Morbidity,rickets and long-bone growth in post-medieval Britain—a cross-population analysis

Background: Vitamin D deficiency rickets is associated with skeletal deformities including swollen rib junctions, bowing of the legs, and the flaring and fraying of the wrist and long-bone metaphyses. There is, however, scarce information on the direct effect of rickets on skeletal growth in either present or past populations.

Aim: The study investigated the effect of vitamin D deficiency rickets on long-bone growth in two post-medieval skeletal populations from East London (Broadgate and Christ Church Spitalfields). Subsequently, inter-population growth variations in relation to non-specific environmental stress (dental enamel defects), industrialization, urbanization and socio-economic status during infancy (birth to 3 years) and early childhood (3–7 years) were examined.

Subjects and methods: Data on long-bone diaphyseal length dimensions and stress indicators of 234 subadults from Anglo-Saxon, late medieval and post-medieval archaeological skeletal samples were analysed using both linear and non-linear growth models.

Results: Rickets had no effect on the growth curves for any of the long bones studied. However, pronounced variations in growth between the four populations were noted, mainly during infancy. The diaphyseal length of long bones of Broadgate were significantly smaller-per-age than those of Spitalfields and the other samples up to the age of 4 years, and were associated with a high prevalence of enamel defects during early infancy.

Conclusion: Socio-economic status, rather than urbanization, industrialization or rickets, was the central factor behind the observed differences in growth among the post-medieval populations. The observed inter-population growth variations were only significant during infancy.

Résumé. Arrière plan: Le rachitisme par déficience en vitamine D est associé à des difformités squelettiques, notamment des jointures costales enflées, des jambes arquées et la dilatation des métaphyses des os longs. On ne dispose cependant pas d’une information abondante sur l’effet direct du rachitisme sur la croissance squelettique dans les populations actuelles ou passées.

Objectif: Etudier l’effet produit sur la croissance des os longs par le rachitisme par déficience en vitamine D, dans deux populations squelettiques post-médiévales de l’est de Londres (Broadgate et Christ Church Spitalfields). Dans cette perspective, on a examiné les variations de croissance entre populations en fonction d’un stress environnemental non spécifique (défauts de l’émail dentaire), industrialisation, urbanisation et statut socioéconomique au cours de la prime enfance (de la naissance à 3 ans) et de la petite enfance (de 3 à 7 ans).

Sujets et méthodes: Des données sur les dimensions diaphysaires d’os longs et les indicateurs de stress de 234 squelettes de jeunes anglo-saxons de gisements archéologiques des périodes médiévale terminale et post médiévale, ont été analysées au moyen de modèles de croissance linéaires et non linéaires.

Résultats: Le rachitisme ne produit pas d’effet sur les courbes de la croissance d’aucun des os longs étudiés, cependant on note des variations prononcées de la croissance entre les quatre populations, principalement pendant la prime enfance. Les longueurs diaphysaires des os longs de Broadgate sont significativement plus petites pour l’âge que celles de Spitalfields et des autres échantillons jusqu’à l’âge de 4 ans et sont associées à une forte prévalence de défauts de l’émail pendant la petite enfance.

Conclusion: Le facteur central des différences de croissance observées dans les populations post-médiévales est le statut socioéconomique plus que l’industrialisation, l’urbanisation ou le rachitisme. Les variations de croissance entre les populations ne sont significatives que pendant la prime enfance.

Zusammungfassung. Hintergrund: Vitamin D-abhängige Rachitis geht mit Skelettveränderungen einher, wie Schwellungen der Rippengelenke, Verbiegungen der Beine und verbreiterten und am Rande ausgezogenen Metaphysen von Handgelenk und langen Röhrenknochen. Es gibt aber nur wenig Information über den direkten Einfluss der Rachitis auf Skelettwachstum sowohl bei heutigen als auch bei früheren Populationen.

Ziel: Die Studie untersuchte den Einfluss der Vitamin D-abhängigen Rachitis auf das Wachstum der langen Röhrenknochen bei zwei nachmittelalterlichen Skelettpopulationen aus dem Osten von London (Broadgate und Christ Church Spitalfields). Danach wurden die zwischen den Populationen auftretenden Variationen des Wachstums in Beziehung zu unspezifischem Umweltstress (Zahnschmelzdefekte), Industrialisierung, Urbanisierung und sozioökonomischem Status während der frühen (Geburt bis 3 Jahre) und mittleren Kindheit (3--7 Jahre) untersucht.

Probanden und Methoden: Daten betreffend Längenmaße der Diaphysen langer Röhrenknochen und Stressindikatoren wurden bei 234 nicht ganz ausgewachsenen Anglosächsischen, spät- und nachmittelalterlichen archäologischen Skelettfunden unter Verwendung von linearen und nicht-linearen Wachstumsmodellen analysiert.

Ergebnisse: Rachitis hatte keinen Einfluss auf die Wachstumskurven irgendeiner der untersuchten langen Röhrenknochen. Allerdings wurden deutliche Variationen im Wachstum zwischen den vier Populationen, vornehmlich in der Säuglingszeit, bemerkt. Die Diaphysenlänge der langen Röhrenknochen aus Broadgate waren bis zum Alter von 4 Jahren, bezogen auf das Alter, signifikant kürzer als die aus Spitalfields und den anderen Stichproben, und sie gingen mit einer hohen Prävalenz von Zahnschmelzdefekten in der Säuglingszeit einher.

Zusammenfassung: Sozioökonomischer Status und nicht Urbanisationsgrad, Industrialisierung oder Rachitis waren die Haupteinflussfaktoren für die beobachteten Unterschiede im Wachstum nachmittelalterlicher Populationen. Die beobachteten zwischen den Populationen auftretenden Variationen im Wachstum waren nur in der Säuglingszeit signifikant.

Resumen. Antecedentes: El raquitismo por déficit de vitamina D está asociado con deformidades esqueléticas que incluyen abultamiento en la unión de las costillas, piernas arqueadas, y ensanchamiento y desgaste de la muñeca y las metáfisis de los huesos largos. No obstante, existe escasa información sobre el efecto directo del raquitismo sobre el crecimiento esquelético en poblaciones actuales o pasadas.

Objetivo: El estudio investigó el efecto del raquitismo por déficit en vitamina D sobre el crecimiento de los huesos largos de dos poblaciones esqueléticas medievales del este de Londres (Broadgate y Christ Church Spitalfields). Posteriormente, se examinaron las variaciones en el crecimiento interpoblacional en relación con el estrés ambiental inespecífico (defectos en el esmalte dental), la industrialización, la urbanización y el nivel socioeconómico durante la infancia (desde el nacimiento a los 3 años de edad) y la temprana niñez (de 3 a 7 años).

Sujetos y métodos: Se analizaron datos de las dimensiones longitudinales de las diáfisis de los huesos largos e indicadores de estrés de 234 subadultos, procedentes de muestras esqueléticas arqueológicas anglosajonas de finales del medioevo y post-medievales, utilizando tanto modelos de crecimiento lineal como no lineal.

Resultados: El raquitismo no tenía efecto sobre las curvas de crecimiento de ninguno de los huesos largos estudiados. Sin embargo, se observaron notables variaciones en el crecimiento de las cuatro poblaciones, principalmente durante la infancia. Las longitudes diafisiarias de los huesos largos de Broadgate eran significativamente menores por edad que las de Spitalfields y las otras muestras hasta los 4 años de edad, y estaban asociadas con una alta prevalencia de defectos en el esmalte durante la primera infancia.

Conclusión: El nivel socioeconómico, más que la urbanización, la industrialización o el raquitismo, es el factor central que subyace en las diferencias observadas en el crecimiento de las poblaciones post-medievales. Las variaciones inter-poblacionales observadas en el crecimiento sólo fueron significativas durante la infancia.     

Giving and receiving a diagnosis of a progressive neurological condition: A scoping review of doctors’ and patients’ perspectives

ObjectiveDelivering a life changing diagnosis can be a distressing experience for patients and a challenging task for professionals. Diagnosis delivery can be especially difficult for individuals with neurodegenerative diseases such as motor neurone disease (MND), multiple sclerosis (MS) and Parkinson’s disease (PD). This review aims to scope the literature on doctors' and patients' perspectives on diagnosis delivery for these conditions in order to enhance our understanding in this area and identify potential research gaps.MethodsA scoping review methodology was used, and data were summarised using content analysis.Results47 studies fulfilled the inclusion criteria. Studies showed that although patients were generally satisfied with diagnosis delivery, a considerable proportion was still dissatisfied with aspects of the consultation, especially the information and time provided and the doctor’s approach. Only six studies addressed doctors' perspectives, which focused more on doctors’ practice.ConclusionThere was a significant research gap in professionals' perspectives. The review also found that although basic standards of good practice were being met, a significant proportion of patients were dissatisfied with diagnosis communication.Practice implicationsProfessionals delivering such diagnoses need to assess and respond to patients' information needs, provide time for questions and maintain an empathic attitude.     

Do doctors’ attachment styles and emotional intelligence influence patients’ emotional expressions in primary care consultations? An exploratory study using multilevel analysis

Objective

To investigate whether and how doctors’ attachment styles and emotional intelligence (EI) might influence patients’ emotional expressions in general practice consultations.

‘Outwalk’: a protocol for clinical gait analysis based on inertial and magnetic sensors

A protocol named Outwalk was developed to easily measure the thorax–pelvis and lower-limb 3D kinematics on children with cerebral palsy (CP) and amputees during gait in free-living conditions, by means of an Inertial and Magnetic Measurement System (IMMS). Outwalk defines the anatomical/functional coordinate systems (CS) for each body segment through three steps: (1) positioning the sensing units (SUs) of the IMMS on the subjects’ thorax, pelvis, thighs, shanks and feet, following simple rules; (2) computing the orientation of the mean flexion–extension axis of the knees; (3) measuring the SUs’ orientation while the subject’s body is oriented in a predefined posture, either upright or supine. If the supine posture is chosen, e.g. when spasticity does not allow to maintain the upright posture, hips and knees static flexion angles must be measured through a standard goniometer and input into the equations that define Outwalk anatomical CSs. In order to test for the inter-rater measurement reliability of these angles, a study was carried out involving nine healthy children (7.9 ± 2 years old) and two physical therapists as raters. Results showed RMS error of 1.4° and 1.8° and a negligible worst-case standard error of measurement of 2.0° and 2.5° for hip and knee angles, respectively. Results were thus smaller than those reported for the same measures when performed through an optoelectronic system with the CAST protocol and support the beginning of clinical trials of Outwalk with children with CP.     

A review and analysis of the use of ‘habit’ in understanding,predicting and influencing health-related behaviour

The term ‘habit’ is widely used to predict and explain behaviour. This paper examines use of the term in the context of health-related behaviour, and explores how the concept might be made more useful. A narrative review is presented, drawing on a scoping review of 136 empirical studies and 8 literature reviews undertaken to document usage of the term ‘habit’, and methods to measure it. A coherent definition of ‘habit’, and proposals for improved methods for studying it, were derived from findings. Definitions of ‘habit’ have varied in ways that are often implicit and not coherently linked with an underlying theory. A definition is proposed whereby habit is a process by which a stimulus generates an impulse to act as a result of a learned stimulus-response association. Habit-generated impulses may compete or combine with impulses and inhibitions arising from other sources, including conscious decision-making, to influence responses, and need not generate behaviour. Most research on habit is based on correlational studies using self-report measures. Adopting a coherent definition of ‘habit’, and a wider range of paradigms, designs and measures to study it, may accelerate progress in habit theory and application.     

Training tomorrow’s doctors to explain ‘medically unexplained’ physical symptoms: An examination of UK medical educators’ views of barriers and solutions

Objective

Co-occuring physical symptoms, unexplained by organic pathology (known as Functional Syndromes, FS), are common and disabling presentations. However, FS is absent or inconsistently taught within undergraduate medical training. This study investigates the reasons for this and identifies potential solutions to improved implementation.

Factors associated with prevalence and types of ‘may be fit’ advice on fit notes: a cross-sectional primary care analysis

Background

The ‘fit note’, with the opportunity for the GP to advise that a patient ‘may be fit’ to do some work, was introduced in April 2010.

Aim

To estimate numbers of fit notes with ‘may be fit’ advice, the types of advice, and factors associated with any inclusion of such advice in the fit note.

Design and setting

Cross-sectional analysis of fit note data from 68 general practices in eight regions of England, Wales and Scotland.

Method

Collection of practice fit note data via GP use of carbonised pads of fit notes for a period of 12 months.

Results

The ‘may be fit’ box was ticked on 5080 fit notes (6.4% of all fit notes in study). But there was a wide variation in completion rates across the 68 practices (from 1% to 15%). The most prevalent individual item of advice was to ‘amend duties’ of patient as a prerequisite for return to work (included in 42% of all notes containing any ‘may be fit’ advice). Advice was often incomplete or irrelevant, with some GPs failing to comply with official guidance. Inclusion of any ‘may be fit’ advice was independently associated with the patient being female, less socially deprived and having a physical health reason for receiving a fit note.

Conclusion

Unlike other studies that have relied upon eliciting opinion, this study investigates how the fit note is being used in practice. Findings provide some evidence that the fit note is not yet being used to the optimum benefit of patients (and their employers).