Does depression diagnosis and antidepressant prescribing vary by location? Analysis of ethnic density associations using a large primary-care dataset.

BACKGROUND: Studies have linked ethnic differences in depression rates with neighbourhood ethnic density although results have not been conclusive. We looked at this using a novel approach analysing whole population data covering just over one million GP patients in four London boroughs. METHOD: Using a dataset of GP records for all patients registered in Lambeth, Hackney, Tower Hamlets and Newham in 2013 we investigated new diagnoses of depression and antidepressant use for: Indian, Pakistani, Bangladeshi, black Caribbean and black African patients. Neighbourhood effects were assessed independently of GP practice using a cross-classified multilevel model. RESULTS: Black and minority ethnic groups are up to four times less likely to be newly diagnosed with depression or prescribed antidepressants compared to white British patients. We found an inverse relationship between neighbourhood ethnic density and new depression diagnosis for some groups, where an increase of 10% own-ethnic density was associated with a statistically significant (p < 0.05) reduced odds of depression for Pakistani [odds ratio (OR) 0.81, 95% confidence interval (CI) 0.70-0.93], Indian (OR 0.88, CI 0.81-0.95), African (OR 0.88, CI 0.78-0.99) and Bangladeshi (OR 0.94, CI 0.90-0.99) patients. Black Caribbean patients, however, showed the opposite effect (OR 1.26, CI 1.09-1.46). The results for antidepressant use were very similar although the corresponding effect for black Caribbeans was no longer statistically significant (p = 0.07). CONCLUSION: New depression diagnosis and antidepressant use was shown to be less likely in areas of higher own-ethnic density for some, but not all, ethnic groups.

Identifying extreme COVID-19 mortality risks in English small areas: a disease cluster approach.

The COVID-19 pandemic is having a huge impact worldwide and has highlighted the extent of health inequalities between countries but also in small areas within a country. Identifying areas with high mortality is important both of public health mitigation in COVID-19 outbreaks, and of longer term efforts to tackle social inequalities in health. In this paper we consider different statistical models and an extension of a recent method to analyze COVID-19 related mortality in English small areas during the first wave of the epidemic in the first half of 2020. We seek to identify hotspots, and where they are most geographically concentrated, taking account of observed area factors as well as spatial correlation and clustering in regression residuals, while also allowing for spatial discontinuities. Results show an excess of COVID-19 mortality cases in small areas surrounding London and in other small areas in North-East and and North-West of England. Models alleviating spatial confounding show ethnic isolation, air quality and area morbidity covariates having a significant and broadly similar impact on COVID-19 mortality, whereas nursing home location seems to be slightly less important.

'Methicillin-resistant' Staphylococcus aureus in a regional neonatology unit.

In December 1985 a neonate was transferred to a Yorkshire Regional Neonatology Unit (RNU) from a neighbouring hospital and was subsequently found to be colonized with a 'methicillin-resistant' strain of Staphylococcus aureus (MRSA). Spread of the MRSA was controlled by routine cross-infection methods. The RNU was not closed to new admissions, the economic cost of control measures was small and no neonatal death was attributable to MRSA infection. Eradication of the MRSA from the RNU was associated with a decline in frequency of coagulase-negative staphylococci (CNS) from blood cultures, but the overall frequency of positive blood cultures did not decline and there was a rise in frequency of isolation of Gram-negative bacterial species. The decline in frequency of CNS isolates from blood cultures may have resulted from a reduction in the level of cross-colonization of neonates with antibiotic-resistant CNS strains and also increased usage of erythromycin and vancomycin.

Modelling inequality in reported long term illness in the UK: combining individual and area characteristics.

STUDY OBJECTIVE: To assess the nature of the relation between health and social factors at both the aggregated scale of geographical areas and the individual scale. DESIGN AND SETTING: The individual data are derived from the sample of anonymised records (SAR) from the census of 1991 in Great Britain, and are combined with area data from this census. The ecological setting (context) was defined using multivariate methods to classify the 278 districts of residence identifiable in the SAR. The outcome health variable is the 1991 census long-term limiting illness question. Health variations were analysed by multilevel logistic regression to examine the compositional variation (at the level of the individual) and the contextual variation (variability operating at the level of districts) in reported illness. PARTICIPANTS: 10 per cent randomised subsample of the SAR who are aged 16+ and are resident in households. MAIN RESULTS: The multi-level modelling revealed that area factors have a significant association with individual health outcome but their effect is smaller than that of individual attributes. The results show evidence for both compositional and contextual effects in the pattern of variation in propensity to report illness. CONCLUSIONS: The results suggest generally higher levels of ill health for individuals who are older, not married, in a semi/unskilled manual social class, and socioeconomically deprived (as measured by a composite deprivation score). All individuals living in areas with high levels of illness (which tend to be more deprived areas) show greater morbidity, even after allowing for their individual characteristics. However, within affluent areas, where morbidity was generally lower, the health inequality (health gradient) between rich and poor individuals was particularly strong. We consider the implications of these findings for health and resource allocation policy.

Analysis of ethnic influence on stillbirths and infant mortality in Bradford 1975-81.

The patterns of mortality from birth to 1 year in Bradford were studied in the seven year period 1975-81. Large differences in mortality between the Asian and non-Asian population were shown. In 1981 77% of Bradford Asian families were of Pakistani origin, the remaining 23% consisting of families from other parts of the Indian subcontinent and a few from East Africa. There were excess mortality with associated congenital abnormality in the Asian population. From 1975 to 1981 there were 133 deaths associated with congenital abnormality (a rate of 12.4 per 1000 total births) in the Asian population compared with a figure of 129 (4.8 per 1000) in the non-Asian population. The differences between the two groups are shown to be largely independent of social class, and other possible reasons for the discrepancy between the Asian and non-Asian populations are discussed.

A comparative review of Asian and British-born maternity patients in Bradford, 1974-8.

The perinatal mortality rate for Asian babies born in Bradford during the five years 1974-8 was persistently higher than for babies born to United Kingdom mothers. A comparative review of 18 924 British indigenous and 6443 Asian immigrant maternity patients delivered in Bradford from 1974-8 demonstrated several differences between the two ethnic groups. Factors operating in favour of Asian women were fewer teenage mothers, lower rates of illegitimacy, and fewer smokers. On the other hand, a greater number of factors presented increased risks to Asian patients-more women aged over 35, lower social class, higher parity, shorter pregnancy intervals, previous perinatal deaths, shorter duration of antenatal care, anaemia, shorter gestations, more babies born without professional help, and more low-birthweight babies. Local health education programmes are now concentrating on encouraging expectant mothers to attend early and regularly for antenatal care, to breast-feed their babies, and to increase the interval between pregnancies to at least one year.

Osteopenia in extremely low birthweight infants.

Fifteen extremely low birthweight (ELBW) white infants (those weighing 1000 g or less) were observed at birth, within eight weeks of birth and near 40 weeks postconception. On the second and third occasions, weight, crown-heel length, and bone mineral content of their forearms were measured. Fifteen infants born at full term on whom similar measurements were made soon after birth acted as controls. Between 32 and 39 weeks the median weight of ELBW infants increased from 970 g to 1850 g and crown-heel length from 35.7 cm to 41.0 cm. There was no evidence, however, of bone mineral accretion in the measurement region; initial and final median measurements of bone mineral content were 76 mg/cm and 86 mg/cm, the median individual difference being only 4 mg/cm with an interquartile range of 25 mg/cm. Median weight, crown-heel length, and bone mineral content of the control group were 3270 g, 50.6 cm, and 196 mg/cm, respectively. Compared with the controls, ELBW infants at 39 weeks were a median (interquartile range) of 1420 (525) g lighter, 9.9 (3.9) cm shorter, and had a bone mineral content deficit of 108 (32) mg/cm. In terms of weight and crown-heel length ELBW infants at 39 weeks were comparable with infants born and observed at 32 weeks' gestation; compared with these infants the bone mineral content deficit in the ELBW group was about 33%.

Area effects on health variation over the life-course: analysis of the longitudinal study sample in England using new data on area of residence in childhood.

There is a growing literature which demonstrates that (a) conditions throughout the life-course are important for health outcomes in older people and (b) "contextual" conditions in the place of residence, as well as individual characteristics influence health variations. This paper contributes to this debate by presenting results of an analysis of data from the Office for National Statistics Longitudinal Study (LS) for England and Wales. The analysis makes use of a new set of variables, which have been added to the LS, describing the social and economic conditions in the 1930s in residential areas where members of the LS sample were registered as living in 1939. The analysis focuses on people who were aged 0-16 in 1939. The health outcomes considered are death between 1981 and 1991, and for those still living, whether long-term illness was reported in the 1991 census. Regression analysis is used to examine the effects of residence in 1981, and data on the registered place of residence in 1939. The analysis shows that individual characteristics and type of area of residence in 1981 were associated with health outcomes. In addition, some variables describing socio-economic conditions in the 1930s contribute independently to the regression models (notably measures of economic deprivation and unemployment). The results suggest that conditions in residential area in early life may help to explain relatively poor health experience of populations in some parts of Britain today.

The relationship between theophylline, caffeine and heart rate in neonates.

Plasma theophylline and caffeine levels were measured in neonates receiving aminophylline for apnoea. Significant levels of caffeine were present in neonates with high plasma theophylline levels and particularly in those children who had been on theophylline for 6 days, or more. Caffeine levels in plasma decreased slowly compared to theophylline. Tachycardia did not occur in any infants even at theophylline values greater than 20 mg/L. For theophylline concentrations above 10 mg/L there was no relationship between heart rate and drug level. Heart rate alone cannot be used to predict toxic drug levels, and high drug levels will not necessarily cause tachycardia.

Measurement of bone mineral content in the human fetus by photon absorptiometry.

A photon absorptiometer designed to measure the bone mineral content (BMC) of the radius and ulna in premature or term babies was used to examine 34 forearm specimens obtained from 25 male and 9 female babies dying before or up to 13 weeks after birth. Gestational age, foot and crown-heel lengths and birth weight were recorded. Radiographic measurements showed that the midshaft of the radius can be located with a positioning error of +/- 1.28 mm (+/- 2 S.E.E.) from the distance between the distal ulnar styloid process and proximal tip of the olecranon, both of which can be palpated in vivo. Scanning at 5 sites showed that effects of positioning errors on BMC measurements are least at the midshaft site. Subsequent measurements of the ash weight of sections of the radius and ulna, centred on the midshaft of the radius, showed that ash weight/unit length can be estimated with a standard error 2.99 mg/cm from scan data.

Health status and healthy life measures for population health need assessment: modelling variability and uncertainty.

It is increasingly recognised that population health need assessments based on the comparison of clinical or demographic end points (e.g. area mortality rates) neglect population variation in broader aspects of health status and health-related quality of life. Similarly, outcome measures which neglect impacts on health-related quality of life may be an inadequate basis for assessing the effectiveness of health interventions. This paper reviews issues in assessing needs and outcomes at population level based on health status valuations. It considers especially the modelling of sources of uncertainty in measures of health status by using Bayesian sampling estimation methods which produce a distribution of summary outcome measures. The modelling issues are illustrated in models for individual level health status from survey responses and their incorporation in area life tables to derive total and healthy life expectancies. In particular, a health status index derived from Short Form 36 profile responses in a health and lifestyle survey in a London health authority provides a case study of community health needs assessment.

Primary care needs assessment and resourcing: complementary practice and geographic perspectives.

This paper considers the use of small area census data in deriving socio-economic health need indices for primary care practices and assesses how far such indices are related to practice activity. A particular goal is the derivation of weightings for resourcing formulae which incorporate the effect of socio-economic deprivation on activity as well as the more usual allowance for patient age alone, so ensuring a closer match between needs and resources across both practices and localities. A case study is undertaken of a health authority in East London with a population of 380 thousand and 97 primary practices. Total rates of inpatient and outpatient referral and of prescribing by practices all show an influence of practice deprivation after allowing for age, and this effect is enhanced for subcategories such as emergency referrals to A&E departments. After taking account of practice age structure and deprivation, practice characteristics themselves (e.g. number of GPs in relation to practice population) are relatively unimportant influences on activity. The paper discusses how variation in need may be incorporated into resourcing via differential weighting.

Small area variations in infant mortality in England and Wales in the inter-war period and their link with socio-economic factors.

This paper considers the changing spatial pattern of infant mortality during the inter-war years (1921-1936) at Local Government District level in England and Wales. As well as vital statistics data for these areas, also available are 1921 and 1931 Census data on unemployment, housing, occupational structure and population density, with additional data on unemployment from 1927 to 1936 for the 62 counties in which Districts are located. The statistical analysis relating changing District mortality to these characteristics derives mortality gradients across categorical forms of the social indicators, and assesses impacts of model re-specification to allow for spatio-temporal correlation. Time varying gradients across unemployment, housing and policy status are then investigated with a view to assessing whether there was a widening in mortality inequalities in the regionalized economic depression of the 1930s.

Electroimmobilization and ovine plasma cortisol concentrations: effect of current intensity, current duration and diazepam.

Whether the increases in plasma cortisol concentrations which are associated with electroimmobilization (E-IM) of conscious sheep are modified by current intensity, current duration or prior treatment with diazepam was assessed. Sheep were electroimmobilized at 30, 40 or 60 mA for one minute and at 40 mA for two or four minutes. After E-IM of one minute's duration, peak plasma cortisol concentrations occurred at 20 minutes and were 39.1 +/- 7.8 ng ml-1 at 0 mA (control), 56.7 +/- 9.6 ng ml-1 at 30 mA, 62.1 +/- 6.9 ng ml-1 at 40 mA and 78.4 +/- 3.2 ng ml-1 at 60 mA. Both the peak plasma cortisol concentrations and the integrated cortisol responses to E-Im were correlated with current intensity (P less than 0.01). The cortisol responses to E-Im at 40 mA for one, two and four minutes were not significantly different and the response to E-IM at 40 mA for one minute was not affected by the administration of diazepam (0.2 mg kg-1 intravenously) 15 minutes before E-IM. These results indicate that the cortisol response to E-IM is directly dependent on current intensity and that adrenocortical activation by E-IM may be minimised by choosing the lowest current at which effective restraint is maintained.

Electro-immobilisation of sheep may not reduce the aversiveness of a painful treatment.

Sheep were repeatedly chased down a race and were then either subjected to the noise of a shearing handpiece or had wool shaved off. An increase in the time that had to be spent pushing the sheep down the race indicated that the latter treatment was aversive. Similar results were obtained when the sheep were subjected to the same two treatments while electro-immobilised. This throws doubt on the analgesic effectiveness of electro-immobilisation.

An analysis of population and social change in London wards in the 1980s.

"This paper discusses the estimation and projection of small area populations in London, [England] and considers trends in intercensal social and demographic indices which can be calculated using these estimates. Information available annually on vital statistics and electorates is combined with detailed data from the Census Small Area Statistics to derive demographic component based population estimates for London's electoral wards over five year periods. The availability of age disaggregated population estimates permits derivation of small area social indicators for intercensal years, for example, of unemployment and mortality. Trends in spatial inequality of such indicators during the 1980s are analysed and point to continuing wide differentials. A typology of population and social indicators gives an indication of the small area distribution of the recent population turnaround in inner London, and of its association with other social processes such as gentrification and ethnic concentration."

Approaches to modelling overdispersion in the analysis of migration.

"In this paper the modelling of overdispersion in generalised Poisson and multinomial models of migration flows and rates is considered, and its importance within the wider question of substantive model specification is shown. It is argued that substantive specification and the modelling of overdispersion are closely interrelated. Simplified ways of estimating the form of overdispersion--moments methods and pseudo-likelihood--are considered wherever possible. Overdispersion is set within the broader context of correlation effects which relate to migration--correlation across different destinations, between spatially adjacent origins and destinations, and between different time periods. The data used to illustrate the modelling development [concern England and Wales and] are drawn from the Office of Population Censuses and Surveys Longitudinal Study, the decennial Census, and the National Health Service Central Register."

Modelling population changes in small English urban areas.

The authors examine processes underlying the growth of small urban areas in England. "There is evidence of 'people-led' growth in environmentally attractive locations (for example, through retirement migration). However, growth of small- and medium-sized towns also reflects employment decentralisation and deconcentration to freestanding or satellite towns, and the extension of commuter hinterlands.... Government policies encouraging growth are also demonstrated to be significant." The processes resulting in population decline in some small towns are identified. "The impact on modelling growth in urban areas of a diversity of causal processes and locational contexts for growth is considered."