Mortality and cancer incidence in UK military veterans involved in human experiments at Porton Down: 48-year follow-up.

BACKGROUND: We investigated whether military personnel involved in chemical warfare agent research at Porton Down had increased rates of mortality or cancer incidence. METHODS: This was a historical cohort study comprising male UK veterans who participated in the 'Service Volunteer Programme', 1941-89, identified from Porton Down experiment books, and a comparison group of similar 'non-Porton Down' veterans identified from military personnel files. Of 19 233 records retrieved for each group, 18 133 (94%) Porton Down and 17 591 (92%) non-Porton Down were included in our analytical sample. Mortality and cancer incidence data were obtained from national registries up to December 2019. RESULTS: Over a median follow-up of 48.1 years, 10 935 Porton Down veterans (60.3%) and 10 658 non-Porton Down veterans (60.6%) had died. After adjustment for age, year of birth and military service characteristics, overall, Porton Down veterans had a 6% higher rate of all-cause mortality compared with non-Porton Down veterans [hazard ratio (HR) = 1.06, 95% confidence interval (CI) 1.03-1.09]. For cause-specific mortality, Porton Down veterans had higher rates of death from genitourinary diseases (HR = 1.34, 95% CI 1.05-1.70) and deaths attributable to alcohol (HR = 1.44, 95% CI 1.07-1.94), with weaker associations observed for deaths from infectious and parasitic diseases (HR = 1.32, 95% CI 0.99-1.78), lung cancer (HR = 1.10, 95% CI 1.01-1.20) and external causes (HR = 1.15, 95% CI 1.00-1.32). Associations with all-cause mortality were stronger for veterans who attended Porton Down between 1960 and 1964 (HR = 1.34, 95% CI 1.19-1.50); likelihood-ratio test, P = 0.006. There was no association between attendance at Porton Down and overall cancer incidence (HR = 1.00, 95% CI 0.95-1.03). CONCLUSIONS: Overall, mortality rates were slightly higher in Porton Down veterans, but there was no difference in cancer incidence. Associations for mortality were stronger in Porton Down veterans who attended in the early 1960s.

The Impact of Prehabilitation on Patient Outcomes in Hepatobiliary, Colorectal, and Upper Gastrointestinal Cancer Surgery: A PRISMA-Accordant Meta-analysis.

OBJECTIVE: To determine the impact of prehabilitation on hospital length of stay, functional capacity, complications, and mortality after surgery in patients with hepatobiliary, colorectal, and upper gastrointestinal cancer. BACKGROUND: "Prehabilitation" encompasses exercise, nutrition, and psychosocial interventions to optimize health before surgery. The benefits of prehabilitation are ill-defined. METHODS: Medline, Embase and Cochrane Databases were searched systematically for the terms "prehabilitation AND exercise," "perioperative care AND cancer surgery," and "colorectal AND hepatobiliary AND hepatopancreatobiliary AND esophagogastric AND recovery AND outcomes." Primary outcomes analyzed were hospital length of stay, functional capacity, significant postoperative complications (Clavien Dindo ≥ III), and mortality. A meta-analysis was conducted on the effect of all-modality prehabilitation for patients with colorectal, hepatopancreatobiliary and upper gastrointestinal cancer surgery using the raw mean difference, risk difference, and a random-effects model. RESULTS: Three hundred and seventy seven original titles were identified. Fifteen studies (randomized controlled trials; n = 9 and uncontrolled trials; n = 6) were included in the meta-analysis. Prehabilitation reduced hospital length of stay by 1.78 days versus standard care (95% CI: -3.36, -0.20, P < 0.05). There was no significant difference in functional capacity with prehabilitation determined using the 6-minute walk test (P = 0.816) and no significant reduction in postoperative complications (P = 0.378) or mortality rates (P = 0.114). CONCLUSIONS: Prehabilitation was associated with reduced hospital length of stay but had no effect on functional capacity, postoperative complications, or mortality rates. Thus, prehabilitation should be recommended to accelerate recovery from cancer surgery, demonstrated by reduced hospital length of stay.

Factors associated with length of stay in care homes: a systematic review of international literature.

BACKGROUND: A number of studies have explored factors associated with resident length of stay in care homes; however the findings of these studies have not been synthesized. The aim of this paper is to provide a systematic review of factors associated with length of stay until death and the strength of evidence supporting each of these factors. METHODOLOGY: This is a systematic review; databases included MEDLINE, EMBASE, PsycINFO, CINAHL, Proquest, the Cochrane Library and Web of Science were searched. Observational studies, either prospective or retrospective, that explored multiple factors associated with length of stay until death in care homes were included. Studies that met the inclusion criteria were sourced, data extracted and assessed for quality. Data synthesis combined the direction and significance of association with the quality of the study, resulting in strong, moderate, weak or inconclusive evidence for each factor identified. RESULTS: Forty-seven studies were identified as meeting the inclusion criteria. After quality assessment, 14 studies were judged to be of a high quality, 31 of a moderate quality and 2 of a low quality. Three factors had strong evidence to support their association with shorter lengths of stay: shortness of breath, receipt of oxygen therapy and admission to a facility providing nursing care. CONCLUSIONS: This review summarized the factors associated with length of stay. It found stronger evidence for physical functioning being associated with shorter lengths of stay than for cognitive functioning. An understanding of expected length of stay for older adults admitted to a care home is important for estimating lifetime costs and the implications of reforming funding arrangements for social care. Further research is needed to explore heterogeneity in this area.

The change of Barthel Index scores from the time of discharge until 3-month post-discharge among acute stroke patients in Malaysia: A random intercept model.

BACKGROUND: Acute stroke results in functional disability measurable using the well-known Barthel Index. The objectives of the study are to describe the change in the Barthel Index score and to model the prognostic factors for Barthel Index change from discharge up to 3 months post-discharge using the random intercept model among patients with acute first ever stroke in Kelantan, Malaysia. METHODS: A total 98 in-hospital first ever acute stroke patients were recruited, and their Barthel Index scores were measured at the time of discharge, at 1 month and 3 months post-discharge. The Barthel Index was scored through telephone interviews. We employed the random intercept model from linear mixed effect regression to model the change of Barthel Index scores during the three months intervals. The prognostic factors included in the model were acute stroke subtypes, age, sex and time of measurement (at discharge, at 1 month and at 3 month post-discharge). RESULTS: The crude mean Barthel Index scores showed an increased trend. The crude mean Barthel Index at the time of discharge, at 1-month post-discharge and 3 months post-discharge were 35.1 (SD = 39.4), 64.4 (SD = 39.5) and 68.8 (SD = 38.9) respectively. Over the same period, the adjusted mean Barthel Index scores estimated from the linear mixed effect model increased from 39.6 to 66.9 to 73.2. The adjusted mean Barthel Index scores decreased as the age increased, and haemorrhagic stroke patients had lower adjusted mean Barthel Index scores compared to the ischaemic stroke patients. CONCLUSION: Overall, the crude and adjusted mean Barthel Index scores increase from the time of discharge up to 3-month post-discharge among acute stroke patients. Time after discharge, age and stroke subtypes are the significant prognostic factors for Barthel Index score changes over the period of 3 months.

Sarin Exposures in A Cohort of British Military Participants in Human Experimental Research at Porton Down 1945-1987.

Background: The effects of exposure to chemical warfare agents in humans are topical. Porton Down is the UK's centre for research on chemical warfare where, since WWI, a programme of experiments involving ~30000 participants drawn from the UK armed services has been undertaken. Objectives: Our aim is to report on exposures to nerve agents, particularly sarin, using detailed exposure data not explored in a previous analysis. Methods: In this paper, we have used existing data on exposures to servicemen who attended the human volunteer programme at Porton Down to examine exposures to nerve agents in general and to sarin in particular. Results: Six principal nerve agents were tested on humans between 1945 and 1987. Of all 4299 nerve agent tests recorded, 3511 (82%) were with sarin, most commonly in an exposure chamber, with inhalation being the commonest exposure route (85%). Biological response to sarin exposure was expressed as percentage change in cholinesterase activity and, less commonly, change in pupil size. For red blood cell cholinesterase, median inhibition for inhalation tests was 41% (interquartile range 28-51%), with a maximum of 87%. For dermal exposures the maximum inhibition recorded was 99%. There was a clear association between increasing exposure to sarin and depression of cholinesterase activity but the strength and direction of the association varied by exposure route and the presence of chemical or physical protection. Pupil size decreased with increased exposure but this relationship was less clear when modifiers, such as atropine drops, were present. Conclusions: These results, drawn from high quality experimental data, offer a unique insight into the effects of these chemical agents on humans.

Differences in survival among adults with HIV-associated Kaposi's sarcoma during routine HIV treatment initiation in Zomba district, Malawi: a retrospective cohort analysis.

Background: The HIV epidemic is a major public health concern throughout Africa. Malawi is one of the worst affected countries in sub-Saharan Africa with a 2014 national HIV prevalence currently estimated at 10% (9.3-10.8%) by UNAIDS. Study reports, largely in the African setting comparing outcomes in HIV patients with and without Kaposi's sarcoma (KS) indicate poor prognosis and poor health outcomes amongst HIV+KS patients. Understanding the mortality risk in this patient group could help improve patient management and care. Methods: Using data for the 559 adult HIV+KS patients who started ART between 2004 and September 2011 at Zomba clinic in Malawi, we estimated relative hazard ratios for all-cause mortality by controlling for age, sex, TB status, occupation, date of starting treatment and distance to the HIV+KS clinic. Results: Patients with tuberculosis (95% CI: 1.05-4.65) and patients who started ART before 2008 (95% CI: 0.34-0.81) were at significantly greater risk of dying. A random-effects Cox model with Log-Gaussian frailties adequately described the variation in the hazard for mortality. Conclusion: The year of starting ART and TB status significantly affected survival among HIV+KS patients. A sub-population analysis of this kind can inform an efficient triage system for managing vulnerable patients.

Modelling and forecasting spatio-temporal variation in the risk of chronic malnutrition among under-five children in Ghana.

BACKGROUND: Spatio-temporal variation in under-5-year-old children malnutrition remains unstudied in most developing countries like Ghana. This study explores and forecasts the spatio-temporal patterns in childhood chronic malnutrition among these children. We also investigate the effect of maternal education on childhood malnutrition. METHODS: We analysed data on 10,036 children residing in 1516 geographic locations. A spatio-temporal model was fitted to the data and was used to produce predictive maps of spatio-temporal variation in the probability of stunting. RESULTS: The study found substantial spatio-temporal variation in the prevalence of stunting. Also, higher levels of mother's education were associated with decreased risk of being stunted. CONCLUSION: Our spatio-temporal model captured variations in childhood stunting over place and time. Our method facilitates and enriches modelling and forecasting of future stunting prevalence to identify areas at high risk. Improving maternal education could be given greater consideration within an overall strategy for addressing childhood malnutrition.

Seasonal Influenza Vaccination amongst Medical Students: A Social Network Analysis Based on a Cross-Sectional Study.

INTRODUCTION: The Chief Medical Officer for England recommends that healthcare workers have a seasonal influenza vaccination in an attempt to protect both patients and NHS staff. Despite this, many healthcare workers do not have a seasonal influenza vaccination. Social network analysis is a well-established research approach that looks at individuals in the context of their social connections. We examine the effects of social networks on influenza vaccination decision and disease dynamics. METHODS: We used a social network analysis approach to look at vaccination distribution within the network of the Lancaster Medical School students and combined these data with the students' beliefs about vaccination behaviours. We then developed a model which simulated influenza outbreaks to study the effects of preferentially vaccinating individuals within this network. RESULTS: Of the 253 eligible students, 217 (86%) provided relational data, and 65% of responders had received a seasonal influenza vaccination. Students who were vaccinated were more likely to think other medical students were vaccinated. However, there was no clustering of vaccinated individuals within the medical student social network. The influenza simulation model demonstrated that vaccination of well-connected individuals may have a disproportional effect on disease dynamics. CONCLUSIONS: This medical student population exhibited vaccination coverage levels similar to those seen in other healthcare groups but below recommendations. However, in this population, a lack of vaccination clustering might provide natural protection from influenza outbreaks. An individual student's perception of the vaccination coverage amongst their peers appears to correlate with their own decision to vaccinate, but the directionality of this relationship is not clear. When looking at the spread of disease within a population it is important to include social structures alongside vaccination data. Social networks influence disease epidemiology and vaccination campaigns designed with information from social networks could be a future target for policy makers.

Childhood Malnutrition and Its Determinants among Under-Five Children in Ghana.

BACKGROUND: Childhood malnutrition adversely affects short- and long-term health and economic well-being of children. Malnutrition is a global challenge and accounts for around 40% of under-five mortality in Ghana. Limited studies are available indicating determinants of malnutrition among children. This study investigates prevalence and determinants of malnutrition among children under-five with the aim of providing advice to policymakers and other stakeholders responsible for the health and nutrition of children. METHODS: The study used data from the 2008 Ghana Demographic and Health Survey (GDHS). Analyses were conducted on 2083 children under 5 years old nested within 1641 households with eligible anthropometric measurements, using multilevel regression analysis. Results from the multilevel models were used to compute probabilities of malnutrition. RESULTS: This study observed that 588 (28%), 276 (13%), and 176 (8%) of the children were moderately 'stunted', moderately 'underweight', and moderately 'wasted' respectively. Older ages are associated with increased risk of stunting and underweight. Longer breast-feeding duration, multiple births, experience of diarrhoeal episodes, small size at birth, absence of toilet facilities in households, poor households, and mothers who are not covered by national health insurance are associated with increased risk of malnutrition. Increase in mother's years of education and body mass index are associated with decreased malnutrition. Strong residual household-level variations in childhood nutritional outcomes were found. CONCLUSION: Policies and intervention strategies aimed at improving childhood nutrition and health should address the risk factors identified and the need to search for additional risk factors that might account for the unexplained household-level variations.

Spatial analysis of health effects of large industrial incinerators in England, 1998-2008: a study using matched case-control areas.

OBJECTIVES: To assess whether residential proximity to industrial incinerators in England is associated with increased risk of cancer incidence and mortality. DESIGN: Retrospective study using matched case-control areas. SETTING: Five circular regions of radius 10 km near industrial incinerators in England (case regions) and five matched control regions, 1998-2008. PARTICIPANTS: All cases of diseases of interest within the circular areas. PRIMARY AND SECONDARY OUTCOME MEASURES: Counts of childhood cancer incidence (<15 years); childhood leukaemia incidence (<15 years); leukaemia incidence; liver cancer incidence; lung cancer incidence; non-Hodgkin's lymphoma incidence; all-cause mortality; infant mortality (<1 year) and liver cancer mortality. RESULTS: The estimated relative risks for case circles versus control circles for the nine outcomes considered  range from 0.94 to 1.14, and show neither elevated risk in case circles compared to control areas nor elevated risk with proximity to incinerators within case circles. CONCLUSIONS: This study applies statistical methods for analysing spatially referenced health outcome data in regions with a hypothesised exposure relative to matched regions with no such exposure. There is no evidence of elevated risk of cancer incidence or mortality in the vicinity of large industrial incinerators in England.