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1.
Int J Law Psychiatry ; 74: 101649, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33418151

RESUMO

This article investigates the lawfulness of isolating residents of care and group homes during the COVID-19 pandemic. Many residents are mobile, and their freedom to move is a central ethical tenet and human right. It is not however an absolute right and trade-offs between autonomy, liberty and health need to be made since COVID-19 is highly infectious and poses serious risks of critical illness and death. People living in care and group homes may be particularly vulnerable because recommended hygiene practices are difficult for them and many residents are elderly, and/or have co-morbidities. In some circumstances, the trade-offs can be made easily with the agreement of the resident and for short periods of time. However challenging cases arise, in particular for residents and occupants with dementia who 'wander', meaning they have a strong need to walk, sometimes due to agitation, as may also be the case for some people with developmental disability (e.g. autism), or as a consequence of mental illness. This article addresses three central questions: (1) in what circumstances is it lawful to isolate residents of social care homes to prevent transmission of COVID-19, in particular where the resident has a strong compulsion to walk and will not, or cannot, remain still and isolated? (2) what types of strategies are lawful to curtail walking and achieve isolation and social distancing? (3) is law reform required to ensure any action to restrict freedoms is lawful and not excessive? These questions emerged during the first wave of the COVID-19 pandemic and are still relevant. Although focussed on COVID-19, the results are also relevant to other future outbreaks of infectious diseases in care and group homes. Likewise, while we concentrate on the law in England and Wales, the analysis and implications have international significance.


Assuntos
/epidemiologia , Lares para Grupos/ética , Lares para Grupos/legislação & jurisprudência , Casas de Saúde/ética , Casas de Saúde/legislação & jurisprudência , Isolamento de Pacientes/ética , Isolamento de Pacientes/legislação & jurisprudência , Inglaterra/epidemiologia , Ética Médica , Humanos , Pandemias , País de Gales/epidemiologia
2.
BJOG ; 128(3): 584-592, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33426798

RESUMO

OBJECTIVE: To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates. DESIGN: Multicentre stepped-wedge cluster design. SETTING: Sixteen maternity units located in four regions across England, Scotland and Wales. POPULATION: Women with singleton live births between October 2016 and March 2018. METHODS: Stepwise region by region roll-out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi-level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case-mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth). MAIN OUTCOME MEASURES: Obstetric anal sphincter injury in singleton live vaginal births. RESULTS: A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26-34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65-0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period. CONCLUSIONS: The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth. TWEETABLE ABSTRACT: OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use.


Assuntos
Parto Obstétrico/normas , Lacerações/epidemiologia , Complicações do Trabalho de Parto/epidemiologia , Melhoria de Qualidade/estatística & dados numéricos , Adulto , Canal Anal/lesões , Cesárea/efeitos adversos , Cesárea/normas , Cesárea/estatística & dados numéricos , Análise por Conglomerados , Parto Obstétrico/efeitos adversos , Parto Obstétrico/estatística & dados numéricos , Inglaterra/epidemiologia , Episiotomia/efeitos adversos , Episiotomia/normas , Episiotomia/estatística & dados numéricos , Feminino , Humanos , Lacerações/prevenção & controle , Modelos Logísticos , Complicações do Trabalho de Parto/prevenção & controle , Períneo/lesões , Gravidez , Projetos de Pesquisa , Fatores de Risco , Escócia/epidemiologia , País de Gales/epidemiologia
4.
Int J Epidemiol ; 49(6): 1951-1962, 2021 01 23.
Artigo em Inglês | MEDLINE | ID: mdl-33349855

RESUMO

BACKGROUND: We estimated population-level associations between ethnicity and coronavirus disease 2019 (COVID-19) mortality using a newly linked census-based data set and investigated how ethnicity-specific mortality risk evolved during the pandemic. METHODS: We conducted a retrospective cohort study of respondents to the 2011 Census of England and Wales in private households, linked to death registrations and adjusted for emigration (n = 47 872 412). The outcome of interest was death involving COVID-19 between 2 March 2020 and 15 May 2020. We estimated hazard ratios (HRs) for ethnic-minority groups compared with the White population, controlling for individual, household and area characteristics. HRs were estimated on the full outcome period and separately for pre- and post-lockdown periods. RESULTS: In age-adjusted models, people from all ethnic-minority groups were at elevated risk of COVID-19 mortality; the HRs for Black males and females were 3.13 (95% confidence interval: 2.93 to 3.34) and 2.40 (2.20 to 2.61), respectively. However, in fully adjusted models for females, the HRs were close to unity for all ethnic groups except Black [1.29 (1.18 to 1.42)]. For males, the mortality risk remained elevated for the Black [1.76 (1.63 to 1.90)], Bangladeshi/Pakistani [1.35 (1.21 to 1.49)] and Indian [1.30 (1.19 to 1.43)] groups. The HRs decreased after lockdown for all ethnic groups, particularly Black and Bangladeshi/Pakistani females. CONCLUSION: Differences in COVID-19 mortality between ethnic groups were largely attenuated by geographical and socio-demographic factors, though some residual differences remained. Lockdown was associated with reductions in excess mortality risk in ethnic-minority populations, which has implications for a second wave of infection.


Assuntos
/etnologia , Censos , Atestado de Óbito , Grupos Étnicos/estatística & dados numéricos , Mortalidade/etnologia , Determinantes Sociais da Saúde , Adolescente , Adulto , Afro-Americanos , Fatores Etários , Grupo com Ancestrais do Continente Asiático , Estudos de Coortes , Inglaterra/epidemiologia , Grupo com Ancestrais do Continente Europeu , Características da Família , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Características de Residência/classificação , Características de Residência/estatística & dados numéricos , Estudos Retrospectivos , Fatores Sexuais , Fatores Socioeconômicos , País de Gales/epidemiologia , Adulto Jovem
5.
Front Public Health ; 8: 562473, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33381484

RESUMO

Background: Social distancing policies aimed to limit Covid-19 across the UK were gradually relaxed between May and August 2020, as peak incidences passed. Population density is an important driver of national incidence rates; however peak incidences in rural regions may lag national figures by several weeks. We aimed to forecast the timing of peak Covid-19 mortality rate in rural North Wales. Methods: Covid-19 related mortality data up to 7/5/2020 were obtained from Public Health Wales and the UK Government. Sigmoidal growth functions were fitted by non-linear least squares and model averaging used to extrapolate mortality to 24/8/2020. The dates of peak mortality incidences for North Wales, Wales and the UK; and the percentage of predicted mortality at 24/8/2020 were calculated. Results: The peak daily death rates in Wales and the UK were estimated to have occurred on the 14/04/2020 and 15/04/2020, respectively. For North Wales, this occurred on the 07/05/2020, corresponding to the date of analysis. The number of deaths reported in North Wales on 07/05/2020 represents 33% of the number predicted to occur by 24/08/2020, compared with 74 and 62% for Wales and the UK, respectively. Conclusion: Policies governing the movement of people in the gradual release from lockdown are likely to impact significantly on areas-principally rural in nature-where cases of Covid-19, deaths and immunity are likely to be much lower than in populated areas. This is particularly difficult to manage across jurisdictions, such as between England and Wales, and in popular holiday destinations.


Assuntos
/epidemiologia , Controle de Doenças Transmissíveis , População Rural , /mortalidade , Simulação por Computador , Inglaterra/epidemiologia , Governo , Humanos , Densidade Demográfica , País de Gales/epidemiologia
6.
PLoS One ; 15(10): e0241102, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33095838

RESUMO

Visiting parks and gardens supports physical and mental health. We quantified access to public parks and gardens in urban areas of England and Wales, and the potential for park crowdedness during periods of high use. We combined data from the Office for National Statistics and Ordnance Survey to quantify (i) the number of parks within 500 and 1,000 metres of urban postcodes (i.e., availability), (ii) the distance of postcodes to the nearest park (i.e., accessibility), and (iii) per-capita space in each park for people living within 1,000m. We examined variability by city and share of flats. Around 25.4 million people (~87%) can access public parks or gardens within a ten-minute walk, while 3.8 million residents (~13%) live farther away; of these 21% are children and 13% are elderly. Areas with a higher share of flats on average are closer to a park but people living in these areas visit parks that are potentially overcrowded during periods of high use. Such disparity in urban areas of England and Wales becomes particularly evident during COVID-19 pandemic and lockdown when local parks, the only available out-of-home space option, hinder social distancing requirements. Cities aiming to facilitate social distancing while keeping public green spaces safe might require implementing measures such as dedicated park times for different age groups or entry allocation systems that, combined with smartphone apps or drones, can monitor and manage the total number of people using the park.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Planejamento Ambiental , Jardins , Controle de Infecções/métodos , Pandemias/prevenção & controle , Parques Recreativos , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Cidades/epidemiologia , Infecções por Coronavirus/virologia , Inglaterra/epidemiologia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Pneumonia Viral/virologia , Logradouros Públicos , População Urbana , País de Gales/epidemiologia , Caminhada , Adulto Jovem
7.
PLoS One ; 15(10): e0241263, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33095841

RESUMO

Kidney disease is a recognised risk factor for poor COVID-19 outcomes. Up to 30 June 2020, the UK Renal Registry (UKRR) collected data for 2,385 in-centre haemodialysis (ICHD) patients with COVID-19 in England and Wales. Overall unadjusted survival at 1 week after date of positive COVID-19 test was 87.5% (95% CI 86.1-88.8%); mortality increased with age, treatment vintage and there was borderline evidence of Asian ethnicity (HR 1.16, 95% CI 0.94-1.44) being associated with higher mortality. Compared to the general population, the relative risk of mortality for ICHD patients with COVID-19 was 45.4 and highest in younger adults. This retrospective cohort study based on UKRR data supports efforts to protect this vulnerable patient group.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/mortalidade , Pneumonia Viral/epidemiologia , Pneumonia Viral/mortalidade , Sistema de Registros , Diálise Renal , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Grupo com Ancestrais do Continente Asiático , Infecções por Coronavirus/etnologia , Infecções por Coronavirus/virologia , Análise de Dados , Inglaterra/epidemiologia , Feminino , Humanos , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/etnologia , Pneumonia Viral/virologia , Estudos Retrospectivos , Fatores de Risco , País de Gales/epidemiologia , Adulto Jovem
8.
BMJ Open ; 10(10): e043010, 2020 10 21.
Artigo em Inglês | MEDLINE | ID: mdl-33087383

RESUMO

INTRODUCTION: The emergence of the novel respiratory SARS-CoV-2 and subsequent COVID-19 pandemic have required rapid assimilation of population-level data to understand and control the spread of infection in the general and vulnerable populations. Rapid analyses are needed to inform policy development and target interventions to at-risk groups to prevent serious health outcomes. We aim to provide an accessible research platform to determine demographic, socioeconomic and clinical risk factors for infection, morbidity and mortality of COVID-19, to measure the impact of COVID-19 on healthcare utilisation and long-term health, and to enable the evaluation of natural experiments of policy interventions. METHODS AND ANALYSIS: Two privacy-protecting population-level cohorts have been created and derived from multisourced demographic and healthcare data. The C20 cohort consists of 3.2 million people in Wales on the 1 January 2020 with follow-up until 31 May 2020. The complete cohort dataset will be updated monthly with some individual datasets available daily. The C16 cohort consists of 3 million people in Wales on the 1 January 2016 with follow-up to 31 December 2019. C16 is designed as a counterfactual cohort to provide contextual comparative population data on disease, health service utilisation and mortality. Study outcomes will: (a) characterise the epidemiology of COVID-19, (b) assess socioeconomic and demographic influences on infection and outcomes, (c) measure the impact of COVID-19 on short -term and longer-term population outcomes and (d) undertake studies on the transmission and spatial spread of infection. ETHICS AND DISSEMINATION: The Secure Anonymised Information Linkage-independent Information Governance Review Panel has approved this study. The study findings will be presented to policy groups, public meetings, national and international conferences, and published in peer-reviewed journals.


Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Assistência à Saúde/normas , Pandemias/prevenção & controle , Pneumonia Viral/terapia , Infecções por Coronavirus/epidemiologia , Humanos , Pneumonia Viral/epidemiologia , Fatores de Risco , País de Gales/epidemiologia
10.
Intensive Care Med ; 46(11): 2035-2047, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33034689

RESUMO

PURPOSE: To describe critical care patients with COVID-19 across England, Wales and Northern Ireland and compare them with a historic cohort of patients with other viral pneumonias (non-COVID-19) and with international cohorts of COVID-19. METHODS: Extracted data on patient characteristics, acute illness severity, organ support and outcomes from the Case Mix Programme, the national clinical audit for adult critical care, for a prospective cohort of patients with COVID-19 (February to August 2020) are compared with a recent retrospective cohort of patients with other viral pneumonias (non-COVID-19) (2017-2019) and with other international cohorts of critical care patients with COVID-19, the latter identified from published reports. RESULTS: 10,834 patients with COVID-19 (70.1% male, median age 60 years, 32.6% non-white ethnicity, 39.4% obese, 8.2% at least one serious comorbidity) were admitted across 289 critical care units. Of these, 36.9% had a PaO2/FiO2 ratio of ≤ 13.3 kPa (≤ 100 mmHg) consistent with severe ARDS and 72% received invasive ventilation. Acute hospital mortality was 42%, higher than for 5782 critical care patients with other viral pneumonias (non-COVID-19) (24.7%), and most COVID-19 deaths (88.7%) occurred before 30 days. Meaningful international comparisons were limited due to lack of standardised reporting. CONCLUSION: Critical care patients with COVID-19 were disproportionately non-white, from more deprived areas and more likely to be male and obese. Conventional severity scoring appeared not to adequately reflect their acute severity, with the distribution across PaO2/FiO2 ratio categories indicating acutely severe respiratory disease. Critical care patients with COVID-19 experience high mortality and place a great burden on critical care services.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Idoso , Estudos de Coortes , Infecções por Coronavirus/terapia , Inglaterra/epidemiologia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Irlanda do Norte/epidemiologia , Pandemias , Pneumonia Viral/terapia , Medicina Estatal , País de Gales/epidemiologia
11.
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
12.
PLoS One ; 15(9): e0237676, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32946449

RESUMO

OBJECTIVES: Proton pump inhibitors (PPIs) are commonly prescribed for prevention and treatment of gastrointestinal conditions or for gastroprotection from other drugs. Research suggests they are linked to increased dementia risk. We use linked national health data to examine the association between PPI use and the development of incident dementia. METHODS AND FINDINGS: A population-based study using electronic health-data from the Secure Anonymised Information Linkage (SAIL) Databank, Wales (UK) from 1999 to 2015. Of data available on 3,765,744 individuals, a cohort who had ever been prescribed a PPI was developed (n = 183,968) for people aged 55 years and over and compared to non-PPI exposed individuals (131,110). Those with prior dementia, mild-cognitive-impairment or delirium codes were excluded. Confounding factors included comorbidities and/or drugs associated with them. Comorbidities might include head injury and some examples of medications include antidepressants, antiplatelets and anticoagulants. These commonly prescribed drugs were investigated as it was not feasible to explore all drugs in this study. The main outcome was a diagnosis of incident dementia. Cox proportional hazard regression modelling was used to calculate the Hazard ratio (HR) of developing dementia in PPI-exposed compared to unexposed individuals while controlling for potential confounders. The mean age of the PPI exposed individuals was 69.9 years and 39.8% male while the mean age of the unexposed individuals was 72.1 years and 41.1% male. The rate of PPI usage was 58.4% (183,968) and incident dementia rate was 11.8% (37,148/315,078). PPI use was associated with decreased dementia risk (HR: 0.67, 95% CI: 0.65 to 0.67, p<0.01). CONCLUSIONS: This study, using large-scale, multi-centre health-data was unable to confirm an association between PPI use and increased dementia risk. Previously reported links may be associated with confounders of people using PPI's, such as increased risk of cardiovascular disease and/or depression and their associated medications which may be responsible for any increased risk of developing dementia.


Assuntos
Demência/induzido quimicamente , Inibidores da Bomba de Prótons/efeitos adversos , Idoso , Estudos de Coortes , Demência/epidemiologia , Feminino , Gastroenteropatias/tratamento farmacológico , Gastroenteropatias/prevenção & controle , Humanos , Masculino , Modelos de Riscos Proporcionais , Inibidores da Bomba de Prótons/uso terapêutico , Fatores de Risco , País de Gales/epidemiologia
14.
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
15.
Int Dent J ; 70(6): 444-454, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32830329

RESUMO

AIM: To address deficits in human resources for oral health data (HROH) in rural and remote areas in Wales, Scotland and Northern Ireland by spatially profiling and modelling the distribution pattern of dental practices according to Health Boards. METHODS: National Health Service (NHS) dental practices were located and mapped against population and rural-urban classifications of Scotland, Wales and Northern Ireland, using Geographic Information System (GIS) tools. All data collected were at the smallest geographical statistical hierarchy level in each country, and population data were retrieved from the 2011 census. RESULTS: A total of 1,695 NHS dental practices were mapped against 27 Health Board regions. In Scotland, Northern Ireland and Wales, 18.3%, 18.7% and 7.7%, respectively, of the population living in the most remote areas resided within 2.5 km of a dental practice. In each country, the Health Boards with the largest proportion of the population living more than 10 km from a dental practice were the Western Isles (Scotland), Western Health and Social Care Trust (HSCT) (Northern Ireland) and Hywel Dda University Health Board (UHB) (Wales). In each country, the highest practice-to-population (PtP) ratios were found in Forth Valley (1:7,194) (Scotland), Southern HSCT (1:5,115) (Northern Ireland) and Hywel Dda UHB (Wales) (1:7,907). CONCLUSION: Dental services are distributed unequally between urban and rural areas. PtP ratios coupled with GIS analysis are important tools to improve HROH distribution.


Assuntos
População Rural , Medicina Estatal , Humanos , Irlanda do Norte/epidemiologia , Escócia/epidemiologia , País de Gales/epidemiologia
17.
Int J Law Psychiatry ; 71: 101572, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32768110

RESUMO

Psychiatric inpatients are particularly vulnerable to the transmission and effects of COVID-19. As such, healthcare providers should implement measures to prevent its spread within mental health units, including adequate testing, cohorting, and in some cases, the isolation of patients. Respiratory isolation imposes a significant limitation on an individual's right to liberty, and should be accompanied by appropriate legal safeguards. This paper explores the implications of respiratory isolation in English law, considering the applicability of the common law doctrine of necessity, the Mental Capacity Act 2005, the Mental Health Act 1983, and public health legislation. We then interrogate the practicality of currently available approaches by applying them to a series of hypothetical cases. There are currently no 'neat' or practicable solutions to the problem of lawfully isolating patients on mental health units, and we discuss the myriad issues with both mental health and public health law approaches to the problem. We conclude by making some suggestions to policymakers.


Assuntos
Infecções por Coronavirus/prevenção & controle , Hospitais Psiquiátricos/ética , Hospitais Psiquiátricos/legislação & jurisprudência , Controle de Infecções/legislação & jurisprudência , Competência Mental/legislação & jurisprudência , Pandemias/prevenção & controle , Isolamento de Pacientes/ética , Isolamento de Pacientes/legislação & jurisprudência , Pneumonia Viral/prevenção & controle , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Inglaterra/epidemiologia , Humanos , Pneumonia Viral/epidemiologia , País de Gales/epidemiologia
18.
Neurology ; 95(12): e1686-e1693, 2020 09 22.
Artigo em Inglês | MEDLINE | ID: mdl-32680951

RESUMO

OBJECTIVE: To determine the association of epilepsy with incident dementia by conducting a nationwide, retrospective data-linkage, cohort study to examine whether the association varies according to dementia subtypes and to investigate whether risk factors modify the association. METHODS: We used linked health data from hospitalization, mortality records, and primary care consultations to follow up 563,151 Welsh residents from their 60th birthday to estimate dementia rate and associated risk factors. Dementia, epilepsy, and covariates (medication, smoking, comorbid conditions) were classified with the use of previously validated code lists. We studied rate of dementia and dementia subtypes in people with epilepsy (PWE) and without epilepsy using (stratified) Kaplan-Meier plots and flexible parametric survival models. RESULTS: PWE had a 2.5 (95% confidence interval [CI] 2.3-2.6) times higher hazard of incident dementia, a 1.6 (95% CI 1.4-1.8) times higher hazard of incident Alzheimer disease (AD), and a 3.1 (95% CI 2.8-3.4) times higher hazard of incident Vascular dementia (VaD). A history of stroke modified the increased incidence in PWE. PWE who were first diagnosed at ≤25 years of age had a dementia rate similar to that of those diagnosed later in life. PWE who had ever been prescribed sodium valproate compared to those who had not were at higher risk of dementia (hazard ratio [HR] 1.6, 99% CI 1.4-1.9) and VaD (HR 1.7, 99% CI 1.4-2.1) but not AD (HR 1.2, 99% CI 0.9-1.5). CONCLUSION: PWE compared to those without epilepsy have an increased dementia risk.


Assuntos
Demência/epidemiologia , Epilepsia/complicações , Distribuição por Idade , Estudos de Coortes , Feminino , Humanos , Incidência , Masculino , Estudos Retrospectivos , Fatores de Risco , País de Gales/epidemiologia
19.
BMC Infect Dis ; 20(1): 545, 2020 Jul 25.
Artigo em Inglês | MEDLINE | ID: mdl-32711452

RESUMO

BACKGROUND: Bloodstream infection is common in the UK and has significant mortality depending on the pathogen involved, site of infection and other patient factors. Healthcare staffing and ward activity may also impact on outcomes in a range of conditions, however there is little specific National Health Service (NHS) data on the impact for patients with bloodstream infection. Bloodstream Infections - Focus on Outcomes is a multicentre cohort study with the primary aim of identifying modifiable risk factors for 28-day mortality in patients with bloodstream infection due to one of six key pathogens. METHODS: Adults under the care of five NHS Trusts in England and Wales between November 2010 and May 2012 were included. Multivariable Cox regression was used to quantify the association between modifiable risk factors, including staffing levels and timing of appropriate therapy, and 28-day mortality, after adjusting for non-modifiable risk factors such as patient demographics and long-term comorbidities. RESULTS: A total of 1676 patients were included in the analysis population. Overall, 348/1676 (20.8%) died within 28 days. Modifiable factors associated with 28-day mortality were ward speciality, ward activity (admissions and discharges), movement within ward speciality, movement from critical care, and time to receipt of appropriate antimicrobial therapy in the first 7 days. For each additional admission or discharge per 10 beds, the hazard increased by 4% (95% CI 1 to 6%) in medical wards and 11% (95% CI 4 to 19%) in critical care. Patients who had moved wards within speciality or who had moved out of a critical care ward had a reduction in hazard of mortality. In the first 7 days, hazard of death increased with increasing time to receipt of appropriate antimicrobial therapy. CONCLUSION: This study underlines the importance of appropriate antimicrobials within the first 7 days, and the potential for ward activity and ward movements to impact on survival in bloodstream infection.


Assuntos
Antibacterianos/uso terapêutico , Antifúngicos/uso terapêutico , Bacteriemia/tratamento farmacológico , Bacteriemia/mortalidade , Candidemia/tratamento farmacológico , Candidemia/mortalidade , Cuidados Críticos/métodos , Idoso , Idoso de 80 Anos ou mais , Inglaterra/epidemiologia , Feminino , Mão de Obra em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Medicina Estatal , Taxa de Sobrevida , Resultado do Tratamento , País de Gales/epidemiologia
20.
PLoS One ; 15(7): e0228309, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32722668

RESUMO

Caesarean section (CS) rates throughout Europe have risen significantly over the last two decades. As well as being an important clinical issue, these changes in mode of birth may have substantial resource implications. Policy initiatives to curb this rise have had to contend with the multiplier effect of women who had a CS for their first birth having a greater likelihood of requiring one during subsequent births, thus making it difficult to decrease CS rates in the short term. Our study examines the long-term resource implications of reducing CS rates among first-time mothers, as well as improving rates of vaginal birth after caesarean section (VBAC), among an annual cohort of women over the course of their most active childbearing years (18 to 44 years) in two public health systems in Europe. We found that the economic benefit of improvements in these two outcomes is considerable, with the net present value of the savings associated with a five-percentage-point change in nulliparous CS rates and VBAC rates being €1.1million and £9.8million per annual cohort of 18-year-olds in Ireland and England/Wales, respectively. Reductions in CS rates among first-time mothers are associated with a greater payoff than comparable increases in VBAC rates. The net present value of achieving CS rates comparable to those currently observed in the best performing Scandinavian countries was €3.5M and £23.0M per annual cohort in Ireland and England/Wales, respectively.


Assuntos
Cesárea/economia , Cesárea/estatística & dados numéricos , Assistência à Saúde/economia , Adolescente , Adulto , Assistência à Saúde/estatística & dados numéricos , Inglaterra/epidemiologia , Feminino , Custos de Cuidados de Saúde , Custos Hospitalares , Humanos , Irlanda/epidemiologia , Gravidez , Processos Estocásticos , Nascimento Vaginal Após Cesárea/economia , Nascimento Vaginal Após Cesárea/estatística & dados numéricos , País de Gales/epidemiologia , Adulto Jovem
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