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1.
BMJ Open ; 10(10): e038390, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33004397

RESUMO

INTRODUCTION: In order to avoid unnecessary hospital admission and associated complications, there is an urgent need to improve the early detection of infection in nursing home residents. Monitoring signs and symptoms with checklists or aids called decision support tools may help nursing home staff to detect infection in residents, particularly during the current COVID-19 pandemic.We plan to conduct a survey exploring views and experiences of how infections are detected and managed in practice by nurses, care workers and managers in nursing homes in England and Sweden. METHODS AND ANALYSIS: An international cross-sectional descriptive survey, using a pretested questionnaire, will be used to explore nurses, care workers and managers views and experiences of how infections are detected and managed in practice in nursing homes. Data will be analysed descriptively and univariate associations between personal and organisational factors explored. This will help identify important factors related to awareness, knowledge, attitudes, belief and skills likely to affect future implementation of a decision support tool for the early detection of infection in nursing home residents. ETHICS AND DISSEMINATION: This study was approved using the self-certification process at the University of Surrey and Linköping University ethics committee (Approval 2018/514-32) in 2018. Study findings will be disseminated through community/stakeholder/service user engagement events in each country, publication in academic peer-reviewed journals and conference presentations. A LAY summary will be provided to participants who indicate they would like to receive this information.This is the first stage of a plan of work to revise and evaluate the Early Detection of Infection Scale (EDIS) tool and its effect on managing infections and reducing unplanned hospital admissions in nursing home residents. Implementation of the EDIS tool may have important implications for the healthcare economy; this will be explored in cost-benefit analyses as the work progresses.


Assuntos
Controle de Doenças Transmissíveis , Infecções por Coronavirus , Sobremedicalização/prevenção & controle , Casas de Saúde/estatística & dados numéricos , Pandemias , Administração dos Cuidados ao Paciente , Pneumonia Viral , Instituições de Cuidados Especializados de Enfermagem/estatística & dados numéricos , Betacoronavirus/isolamento & purificação , Controle de Doenças Transmissíveis/métodos , Controle de Doenças Transmissíveis/organização & administração , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Análise Custo-Benefício , Estudos Transversais , Inglaterra/epidemiologia , Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde/normas , Hospitalização , Humanos , Administração dos Cuidados ao Paciente/economia , Administração dos Cuidados ao Paciente/métodos , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Gerenciamento da Prática Profissional/economia , Projetos de Pesquisa , Suécia/epidemiologia
2.
Viruses ; 12(10)2020 10 09.
Artigo em Inglês | MEDLINE | ID: mdl-33050264

RESUMO

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), responsible for the ongoing coronavirus disease (COVID-19) pandemic, is frequently shed in faeces during infection, and viral RNA has recently been detected in sewage in some countries. We have investigated the presence of SARS-CoV-2 RNA in wastewater samples from South-East England between 14th January and 12th May 2020. A novel nested RT-PCR approach targeting five different regions of the viral genome improved the sensitivity of RT-qPCR assays and generated nucleotide sequences at sites with known sequence polymorphisms among SARS-CoV-2 isolates. We were able to detect co-circulating virus variants, some specifically prevalent in England, and to identify changes in viral RNA sequences with time consistent with the recently reported increasing global dominance of Spike protein G614 pandemic variant. Low levels of viral RNA were detected in a sample from 11th February, 3 days before the first case was reported in the sewage plant catchment area. SARS-CoV-2 RNA concentration increased in March and April, and a sharp reduction was observed in May, showing the effects of lockdown measures. We conclude that viral RNA sequences found in sewage closely resemble those from clinical samples and that environmental surveillance can be used to monitor SARS-CoV-2 transmission, tracing virus variants and detecting virus importations.


Assuntos
Betacoronavirus/genética , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/virologia , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia , Esgotos/virologia , Betacoronavirus/isolamento & purificação , Inglaterra/epidemiologia , Monitoramento Ambiental , Variação Genética , Genoma Viral/genética , Humanos , Pandemias , RNA Viral/genética , Reação em Cadeia da Polimerase em Tempo Real , Análise de Sequência de DNA , Águas Residuárias/virologia
3.
Mayo Clin Proc ; 95(10): 2110-2124, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33012342

RESUMO

OBJECTIVE: To address the issue of limited national data on the prevalence and distribution of underlying conditions among COVID-19 deaths between sexes and across age groups. PATIENTS AND METHODS: All adult (≥18 years) deaths recorded in England and Wales (March 1, 2020, to May 12, 2020) were analyzed retrospectively. We compared the prevalence of underlying health conditions between COVID and non-COVID-related deaths during the COVID-19 pandemic and the age-standardized mortality rate (ASMR) of COVID-19 compared with other primary causes of death, stratified by sex and age group. RESULTS: Of 144,279 adult deaths recorded during the study period, 36,438 (25.3%) were confirmed COVID deaths. Women represented 43.2% (n=15,731) of COVID deaths compared with 51.9% (n=55,980) in non-COVID deaths. Overall, COVID deaths were younger than non-COVID deaths (82 vs 83 years). ASMR of COVID-19 was higher than all other common primary causes of death, across age groups and sexes, except for cancers in women between the ages of 30 and 79 years. A linear relationship was observed between ASMR and age among COVID-19 deaths, with persistently higher rates in men than women across all age groups. The most prevalent reported conditions were hypertension, dementia, chronic lung disease, and diabetes, and these were higher among COVID deaths. Pre-existing ischemic heart disease was similar in COVID (11.4%) and non-COVID (12%) deaths. CONCLUSION: In a nationwide analysis, COVID-19 infection was associated with higher age-standardized mortality than other primary causes of death, except cancer in women of select age groups. COVID-19 mortality was persistently higher in men and increased with advanced age.


Assuntos
Betacoronavirus , Infecções por Coronavirus/mortalidade , Disparidades em Assistência à Saúde/estatística & dados numéricos , Mortalidade Hospitalar/tendências , Pneumonia Viral/mortalidade , Adulto , Distribuição por Idade , Fatores Etários , Idoso , Causas de Morte , Inglaterra/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Estudos Retrospectivos , Distribuição por Sexo , Fatores Socioeconômicos , País de Gales/epidemiologia
4.
BMJ ; 371: m3377, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-33004347

RESUMO

OBJECTIVES: To determine the rate of complicated birth at term in women classified at low risk according to the National Institute for Health and Care Excellence guideline for intrapartum care (no pre-existing medical conditions, important obstetric history, or complications during pregnancy) and to assess if the risk classification can be improved by considering parity and the number of risk factors. DESIGN: Cohort study using linked electronic maternity records. PARTICIPANTS: 276 766 women with a singleton birth at term after a trial of labour in 87 NHS hospital trusts in England between April 2015 and March 2016. MAIN OUTCOME MEASURE: A composite outcome of complicated birth, defined as a birth with use of an instrument, caesarean delivery, anal sphincter injury, postpartum haemorrhage, or Apgar score of 7 or less at five minutes. RESULTS: Multiparous women without a history of caesarean section had the lowest rates of complicated birth, varying from 8.8% (4879 of 55 426 women, 95% confidence interval 8.6% to 9.0%) in those without specific risk factors to 21.8% (613 of 2811 women, 20.2% to 23.4%) in those with three or more. The rate of complicated birth was higher in nulliparous women, with corresponding rates varying from 43.4% (25 805 of 59 413 women, 43.0% to 43.8%) to 64.3% (364 of 566 women, 60.3% to 68.3%); and highest in multiparous women with previous caesarean section, with corresponding rates varying from 42.9% (3426 of 7993 women, 41.8% to 44.0%) to 66.3% (554 of 836 women, 63.0% to 69.5%). CONCLUSIONS: Nulliparous women without risk factors have substantially higher rates of complicated birth than multiparous women without a previous caesarean section even if the latter have multiple risk factors. Grouping women first according to parity and previous mode of birth, and then within these groups according to presence of specific risk factors would provide greater and more informed choice to women, better targeting of interventions, and fewer transfers during labour than according to the presence of risk factors alone.


Assuntos
Parto Obstétrico , Complicações do Trabalho de Parto , Paridade , Nascimento a Termo , Adulto , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Inglaterra/epidemiologia , Feminino , Humanos , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/epidemiologia , Complicações do Trabalho de Parto/etiologia , Assistência Perinatal/métodos , Assistência Perinatal/normas , Gravidez , Resultado da Gravidez/epidemiologia , Melhoria de Qualidade , História Reprodutiva , Medição de Risco , Fatores de Risco
6.
BMJ Open ; 10(9): e041370, 2020 09 28.
Artigo em Inglês | MEDLINE | ID: mdl-32988953

RESUMO

OBJECTIVES: To use Population Health Management (PHM) methods to identify and characterise individuals at high-risk of severe COVID-19 for which shielding is required, for the purposes of managing ongoing health needs and mitigating potential shielding-induced harm. DESIGN: Individuals at 'high risk' of COVID-19 were identified using the published national 'Shielded Patient List' criteria. Individual-level information, including current chronic conditions, historical healthcare utilisation and demographic and socioeconomic status, was used for descriptive analyses of this group using PHM methods. Segmentation used k-prototypes cluster analysis. SETTING: A major healthcare system in the South West of England, for which linked primary, secondary, community and mental health data are available in a system-wide dataset. The study was performed at a time considered to be relatively early in the COVID-19 pandemic in the UK. PARTICIPANTS: 1 013 940 individuals from 78 contributing general practices. RESULTS: Compared with the groups considered at 'low' and 'moderate' risk (ie, eligible for the annual influenza vaccination), individuals at high risk were older (median age: 68 years (IQR: 55-77 years), cf 30 years (18-44 years) and 63 years (38-73 years), respectively), with more primary care/community contacts in the previous year (median contacts: 5 (2-10), cf 0 (0-2) and 2 (0-5)) and had a higher burden of comorbidity (median Charlson Score: 4 (3-6), cf 0 (0-0) and 2 (1-4)). Geospatial analyses revealed that 3.3% of rural and semi-rural residents were in the high-risk group compared with 2.91% of urban and inner-city residents (p<0.001). Segmentation uncovered six distinct clusters comprising the high-risk population, with key differentiation based on age and the presence of cancer, respiratory, and mental health conditions. CONCLUSIONS: PHM methods are useful in characterising the needs of individuals requiring shielding. Segmentation of the high-risk population identified groups with distinct characteristics that may benefit from a more tailored response from health and care providers and policy-makers.


Assuntos
Infecções por Coronavirus , Sistemas de Informação em Saúde/estatística & dados numéricos , Pandemias , Pneumonia Viral , Gestão da Saúde da População , Medição de Risco/métodos , Gestão de Riscos , Idoso , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Estudos Transversais , Demografia , Inglaterra/epidemiologia , Feminino , Medicina Geral/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Determinação de Necessidades de Cuidados de Saúde , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Fatores de Risco , Gestão de Riscos/métodos , Gestão de Riscos/organização & administração , Índice de Gravidade de Doença
7.
BMC Public Health ; 20(1): 1464, 2020 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-32993588

RESUMO

BACKGROUND: The winter pressure often experienced by NHS hospitals in England is considerably contributed to by severe cases of seasonal influenza resulting in hospitalisation. The prevention planning and commissioning of the influenza vaccination programme in the UK does not always involve those who control the hospital budget. The objective of this study was to describe the direct medical costs of secondary care influenza-related hospital admissions across different age groups in England during two consecutive influenza seasons. METHODS: The number of hospital admissions, length of stay, and associated costs were quantified as well as determining the primary costs of influenza-related hospitalisations. Data were extracted from the Hospital Episode Statistics (HES) database between September 2017 to March 2018 and September 2018 to March 2019 in order to incorporate the annual influenza seasons. The use of international classification of disease (ICD)-10 codes were used to identify relevant influenza hospitalisations. Healthcare Resource Group (HRG) codes were used to determine the costs of influenza-related hospitalisations. RESULTS: During the 2017/18 and 2018/19 seasons there were 46,215 and 39,670 influenza-related hospital admissions respectively. This resulted in a hospital cost of £128,153,810 and £99,565,310 across both seasons. Results showed that those in the 65+ year group were associated with the highest hospitalisation costs and proportion of in-hospital deaths. In both influenza seasons, the HRG code WJ06 (Sepsis without Interventions) was found to be associated with the longest average length of stay and cost per admission, whereas PD14 (Paediatric Lower Respiratory Tract Disorders without Acute Bronchiolitis) had the shortest length of stay. CONCLUSION: This study has shown that influenza-related hospital admissions had a considerable impact on the secondary healthcare system during the 2017/18 and 2018/19 influenza seasons, before taking into account its impact on primary health care.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Influenza Humana/economia , Vacinação/economia , Adulto , Inglaterra , Feminino , Recursos em Saúde , Hospitalização/estatística & dados numéricos , Humanos , Classificação Internacional de Doenças , Masculino , Pessoa de Meia-Idade , Estações do Ano , Vacinação/estatística & dados numéricos
9.
Nat Commun ; 11(1): 4661, 2020 09 16.
Artigo em Inglês | MEDLINE | ID: mdl-32938925

RESUMO

The recent years have seen a growing number of studies investigating evolutionary questions using ancient DNA. To address these questions, one of the most frequently-used method is principal component analysis (PCA). When PCA is applied to temporal samples, the sample dates are, however, ignored during analysis, leading to imperfect representations of samples in PC plots. Here, we present a factor analysis (FA) method in which individual scores are corrected for the effect of allele frequency drift over time. We obtained exact solutions for the estimates of corrected factors, and we provided a fast algorithm for their computation. Using computer simulations and ancient European samples, we compared geometric representations obtained from FA with PCA and with ancestry estimation programs. In admixture analyses, FA estimates agreed with tree-based statistics, and they were more accurate than those obtained from PCA projections and from ancestry estimation programs. A great advantage of FA over existing approaches is to improve descriptive analyses of ancient DNA samples without requiring inclusion of outgroup or present-day samples.


Assuntos
DNA Antigo/análise , Análise Fatorial , Genoma Humano , Metagenômica/estatística & dados numéricos , Algoritmos , Inglaterra , Europa (Continente) , Frequência do Gene , Deriva Genética , Genética Populacional/estatística & dados numéricos , Humanos , Modelos Genéticos , Análise de Componente Principal
11.
J Law Med ; 27(4): 1014-1046, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32880417

RESUMO

A major postpartum depression may develop insidiously and go untreated and represent a potentially serious hazard to the wellbeing of both the mother and her child or children. Infanticide is the term used to describe the deliberate act of a parent killing their own young child. The original Infanticide Act 1922 of England and Wales applied to a woman who caused the death of her "newly born" child at the time when she had not fully recovered from the effect of giving birth to such child and by reason thereof "the balance of her mind was disturbed". The subsequent Infanticide Act 1938 (1 & 2 Geo 6, c 36) provided that the victim child could be any age up to 12 months. After reviewing the phenomenology of postpartum depression, maternal child murder (infanticide and filicide) and post-traumatic stress disorder, this article examines the recommendations of various law reform commissions and the development of infanticide statutes in Australia and New Zealand. The article compares and contrasts the different provisions and concludes with some recommendations for law reform.


Assuntos
Infanticídio , Austrália , Criança , Inglaterra , Feminino , Humanos , Nova Zelândia , Gravidez , País de Gales
13.
PLoS One ; 15(9): e0238614, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32936826

RESUMO

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and associated with severe respiratory illness emerged in Wuhan, China, in late 2019. The virus has been able to spread promptly across all continents in the world. The current pandemic has posed a great threat to public health concern and safety. Currently, there are no specific treatments or licensed vaccines available for COVID-19. We isolated SARS-CoV-2 from the nasopharyngeal sample of a patient in Turkey with confirmed COVID-19. We determined that the Vero E6 and MA-104 cell lines are suitable for supporting SARS-CoV-2 that supports viral replication, development of cytopathic effect (CPE) and subsequent cell death. Phylogenetic analyses of the whole genome sequences showed that the hCoV-19/Turkey/ERAGEM-001/2020 strain clustered with the strains primarily from Australia, Canada, England, Iran and Kuwait and that the cases in the nearby clusters were reported to have travel history to Iran and to share the common unique nucleotide substitutions.


Assuntos
Betacoronavirus/isolamento & purificação , Pandemias , Cultura de Vírus/métodos , Animais , Austrália , Betacoronavirus/genética , Betacoronavirus/fisiologia , Canadá , Linhagem Celular , Chlorocebus aethiops , Busca de Comunicante , Infecções por Coronavirus , Efeito Citopatogênico Viral , DNA Complementar/genética , DNA Viral/genética , Inglaterra , Genoma Viral , Células HeLa , Humanos , Irã (Geográfico) , Kuweit , Macaca mulatta , Nasofaringe/virologia , Filogenia , Pneumonia Viral , Análise de Sequência de DNA , Viagem , Turquia/epidemiologia , Células Vero , Replicação Viral
16.
PLoS Med ; 17(8): e1003291, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32866147

RESUMO

BACKGROUND: Nearly 100,000 people underwent total hip replacement (THR) in the United Kingdom in 2018, and most can expect it to last at least 25 years. However, some THRs fail and require revision surgery, which results in worse outcomes for the patient and is costly to the health service. Variation in the survival of THR implants has been observed between units and reducing this unwarranted variation is one focus of the "Getting it Right First Time" (GIRFT) program in the UK. We aimed to investigate whether the statistically improved implant survival of THRs in a high-performing unit is associated with the implants used or other factors at that unit, such as surgical skill. METHODS AND FINDINGS: We analyzed a national, mandatory, prospective, cohort study (National Joint Registry for England, Wales, Northern Ireland and the Isle of Man [NJR]) of all THRs performed in England and Wales. We included the 664,761 patients with records in the NJR who have received a stemmed primary THR between 1 April 2003 and 31 December 2017 in one of 461 hospitals, with osteoarthritis as the only indication. The exposure was the unit (hospital) in which the THR was implanted. We compared survival of THRs implanted in the "exemplar" unit with THRs implanted anywhere else in the registry. The outcome was revision surgery of any part of the THR construct for any reason. Net failure was calculated using Kaplan-Meier estimates, and adjusted analyses employed flexible parametric survival analysis. The mean age of patients contributing to our analyses was 69.9 years (SD 10.1), and 61.1% were female. Crude analyses including all THRs demonstrated better implant survival at the exemplar unit with an all-cause construct failure of 1.7% (95% CI 1.3-2.3) compared with 2.9% (95% CI 2.8-3.0) in the rest of the country after 13.9 years (log-rank test P < 0.001). The same was seen in analyses adjusted for age, sex, and American Society of Anesthesiology (ASA) score (difference in restricted mean survival time 0.12 years [95% CI 0.07-0.16; P < 0.001]). Adjusted analyses restricted to the same implants as the exemplar unit show no demonstrable difference in restricted mean survival time between groups after 13.9 years (P = 0.34). A limitation is that this study is observational and conclusions regarding causality cannot be inferred. Our outcome is revision surgery, and although important, we recognize it is not the only marker of success of a THR. CONCLUSIONS: Our results suggest that the "better than expected" implant survival results of this exemplar center are associated with implant choice. The survival results may be replicated by adopting key treatment decisions, such as implant selection. These decisions are easier to replicate than technical skills or system factors.


Assuntos
Artroplastia de Quadril/instrumentação , Artroplastia de Quadril/tendências , Bases de Dados Factuais/tendências , Falha de Prótese/tendências , Sistema de Registros , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/normas , Estudos de Coortes , Inglaterra/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Irlanda do Norte/epidemiologia , Estudos Prospectivos , Reino Unido/epidemiologia , País de Gales/epidemiologia
17.
Lancet Public Health ; 5(9): e501-e511, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32888443

RESUMO

BACKGROUND: Since October, 2017 (and until October, 2020), pre-exposure prophylaxis (PrEP) has only been available in England, UK, through the PrEP Impact Trial, by purchasing it from some genitourinary medicine clinics, or via online sources. Here we report changes from 2013 to 2018 in PrEP and postexposure prophylaxis (PEP) awareness and use among HIV-negative gay, bisexual, and other men who have sex with men (MSM) and assess predictors of PrEP initiation. METHODS: In the prospective cohort study Attitudes to, and Understanding of Risk of Acquisition of HIV 2 (AURAH2), MSM were recruited from three sexual health clinics in England: two in London and one in Brighton, UK. Men were eligible if they were aged 18 years or older and HIV-negative or of unknown HIV status. Participants self-completed a baseline paper questionnaire at one of the three clinics between July 30, 2013, and April 30, 2016, and were subsequently able to complete 4-monthly and annual online questionnaires, which were available between March 1, 2015, and March 31, 2018, and collected information on sociodemographics, health and wellbeing, HIV status, and sexual behaviours. PrEP and PEP use in the previous 12 months was obtained at baseline and in annual questionnaires. We assessed trends over calendar time in 3-month periods from first enrolment to the end of the study period (July-December, 2013, was counted as one period) in use of PrEP and PEP using generalised estimating equation logistic models. We used age-adjusted Poisson models to assess factors associated with PrEP initiation among participants who reported never having used PrEP at baseline. FINDINGS: 1162 men completed a baseline questionnaire, among whom the mean age was 34 years (SD 10·4), and of those with available data, 942 (82%) of 1150 were white, 1076 (94%) of 1150 were gay, and 857 (74%) of 1159 were university educated. 622 (54%) of 1162 men completed at least one follow-up online questionnaire, of whom 483 (78%) completed at least one annual questionnaire. Overall, PrEP use in the past year increased from 0% (none of 28 respondents) in July to December, 2013, to 43% (23 of 53) in January to March, 2018. The corresponding increase in PrEP use among men who reported condomless sex with two or more partners was from 0% (none of 13 respondents) to 78% (21 of 27). PEP use peaked in April to June, 2016, at 28% (41 of 147 respondents), but decreased thereafter to 8% (four of 53) in January to March, 2018. Among 460 men who had never used PrEP at baseline, predictors of initiating PrEP included age 40-44 years (incidence rate ratio [IRR] 4·25, 95% CI 1·14-15·79) and 45 years and older (3·59, 1·08-11·97) versus younger than 25 years; and after adjustment for age, recent HIV test (5·17, 1·89-14·08), condomless sex (5·01, 2·16-11·63), condomless sex with two or more partners (5·43, 2·99-9·86), group sex (1·69, 1·01-2·84), and non-injection chemsex-related drugs use (2·86, 1·67-4·91) in the past 3 months, PEP use (4·69, 2·83-7·79) in the past 12 months, and calendar year (Jan 1, 2017, to March 31, 2018 vs July 30, 2013, to Dec 31, 2015: 21·19, 9·48-47·35). Non-employment (0·35, 0·14-0·91) and unstable or no housing (vs homeowner 0·13, 0·02-0·95) were associated with reduced rates of PrEP initiation after adjustment for age. About half of PrEP was obtained via the internet, even after the PrEP Impact trial had started (11 [48%] of 23 respondents in January to March, 2018). INTERPRETATION: PrEP awareness and use increased substantially from 2013 to 2018 among a cohort of MSM in England. Improving access to PrEP by routine commissioning by National Health Service England could increase PrEP use among all eligible MSM, but should include public health strategies to target socioeconomic and demographic disparities in knowledge and use of PrEP. FUNDING: National Institute for Health Research.


Assuntos
Infecções por HIV/prevenção & controle , Conhecimentos, Atitudes e Prática em Saúde , Homossexualidade Masculina/psicologia , Profilaxia Pré-Exposição/estatística & dados numéricos , Adulto , Inglaterra , Homossexualidade Masculina/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
18.
PLoS Med ; 17(9): e1003225, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32926731

RESUMO

BACKGROUND: Early studies of narcolepsy after AS03-adjuvanted pandemic A/H1N12009 vaccine (Pandemrix) could not define the duration of elevated risk post-vaccination nor the risk in children aged under 5 years who may not present until much older. METHODS/FINDINGS: Clinical information and sleep test results, extracted from hospital notes at 3 large pediatric sleep centers in England between September 2017 and June 2018 for narcolepsy cases aged 4-19 years with symptom onset since January 2009, were reviewed by an expert panel to confirm the diagnosis. Vaccination histories were independently obtained from general practitioners (GPs). The odds of vaccination in narcolepsy cases compared with the age-matched English population was calculated after adjustment for clinical conditions that were indications for vaccination. GP questionnaires were returned for 242 of the 244 children with confirmed narcolepsy. Of these 5 were under 5 years, 118 were 5-11 years, and 119 were 12-19 years old at diagnosis; 39 were vaccinated with Pandemrix before onset. The odds ratio (OR) for onset at any time after vaccination was 1.94 (95% confidence interval [CI] 1.30-2.89), The elevated risk period was restricted to onsets within 12 months of vaccination (OR 6.65 [3.44-12.85]) and was highest within the first 6 months. After one year, ORs were not significantly different from 1 up to 8 years after vaccination. The ORs were similar in under five-year-olds and older ages. The estimated attributable risk was 1 in 34,500 doses. Our study is limited by including cases from only 3 sleep centers, who may differ from cases diagnosed in nonparticipating centers, and by imprecision in defining the centers' catchment population. The potential for biased recall of onset shortly after vaccination in cases aware of the association cannot be excluded. CONCLUSIONS: In this study, we found that vaccine-attributable cases have onset of narcolepsy within 12 months of Pandemrix vaccination. The attributable risk is higher than previously estimated in England because of identification of vaccine-attributable cases with late diagnoses. Absence of a compensatory drop in risk 1-8 years after vaccination suggests that Pandemrix does not trigger onsets in those in whom narcolepsy would have occurred later.


Assuntos
Narcolepsia/etiologia , Polissorbatos/efeitos adversos , Esqualeno/efeitos adversos , Vacinação/efeitos adversos , alfa-Tocoferol/efeitos adversos , Adolescente , Criança , Pré-Escolar , Combinação de Medicamentos , Inglaterra/epidemiologia , Feminino , Humanos , Vírus da Influenza A Subtipo H1N1/imunologia , Vacinas contra Influenza/efeitos adversos , Vacinas contra Influenza/uso terapêutico , Influenza Humana/epidemiologia , Masculino , Narcolepsia/epidemiologia , Narcolepsia/imunologia , Razão de Chances , Pandemias , Fatores de Risco , Inquéritos e Questionários
19.
PLoS Med ; 17(9): e1003336, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32956399

RESUMO

BACKGROUND: Research has questioned the safety of delaying or withholding antibiotics for suspected urinary tract infection (UTI) in older patients. We evaluated the association between antibiotic treatment for lower UTI and risk of bloodstream infection (BSI) in adults aged ≥65 years in primary care. METHODS AND FINDINGS: We analyzed primary care records from patients aged ≥65 years in England with community-onset UTI using the Clinical Practice Research Datalink (2007-2015) linked to Hospital Episode Statistics and census data. The primary outcome was BSI within 60 days, comparing patients treated immediately with antibiotics and those not treated immediately. Crude and adjusted associations between exposure and outcome were estimated using generalized estimating equations. A total of 147,334 patients were included representing 280,462 episodes of lower UTI. BSI occurred in 0.4% (1,025/244,963) of UTI episodes with immediate antibiotics versus 0.6% (228/35,499) of episodes without immediate antibiotics. After adjusting for patient demographics, year of consultation, comorbidities, smoking status, recent hospitalizations, recent accident and emergency (A&E) attendances, recent antibiotic prescribing, and home visits, the odds of BSI were equivalent in patients who were not treated with antibiotics immediately and those who were treated on the date of their UTI consultation (adjusted odds ratio [aOR] 1.13, 95% CI 0.97-1.32, p-value = 0.105). Delaying or withholding antibiotics was associated with increased odds of death in the subsequent 60 days (aOR 1.17, 95% CI 1.09-1.26, p-value < 0.001), but there was limited evidence that increased deaths were attributable to urinary-source BSI. Limitations include overlap between the categories of immediate and delayed antibiotic prescribing, residual confounding underlying differences between patients who were/were not treated with antibiotics, and lack of microbiological diagnosis for BSI. CONCLUSIONS: In this study, we observed that delaying or withholding antibiotics in older adults with suspected UTI did not increase patients' risk of BSI, in contrast with a previous study that analyzed the same dataset, but mortality was increased. Our findings highlight uncertainty around the risks of delaying or withholding antibiotic treatment, which is exacerbated by systematic differences between patients who were and were not treated immediately with antibiotics. Overall, our findings emphasize the need for improved diagnostic/risk prediction strategies to guide antibiotic prescribing for suspected UTI in older adults.


Assuntos
Antibacterianos/uso terapêutico , Bacteriemia/etiologia , Infecções Urinárias/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Registros Eletrônicos de Saúde , Inglaterra/epidemiologia , Feminino , Humanos , Masculino , Pacientes , Padrões de Prática Médica/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Fatores de Risco
20.
BMJ Open ; 10(9): e039749, 2020 09 29.
Artigo em Inglês | MEDLINE | ID: mdl-32994257

RESUMO

OBJECTIVES: The growth of COVID-19 infections in England raises questions about system vulnerability. Several factors that vary across geographies, such as age, existing disease prevalence, medical resource availability and deprivation, can trigger adverse effects on the National Health System during a pandemic. In this paper, we present data on these factors and combine them to create an index to show which areas are more exposed. This technique can help policy makers to moderate the impact of similar pandemics. DESIGN: We combine several sources of data, which describe specific risk factors linked with the outbreak of a respiratory pathogen, that could leave local areas vulnerable to the harmful consequences of large-scale outbreaks of contagious diseases. We combine these measures to generate an index of community-level vulnerability. SETTING: 91 Clinical Commissioning Groups (CCGs) in England. MAIN OUTCOME MEASURES: We merge 15 measures spatially to generate an index of community-level vulnerability. These measures cover prevalence rates of high-risk diseases; proxies for the at-risk population density; availability of staff and quality of healthcare facilities. RESULTS: We find that 80% of CCGs that score in the highest quartile of vulnerability are located in the North of England (24 out of 30). Here, vulnerability stems from a faster rate of population ageing and from the widespread presence of underlying at-risk diseases. These same areas, especially the North-East Coast areas of Lancashire, also appear vulnerable to adverse shocks to healthcare supply due to tighter labour markets for healthcare personnel. Importantly, our index correlates with a measure of social deprivation, indicating that these communities suffer from long-standing lack of economic opportunities and are characterised by low public and private resource endowments. CONCLUSIONS: Evidence-based policy is crucial to mitigate the health impact of pandemics such as COVID-19. While current attention focuses on curbing rates of contagion, we introduce a vulnerability index combining data that can help policy makers identify the most vulnerable communities. We find that this index is positively correlated with COVID-19 deaths and it can thus be used to guide targeted capacity building. These results suggest that a stronger focus on deprived and vulnerable communities is needed to tackle future threats from emerging and re-emerging infectious disease.


Assuntos
Controle de Doenças Transmissíveis , Infecções por Coronavirus , Transmissão de Doença Infecciosa/prevenção & controle , Recursos em Saúde/provisão & distribução , Acesso aos Serviços de Saúde/normas , Pandemias , Pneumonia Viral , Betacoronavirus , Controle de Doenças Transmissíveis/métodos , Controle de Doenças Transmissíveis/organização & administração , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Inglaterra/epidemiologia , Disparidades nos Níveis de Saúde , Humanos , Determinação de Necessidades de Cuidados de Saúde , Pandemias/prevenção & controle , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Prevalência , Saúde Pública/métodos , Saúde Pública/tendências , Melhoria de Qualidade/organização & administração , Fatores de Risco , Análise Espacial
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