Despite the higher hospital admission rates for boys aged 10-14 years, girls in this age group had higher readmission rates for asthma from 1981 to 1989 (odds ratio (OR) 1.6 for girls; 95% confidence intervals (CI) 1.3 to 1.9). Similar increases were observed in readmission rates for asthma among children aged 5-9 years from 1985 to 1989 (OR 1.3 for girls; 95% CI 1.1 to 1.5). CONCLUSIONS--Readmissions for asthma do not seem to explain the increasing trend in hospital admissions for asthma in children. In children aged 10-14 years girls had higher hospital readmission rates for asthma than boys, and further studies are required to find factors related to the increased readmissions among girls in this age group.     

The effect of socioeconomic deprivation on fracture incidence in the United Kingdom

Lifestyle factors such as diet and physical activity vary in different social and income groups, and are known to be important influences on the incidence of osteoporotic fractures. Financial and social pressures are a common concern for older people. We set out to study the effect of socioeconomic deprivation on the incidence of fracture in older people and to compare the findings with those for younger groups. The All Wales Injury Surveillance System (AWISS) is a computerized system that collects injury data from most A&E departments throughout Wales. In this population-based study of 1.8 million people living in the 445 electoral tracts covered by AWISS in south, west, and northeastern Wales, we identified all 60,106 residents who presented with a fracture in 1999 and 2000. We linked details of their fracture with published Townsend deprivation scores for the electoral tract in which they were living and calculated fracture rates by fifths of deprivation. We observed the expected pattern of increasing fracture incidence in older age groups. Fracture incidence was significantly higher in electoral wards with poorer Townsend scores, resulting from a marked effect of socioeconomic deprivation on fracture incidence among younger adults with a rate ratio of 1.64 (95% CI, 1.57 to 1.72). This effect diminished with age, and was not observed in older age groups. At ages 85 and over the rate ratio was 0.94 (95% CI, 0.87 to 1.01). Socioeconomic factors clearly play a part in the causation of fracture in younger adults. Lifestyle influences are important in older age groups, but socioeconomic deprivation does not appear to be a risk factor for the development of osteoporotic fractures in elderly people.     

Proximity to coke works and hospital admissions for respiratory and cardiovascular disease in England and Wales

BACKGROUND: The incidence of hospital admissions for respiratory and cardiovascular diseases in areas close to operating coke works in England and Wales was investigated. METHODS: A small area study using distance from source as a proxy for exposure was undertaken in subjects aged 65 or over and children under 5 years within 7.5 km of four coke works (1991 estimated populations 87 760 and 43 932, respectively). The main outcome measures were emergency hospital admissions in 1992/3-1994/5 with a primary diagnosis of coronary heart disease (ICD 410-414), stroke (ICD 431-438), all respiratory diseases (ICD 460-519), chronic obstructive pulmonary disease (ICD 491-492), and asthma (ICD 493) in those aged 65 or over, and all respiratory and asthma admissions in children under 5 years of age. RESULTS: At age 65 or over the combined estimate of relative risk with proximity to coke works (per km) ranged from 0.99 (95% CI 0.90 to 1.09) for chronic obstructive pulmonary disease to 1.03 (95% CI 0.94 to 1.13) for asthma. For children under 5 years the combined estimate of risk was 1.08 (95% CI 0.98 to 1.20) for all respiratory disease and 1.07 (95% CI 0.98 to 1.18) for asthma. There was evidence of significant heterogeneity in risk estimates between coke work groups, especially in children under 5 years (p<0.001 and p=0.004 for respiratory disease and asthma, respectively). For the Teesside coke works in North East England the relative risk with proximity (per km) was 1.09 (95% CI 1.06 to 1.12) for respiratory disease and 1.09 (95% CI 1.04 to 1.15) for asthma. CONCLUSIONS: No evidence overall was found for an association between hospital admissions and living near operational coke works in England and Wales. Trends of a higher risk of hospital admission for respiratory disease and asthma among children with proximity to the Teesside plant require further investigation.     

Health effects of an air pollution episode in London, December 1991.

BACKGROUND--In December 1991 London experienced a unique air pollution episode during which concentrations of nitrogen dioxide rose to record levels, associated with moderate increases in black smoke. The aim of this study was to investigate whether this episode was associated with adverse health effects and whether any such effects could be attributed to air pollution. METHODS--The numbers of deaths and hospital admissions occurring in Greater London during the week of the episode were compared with those predicted using data from the week before the episode and from equivalent periods from the previous four years. Relative risks (RR) (episode week versus predicted) for adverse health events were estimated using log linear modelling and these were compared with estimates from control areas which had similar cold weather but without increased air pollution. RESULTS--In all age groups mortality was increased for all causes (excluding accidents) (relative risk = 1.10) and cardiovascular diseases (1.14); non-significant increases were observed for all respiratory diseases (1.22), obstructive lung diseases (1.23), and respiratory infections (1.23). In the elderly (65 + years) the relative risk of hospital admission was increased for all respiratory diseases (1.19) and for obstructive lung diseases (1.43), and a non-significant increase was observed for ischaemic heart disease (1.04). In children (0-14 years) there was no increase in admissions for all respiratory diseases and only a small non-significant increase for asthma. When compared with control areas the relative risks became non-significant but remained increased. CONCLUSIONS--The air pollution episode was associated with an increase in mortality and morbidity which was unlikely to be explained by the prevailing weather, a coincidental respiratory epidemic, or psychological factors due to publicity. Air pollution is a plausible explanation but the relative roles of nitrogen dioxide and particulates cannot be distinguished.     

Study of modifiable risk factors for asthma exacerbations: virus infection and allergen exposure increase the risk of asthma hospital admissions in children

BACKGROUND: Asthma exacerbation is the most common cause of hospital admission in children. A study was undertaken to investigate the importance of allergen exposure in sensitised individuals in combination with viral infections and other potentially modifiable risk factors precipitating asthma hospital admission in children. METHODS: Eighty four children aged 3-17 years admitted to hospital over a 1 year period with an acute asthma exacerbation (AA) were matched for age and sex with two control groups: stable asthmatics (SA) and children admitted to hospital with non-respiratory conditions (IC). Risk factors were assessed by questionnaires and determination of allergen sensitisation, home allergen exposure, pollen exposure, and respiratory virus infection. RESULTS: Several non-modifiable factors (atopy, duration of asthma) were associated with increased risk. Among the modifiable factors, pet ownership, housing characteristics, and parental smoking did not differ between the groups. Regular inhaled corticosteroid treatment was significantly less common in the AA group than in the SA group (OR 0.2, 95% CI 0.1 to 0.6; p = 0.002). A significantly higher proportion of the AA group were virus infected (44%) and sensitised and highly exposed to sensitising allergen (76%) compared with the SA (18% and 48%) and IC groups (17% and 28%; both p<0.001). In a multiple conditional logistic regression (AA v SA), allergen sensitisation and exposure or virus detection alone were no longer independently associated with hospital admission. However, the combination of virus detection and sensitisation with high allergen exposure substantially increased the risk of admission to hospital (OR 19.4, 95% CI 3.7 to 101.5, p<0.001). CONCLUSIONS: Natural virus infection and real life allergen exposure in allergic asthmatic children increase the risk of hospital admission. Strategies for preventing exacerbations will need to address these factors.     

Ethnic differences in prevalence of asthma symptoms and bronchial hyperresponsiveness in New Zealand schoolchildren

Maoris and Pacific Islanders in New Zealand have a higher asthma mortality and hospital admission rates than Europeans. To determine whether difference in asthma prevalence is the major factor underlying these differences in mortality, 2053 Auckland children aged 7-10 years (European 1084, Maori 509, Pacific Islander 460) were randomly sampled from school classes in the Auckland Urban Area, and studied by questionnaire (completed by parents) and histamine inhalation challenge to assess the provocative dose of histamine causing a 20% fall in FEV1 (PD20). Maoris had the highest prevalence rates of respiratory symptoms, and Europeans had rates similar to Pacific Islanders. For "any current wheeze" for example, the prevalence in Maoris was 22.2% compared with 16.1% and 16.3% in the Europeans and Pacific Islanders. The prevalence of diagnosed asthma was similar in the three groups. When bronchial hyperresponsiveness (defined as a PD20 less than or equal to 7.8 mumol histamine) was considered, Europeans had the highest rates (20%), followed by Maoris (13%), and then Pacific Islanders (8.7%). These differences were not accounted for by differences in socioeconomic status, rates of smoking in the home, age, gender, or height. It is concluded that differences in asthma prevalence do not satisfactorily explain the mortality and admission rate differences, although the higher symptom prevalence in the Maoris could be relevant to the higher mortality rate. Maori and Pacific Island children with symptoms of asthma were less likely to be taking prophylactic medication than European children. It is proposed that differences in management are important factors relevant to the increased mortality and morbidity from asthma in Polynesians.     

Respiratory symptoms of rural Fijian and Indian children in Fiji.

BACKGROUND--Significant ethnic differences exist in the respiratory morbidity of children in the Fiji Islands. Indian children have higher national hospital admission rates for asthma whereas Fijian children have higher admission rates for pneumonia. In Suva City the prevalence of wheeze is similar in Fijian and Indian children, productive cough is more common in Fijians, and bronchial hyperresponsiveness is more common in Indians. This study was undertaken to see whether ethnic differences in national hospital admission rates are reflected in the prevalence of respiratory symptoms in rural children. METHODS--A respiratory symptoms questionnaire in three languages with known repeatability was returned by 487 (98.2%) of 496 class 4 primary school children with a mean age of 9.3 years living in Nausori District, an agrarian region with a climate similar to Suva City. RESULTS--The prevalence of one or more episodes of wheezing in the last 12 months was similar in Fijians (19.8%) and Indians (19.4%). However, 8.9% of Indian children had experienced four or more episodes of wheeze in the last 12 months compared with only 2.9% of Fijian children. Productive cough on most mornings occurred more frequently in Fijians (35.8%) than Indians (23.9%), but this difference was not significant after controlling for the presence of a smoker in the home. CONCLUSIONS--This study provides the first evidence that frequent wheeze (four or more episodes in the last 12 months) is more prevalent in Indian than Fijian children. The higher prevalence of productive cough in Fijian children may be related to exposure to smoking in the home.     

The epidemiology of burns and smoke inhalation in secondary care: a population-based study covering Lancashire and South Cumbria

The epidemiology of burns and smoke inhalation in secondary care, for the population (1.6 million) of the four U.K. health authorities of Lancashire and South Cumbria is presented. Using health authority data from 1997 to 1999, it was found that 925 patients were admitted to hospital with either a primary diagnosis of burns or a primary diagnosis of smoke inhalation, in which 66% were male and 34% were female. The overall rate of admission was 0.29 per thousand. Highest rates were observed in children under the age of 5 and the elderly over the age of 75.Regression analysis confirmed an increase in admissions with increasing social deprivation.Mortality rates were shown to be highest in the over 75s. Rates of admitted burns in this study are higher than those reported from southern England. Paediatric and elderly injuries have been highlighted as high incidence groups. The epidemiology described here should assist in formulating strategies for prevention and the planning of further research.     

Nitrogen dioxide exposure from domestic gas cooking and airway response in asthmatic women

BACKGROUND: Previous studies have not found a consistent association between exposure to domestic cooking using gas appliances and exacerbation of asthma. We investigated the immediate airflow response to acute exposure from single episodes of gas cooking, and peak airflow variability from continued exposure to repeated episodes of gas cooking in a group of non-smoking asthmatic women. METHODS: Sixteen adult non-smoking women with mild to severe persistent asthma were studied. The acute short term level of nitrogen dioxide (NO2) during gas cooking episodes and the mean exposure to NO2 from repeated gas cooking episodes were measured over a 2 week period, as well as proxy measures of frequency of cooking on each day and the length of time spent cooking each day. Their asthma status was monitored using peak expiratory flow rates (PEFR) before and after cooking, 2 week self-recorded serial readings of PEFR, respiratory symptom severity score, and use of rescue bronchodilators for acute asthma attacks. RESULTS: Cooking was significantly associated with an immediate mean fall in PEFR of 3.4% (p=0.015, paired t test). The acute short term NO2 level during cooking was significantly correlated with the fall in PEFR (r=-0.579; p=0.019). The frequency of cooking over a 2 week period was positively correlated with the mean exposure to NO2 (r=0.529; p=0.042). Continued exposure to NO2 over a 2 week period was associated significantly with increased frequency of rescue bronchodilator usage for asthma attacks (r=0.597; p=0.031). However, it was negatively associated with PEFR variability (r=-0.512; p=0.051) and respiratory symptom severity score (r= -0.567; p=0.043), probably due to the masking effects of bronchodilator treatment. CONCLUSIONS: Acute short term exposure to NO2 from single episodes of gas cooking is associated with immediate airflow limitation. Continued exposure from repeated episodes of gas cooking in asthmatic women is associated with greater use of rescue bronchodilators.     

Changing patterns of hospital admission for asthma, 1981-97

BACKGROUND: Hospital admission rates for asthma have stopped rising in several countries. The aim of this study was to use linked hospital admission data to explore recent trends in asthma admissions in Scotland. METHODS: Linked Scottish Morbidity Records (SMR1) for asthma (ICD-9 493 and ICD-10 J45-6) from 1981 to 1997 were used to describe rates of first admissions and readmissions by age and sex. As a measure of resource use, annual trends in bed days used were also explored by age and sex. RESULTS: There were 160 039 hospital admissions for asthma by 82 421 individuals in Scotland during the study period. The overall hospital admission rate increased by 122% (from 106.7 to 236.7 per 100 000 population) but this varied by sex, age, and admission type. First admissions rose by 70% from 73.2 per 100 000 in 1986 to 124.8 per 100 000 in 1997 while readmissions fell. Children (<15 years) experienced a decline in overall admissions after 1992 due to falls in both new admissions and readmissions. By 1997 the ratio of female to male admissions was 0.57 in children, but 1.50 above 14 years of age. Mean lengths of stay fell from 10.7 days to 3.7 days between 1981 and 1997 and bed days used showed little change except for a decline after 1992 in children. CONCLUSIONS: After a period of increasing hospitalisation for asthma in Scotland, rates of admission among children have begun to fall but among adults admissions continue to rise.     

Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study

BACKGROUND: Re-admissions to hospital in childhood asthma are common with studies reporting that 25% or more of children will be re-admitted within a year. There is a need for strategies to reduce re-admissions. METHODS: A prospective randomised control study of an asthma home management training programme was performed in children aged two years or over admitted with acute asthma. Two hundred and one children were randomised at admission to either an intervention group (n = 96) which received the teaching programme or a control group (n = 105). A nurse- led teaching programme used the current attack as a model for the management of future attacks and included discussion, written information, subsequent follow up and telephone advice aimed at developing and reinforcing individualised asthma management plans. Parents were also provided with a course of oral steroids and guidance on when to start them. RESULTS: The groups were similar in degree of social deprivation, length of stay, number of previous admissions, acute asthma treatment, and asthma treatment at discharge. Subsequent re-admissions were significantly reduced in the intervention group from 25% to 8% in individual follow up periods that ranged from two to 14 months (chi 2 = 9.63; p = 0.002). This reduction was not accompanied by any increase in subsequent emergency room attendances nor, in the short term, by any increase in urgent community asthma treatment. The intervention group also showed significant reductions in day and night morbidity 3-4 weeks after admission to hospital. CONCLUSIONS: A nurse- led asthma home management training programme administered during a hospital admission can significantly reduce subsequent admissions to hospital for asthma. Acute hospitalisation may be a particularly effective time to deliver home management training.


     

THIS ARTICLE HAS BEEN RETRACTED Trends in prostate cancer incidence and survival in various socioeconomic classes: A population-based study

OBJECTIVES: Prostate cancer is currently the commonest cancer in men of all ages in UK, but robust demographic data of its distribution in various socioeconomic classes is lacking. We aimed to analyze its incidence, mortality and survival trends in West Midlands, England, from 1986 to 2000 in terms of socioeconomic deprivation. METHODS: Data were collated from the regional cancer registry database and a well-validated demographic score, the Townsend band, was employed as an indicator of social deprivation, including four variables as proxy indicators of socioeconomic status. Individual cases were allocated to one of five deprivation categories using postcode at diagnosis. Regression trend analysis at 1 and 5 years was performed and a P-value derived from the t-test statistic. RESULTS: In the mid-1980s, the incidence rate ratio in affluent:deprived classes was 0.9, with age-standardized rates of 35.23 and 39.53 per 100 000 people. This ratio increased to 1.5 by 2000 with age-standardized rates of 95.98 and 63.13, respectively (172% increase in affluent compared with 60% in deprived). The affluent groups had a 7 and 13% survival advantage at 1 and 5 years; the survival advantage at 1 year was statistically significant (P=0.03). CONCLUSIONS: The preferential changes in incidence and survival in the affluent social classes are likely to be due to heightened awareness, resulting in increased prostate-specific antigen testing, which captures early and relatively slow-growing tumors with a better overall prognosis. If these bipolar trends are allowed to persist, then the gap between the affluent and deprived will continue to widen.     

Directly measured second hand smoke exposure and asthma health outcomes

BACKGROUND: Because they have chronic airway inflammation, adults with asthma could have symptomatic exacerbation after exposure to second hand smoke (SHS). Surprisingly, data on the effects of SHS exposure in adults with asthma are quite limited. Most previous epidemiological studies used self-reported SHS exposure which could be biased by inaccurate reporting. In a prospective cohort study of adult non-smokers recently admitted to hospital for asthma, the impact of SHS exposure on asthma health outcomes was examined. METHODS: Recent SHS exposure during the previous 7 days was directly measured using a personal nicotine badge (n = 189) and exposure during the previous 3 months was estimated using hair nicotine and cotinine levels (n = 138). Asthma severity and health status were ascertained during telephone interviews, and subsequent admission to hospital for asthma was determined from computerised utilisation databases. RESULTS: Most of the adults with asthma were exposed to SHS, with estimates ranging from 60% to 83% depending on the time frame and methodology. The highest level of recent SHS exposure, as measured by the personal nicotine badge, was related to greater asthma severity (mean score increment for highest tertile of nicotine level 1.56 points; 95% CI 0.18 to 2.95), controlling for sociodemographic covariates and previous smoking history. Moreover, the second and third tertiles of hair nicotine exposure during the previous month were associated with a greater baseline prospective risk of hospital admission for asthma (HR 3.73; 95% CI 1.04 to 13.30 and HR 3.61; 95% CI 1.0 to 12.9, respectively). CONCLUSIONS: Directly measured SHS exposure appears to be associated with poorer asthma outcomes. In public health terms, these results support efforts to prohibit smoking in public places.     

Personal exposure to nitrogen dioxide and risk of airflow obstruction in asthmatic children with upper respiratory infection

BACKGROUND: Several studies have linked air pollution by nitrogen dioxide (NO(2)) with increased hospital admissions for asthma in children. Exacerbations of asthma in children are often precipitated by upper respiratory infections. It is therefore possible that NO(2) increases the risk of airways obstruction when asthmatic children develop upper respiratory infections. METHODS: To test this hypothesis a sample of 114 asthmatic children aged 7-12 years were followed for a total of up to 13 months. Probable upper respiratory infections were identified by consensus review of daily symptom diaries, and episodes of airways obstruction from serial records of peak expiratory flow (PEF). Personal exposures to NO(2) were measured with Palmes tubes that were changed weekly. Generalised estimating equations were used to assess the relative risk (RR) of an asthmatic exacerbation starting within seven days of an upper respiratory infection according to estimated NO(2) exposure during the one week period from two days before to four days after the onset of the infection. RESULTS: The children were followed for an average of 34 weeks during which 318 upper respiratory infections and 224 episodes of reduced PEF were diagnosed. PEF episodes were much more likely to occur in the seven days following the onset of an upper respiratory infection than at other times. Estimated exposures to NO(2) at the time of infections were generally low (geometric mean 10.6 microg/m(3)). Compared with exposures of < or = 8 microg/m(3), exposures of >28 microg/m(3) were associated with a RR of 1.9 (95% confidence interval 1.1 to 3.4) for the development of an asthmatic episode within seven days of an infection. CONCLUSIONS: The findings give some support to the hypothesis that NO(2) increases the risk of asthmatic exacerbations following respiratory infections, even at relatively low levels of exposure. Further studies in populations with higher exposures would be useful.