Geographical Regions In England Research Articles

Risk of serious adverse events after primary shoulder replacement: development and external validation of a prediction model using linked national data from England and Denmark

Despite a rising rate of serious medical complications after shoulder replacement surgery, there are no prediction models in widespread use to guide surgeons in identifying patients at high risk and to provide patients with personalised risk estimates to support shared decision making. Our aim was to develop and externally validate a prediction model for serious adverse events within 90 days of primary shoulder replacement surgery. Linked data from the National Joint Registry, National Health Service Hospital Episode Statistics Admitted Patient Care of England, and Civil Registration Mortality databases and Danish Shoulder Arthroplasty Registry and National Patient Register were used for our modelling study. Patients aged 18-100 years who had a primary shoulder replacement between April 1, 2012, and Oct 2, 2020, in England, and April 1, 2012, and Oct 2, 2018, in Denmark, were included. We developed a multivariable logistic regression model using the English dataset to predict the risk of 90-day serious adverse events, which were defined as medical complications requiring admission to hospital and all-cause death. We undertook internal validation using bootstrapping, and internal-external cross-validation across different geographical regions of England. The English model was externally validated on the Danish dataset. Data for 40 631 patients undergoing primary shoulder replacement (mean age 72·5 years [SD 9·9]; 28 709 [70·7%] women and 11 922 [29·3%] men) were used for model development, of whom 2270 (5·6%) had a 90-day serious adverse event. On internal validation, the model had a C-statistic of 0·717 (95% CI 0·707-0·728) and was well calibrated. Internal-external cross-validation showed consistent model performance across all regions in England. Upon external validation on the Danish dataset (n=6653; mean age 70·5 years [SD 10·3]; 4503 [67·7%] women and 2150 [32·3%] men), the model had a C-statistic of 0·750 (95% CI 0·723-0·776). Decision curve analysis showed clinical utility, with net benefit across all risk thresholds. This externally validated prediction model uses commonly available clinical variables to accurately predict the risk of serious medical complications after primary shoulder replacement surgery. The model is generalisable and applicable to most patients in need of a shoulder replacement. Its use offers support to clinicians and could inform and empower patients in the shared decision-making process. National Institute for Health and Care Research and the Department of Orthopaedic Surgery, Herlev and Gentofte Hospital, Denmark.

Comprehensive analysis of UK AADF traffic dataset set within four geographical regions of England

AbstractTraffic flow detection plays a significant part in freeway traffic surveillance systems. Currently, effective autonomous traffic analysis is a challenging task due to the complexity of traffic delays, despite the significant investment spent by authorities in monitoring and analysing traffic congestion. This study builds an intelligent analytic method based on machine‐learning algorithms to investigate and predict road traffic flows in four locations in the United Kingdom (London, Yorkshire and the Humber, North East, and North West) with a range of relevant factors. While aiming to conduct the study, the dataset ‘estimated annual average daily flows (AADFs) Data—major and minor roads’ from the UK government was used. Machine‐learning algorithms are used for this research and classification applied consists of Logistic Regression, Decision Trees, Random Forests, K‐Nearest Neighbors, and Gradient Boosting. Each of these algorithms achieves an accuracy of over 93% and the F1 score of over 95%, with Random Forest outperforming the other algorithms. This analytical approach helps to focus attention on critical areas to reduce traffic flows on major and minor roads in the area. In summary, the findings on traffic analysis have been discussed in detail to demonstrate the practical insights of this study.

P66 Uptake of biosimilars for psoriasis: a drug utilization study from the British Association of Dermatologists Biologics and Immunomodulators Register

Abstract Tumour necrosis factor-α inhibitors (TNFi) have revolutionized the treatment of moderate-to-severe psoriasis. Following patent expirations of TNFi originators, TNFi biosimilars became available, presenting the opportunity for significant reductions in drug costs. This observational cohort study aimed to describe the uptake of TNFi biosimilars for psoriasis treatment in the UK and Republic of Ireland (RoI). This study utilized data from the British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR), a national pharmacovigilance register for patients with psoriasis on systemic treatments. We analysed biosimilar uptake trends over time in nine geographical regions of England, along with Wales, Scotland, Northern Ireland and the RoI. We assessed the incidence of switching to biosimilars in an originator-user cohort (switchers). Patients on originator infliximab, etanercept and adalimumab at the time originator patents expired entered the cohort on 1 February 2015, August 2015 and October 2018, respectively, and were followed up until 31 October 2021. Trends in biosimilar initiations were assessed in an adalimumab-naïve cohort who started adalimumab between 1 October 2018 and 31 July 2019 (starters). We assessed the associations between patient factors and originator-to-biosimilar switching and biosimilar initiation using a multivariable Cox regression model and a multivariable logistic regression model. In total, 4202 patients (209 on infliximab, 742 on etanercept and 3251 on adalimumab) were included in the originator-user cohort. For infliximab, etanercept and adalimumab, the cumulative incidence of originator-to-biosimilar switching increased with time to 14.8%, 23.6% and 66.6% after 3 years, respectively. Across geographical regions, 3-year switching rates varied from 0% (North East England, London, Scotland, Northern Ireland, RoI) to 43.7% (East Midlands) for infliximab; from 0% (RoI) to 40.4% (South West England) for etanercept; and from 12.5% (London) to 84.3% (North East England) for adalimumab. After switching to biosimilars, 2.8% of switchers cross-switched to other biosimilars, 1.1% switched back to the originator and 17.1% discontinued or switched to other biologic medicines. In total, 528 patients were included in the adalimumab-naïve cohort, of whom 67.8% started on biosimilars. Amgevita® and Imraldi® were the most commonly used biosimilars among adalimumab biosimilar switchers (56.8% and 39.1%, respectively) and starters (53.6% and 34.4%, respectively). Originator-to-biosimilar switching and biosimilar initiation were more common in patients who were male or had lower a Psoriasis Area and Severity Index at cohort entry. The uptake of biosimilars increased over time and varied considerably across the UK and RoI; adalimumab had the highest biosimilar uptake rate compared with other TNFi.

Towards justice-oriented science teaching: examining the impact of the science capital teaching approach on teachers

While several initiatives for justice-oriented pedagogies have been developed and implemented over the years, there is limited understanding of the ways in which teachers, and their practice, are impacted by these. This article presents data documenting the impact of a pedagogical approach – the science capital teaching approach – on a cohort of teachers. The approach, developed over a period of six years working in close partnership with primary and secondary teachers in England, aimed to support teachers to move towards more equitable and socially just pedagogical practice. This article explores the empirical impact of the approach on teacher practice. The data set comprises the experiences of 43 secondary and 20 Primary school teachers from different geographical regions in England, covering both rural and urban schools. Qualitative data include teacher interviews, observations and discussions and indicate that implementation of the approach resulted in a range of changes: (1) a deepened understanding of, and reflection on, issues of power and equity; (2) greater sharing of authorial roles with students; and (3) stronger relationships of trust between students and teachers. The article concludes by arguing that the implementation of the science capital teaching approach has had a positive effect on teachers and has supported their practice of justice-oriented science teaching.

Developing, Nurturing, and Sustaining an Adolescent and Young Adult-Centered Culture of Care.

Adolescents and young adults have unique needs which differ from those of children or adults. In the United Kingdom, we have dedicated services, which are diverse in how they are managed and delivered. A multiple-case study was conducted in young people's cancer services in four geographical regions of England. Data collection included: semi-structured interviews with healthcare professionals (n = 41) and young people (n = 29); and observation (total = 120 hours). Thematic analysis was used to synthesize and interpret five emerging themes describing the way a culture of adolescent and young adult-specific care developed. To develop a cultural attitude which embraced and promoted core values, leadership was needed, as well as high patient volume accessing a service. Time was essential, an adolescent and young adult-centered culture of care does not happen overnight, it needs time and dedicated staff to evolve, but once in place, services have a significant impact on the experience of care.

Mixed Methods Process Evaluation of a National Peer-Led Training Program to Increase Brief Advice on Physical Activity Given By Health Care Professionals.

Health care professionals are well-positioned to encourage physical activity. The Clinical Champions Physical Activity Training Program (CCTP) aimed to increase population-level physical activity across England. This study aimed to (1)evaluate CCTP uptake and utilization; (2)explore CCTP fidelity, barriers, facilitators, and satisfaction; and (3)provide recommendations for program improvement. Physical Activity Clinical Champions were recruited and trained to deliver training to other health care professionals about physical activity. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to conduct a process evaluation using data collected from CCTP training sessions delivered (often at hospitals and General Practitioner surgeries) between February and December 2018. About 509 training sessions were delivered, with 89% of sessions delivered by doctor/physician and nurse Clinical Champions; 8917 health care professionals attended a training session. Sessions lasted on average 1hour 28minutes and core slide sets were used in 65% of sessions. Barriers related to arranging the sessions and time available to deliver sessions. The process evaluation demonstrated a national peer-led training program can reach all geographical regions of England; however, barriers need to be addressed. Recommendations include providing more administrative support to the Clinical Champions, improving communication and advertising to raise awareness of the CCTP, and standardizing training session duration and content.

Connect Resound: Using online technology to deliver music education to remote communities

This article describes an action research project that aimed to widen participation for music education in schools in England (United Kingdom). The Connect Resound project involved a pilot stage in North Yorkshire (England, United Kingdom) followed by a roll-out to four further geographical regions of England: Cumbria; Durham/Darlington; East Riding of Yorkshire; and Cornwall. The project involved testing a technological framework created to bring music education to schools with little or no music instrumental lessons within primary schools at key stage 2 (pupils aged 7–11 years). The pilot and roll-out phases refined the approach and established a business case for a grant to roll out the project nationally in 2017. The approach used in the study provided not only the instrumental lessons but also continuing professional development for teachers, on-demand technical support, and access to music performances and masterclasses. The research team designed and tested several scenarios for using technology in this environment some of which were using single cameras and others that used a multi-camera set-up. One of the approaches used technology to allow the teachers and pupils access to different camera angles and high-quality audio to deliver the lessons which proved beneficial. The project team captured both video data as well as interviews and questionnaires with participants in order to better understand and refine the approach developed. This article reports upon the challenges and opportunities provided by the project in terms of the technology and environment, an evaluation using a case study approach of how the teachers used the technology, and feedback in the form of questionnaires from pupils and parents/carers concerning the lessons. Issues around the technology concerned time lag, initial technical problems, and background noise in the teaching environment amplified by the technology. The different camera angles adopted in the project proved valuable for teachers, potential issues with assembling and tuning instruments were considered, and beginner technique could be demonstrated using this approach.

Paramedic Acute Stroke Treatment Assessment (PASTA): study protocol for a randomised controlled trial

BackgroundDespite evidence from clinical trials that intravenous (IV) thrombolysis is a cost-effective treatment for selected acute ischaemic stroke patients, there remain large variations in the rate of IV thrombolysis delivery between stroke services. This study is evaluating whether an enhanced care pathway delivered by paramedics (the Paramedic Acute Stroke Treatment Assessment (PASTA)) could increase the number of patients who receive IV thrombolysis treatment.MethodsStudy design: Cluster randomised trial with economic analysis and parallel process evaluation.Setting: National Health Service ambulance services, emergency departments and hyper-acute stroke units within three geographical regions of England and Wales.Randomisation: Ambulance stations within each region are the units of randomisation. According to station allocation, paramedics based at a station deliver the PASTA pathway (intervention) or continue with standard stroke care (control).Study intervention: The PASTA pathway includes structured pre-hospital information collection, prompted pre-notification, structured handover of information in hospital and assistance with simple tasks during the initial hospital assessment. Study-trained intervention group paramedics deliver this pathway to adults within 4 h of suspected stroke onset.Study control: Standard stroke care according to national and local guidelines for the pre-hospital and hospital assessment of suspected stroke.Participants: Participants enrolled in the study are adults with confirmed stroke who were assessed by a study paramedic within 4 h of symptom onset.Primary outcome: Proportion of participants receiving IV thrombolysis.Sample size: 1297 participants provide 90% power to detect a 10% difference in the proportion of patients receiving IV thrombolysis.DiscussionThe results from this trial will determine whether an enhanced care pathway delivered by paramedics can increase thrombolysis delivery rates.Trial registrationISRCTN registry, ISRCTN12418919. Registered on 5 November 2015.

Prevalence of recent fentanyl use among treated users of illicit opioids in England: based on piloted urine drug screens

Objective: To use a pilot of national fentanyl screening to establish the current prevalence of recent fentanyl use among treated users of illicit opioids in the English treatment system and inform the design of a full study.Design: Cross-sectional fentanyl metabolite urine screening in randomly-selected study sites, stratified to cover all nine geographical regions of England, supplemented with self-report subsequent to a positive fentanyl test.Patients: 468 adult (18 years of age and above) patients receiving treatment for opioid use disorder, screened December 2017 to May 2018.Results: The fentanyl-positive rate in patients receiving treatment for opioid use disorder in the English treatment system was 3% (15/468, 95% CI 1.8% to 5.2%) with a per-site range (for the 10 sites in 9 regions where fentanyl was detected) of between 2% (1/57) and 15% (4/27). Self-report data indicated that the majority of fentanyl-positives (12/15, 80%) was unaware of having purchased fentanyl.Conclusions: Despite alerts already in place, patients receiving treatment for opioid use disorder, who were fentanyl-positive, were unwittingly purchasing and consuming fentanyl.

Economic Policy Uncertainty and House Prices: Evidence from Geographical Regions of England and Wales

AbstractThis article empirically investigates the effect of the economic policy uncertainty on house prices across 10 different geographical regions of England and Wales. The empirical study is conducted by means of the autoregressive distributed lag bounds cointegration test. Results show a stable long‐run relationship (cointegration) between house prices and its determinants (including economic policy uncertainty) in nine of the regions. Results also evince long‐ and short‐term negative effect of uncertainty to house prices. These results clearly indicate the importance of economic policy uncertainty in the determination of UK house prices and demand.

Is cancer survival associated with cancer symptom awareness and barriers to seeking medical help in England? An ecological study.

Background:Campaigns aimed at raising cancer awareness and encouraging early presentation have been implemented in England. However, little is known about whether people with low cancer awareness and increased barriers to seeking medical help have worse cancer survival, and whether there is a geographical variation in cancer awareness and barriers in England.Methods:From population-based surveys (n=35 308), using the Cancer Research UK Cancer Awareness Measure, we calculated the age- and sex-standardised symptom awareness and barriers scores for 52 primary care trusts (PCTs). These measures were evaluated in relation to the sex-, age-, and type of cancer-standardised cancer survival index of the corresponding PCT, from the National Cancer Registry, using linear regression. Breast, lung, and bowel cancer survival were analysed separately.Results:Cancer symptom awareness and barriers scores varied greatly between geographical regions in England, with the worst scores observed in socioeconomically deprived parts of East London. Low cancer awareness score was associated with poor cancer survival at PCT level (estimated slope=1.56, 95% CI: 0.56; 2.57). The barriers score was not associated with overall cancer survival, but it was associated with breast cancer survival (estimated slope=−0.66, 95% CI: −1.20; −0.11). Specific barriers, such as embarrassment and difficulties in arranging transport to the doctor's surgery, were associated with worse breast cancer survival.Conclusions:Cancer symptom awareness and cancer survival are associated. Campaigns should focus on improving awareness about cancer symptoms, especially in socioeconomically deprived areas. Efforts should be made to alleviate barriers to seeking medical help in women with symptoms of breast cancer.

Best practice for providing social care and support to people living with concurrent sight loss and dementia: professional perspectives

Purpose – Approximately 100,000 people in the UK aged 75 and over have concurrent dementia and sight loss, but current understanding of their experiences, needs and preferences is limited. The purpose of this paper is to report on a research project that explored the provision of social care and support for older people with both conditions. Design/methodology/approach – The project was a collaboration between the universities of York, Worcester, Bournemouth and Cambridge, supported by the Thomas Pocklington Trust and the Housing and Dementia Research Consortium. Data for this paper were drawn from focus groups held in 2013 involving 47 professionals across the dementia, sight loss and housing sectors. Findings – Thematic analysis identified five main barriers to providing high-quality, cost-effective social care and support: time constraints; financial limitations; insufficient professional knowledge; a lack of joint working; and inconsistency of services. The requirements of dementia and sight loss often conflict, which can limit the usefulness of equipment, aids and adaptations. Support and information needs to address individual needs and preferences. Research limitations/implications – Unless professionals consider dementia and sight loss together, they are unlikely to think about the impact of both conditions and the potential of their own services to provide effective support for individuals and their informal carers. Failing to consider both conditions together can also limit the availability and accessibility of social care and support services. This paper is based on input from a small sample of self-selecting professionals across three geographical regions of England. More research is needed in this area. Practical implications – There are growing numbers of people living with concurrent dementia and sight loss, many of whom wish to remain living in their own homes. There is limited awareness of the experiences and needs of this group and limited provision of appropriate services aids/adaptations. A range of measures should be implemented in order to support independence and well-being for people living with both conditions and their family carers. These include increased awareness, improved assessment, more training and greater joint working. Social implications – People living with dementia or sight loss are at high risk of social isolation, increasingly so for those with both conditions. Services that take an inclusive approach to both conditions can provide crucial opportunities for social interaction. Extra care housing has the potential to provide a supportive, community-based environment that can help residents to maintain social contact. Originality/value – This paper adds much-needed evidence to the limited existing literature, and reflects the views of diverse professionals across housing, health and social care.

How common is childhood myasthenia? The UK incidence and prevalence of autoimmune and congenital myasthenia

ObjectiveTo ascertain the frequency of childhood myasthenia in the UK. Specifically, we aimed to identify the detected incidence of autoimmune myasthenia and the detected prevalence of genetically confirmed congenital myasthenic...

ASPIRE-2-PREVENT: a survey of lifestyle, risk factor management and cardioprotective medication in patients with coronary heart disease and people at high risk of developing cardiovascular disease in the UK

ObjectiveTo determine in patients with coronary heart disease (CHD) and people at high risk of developing cardiovascular disease (CVD) whether the Joint British Societies' guidelines on CVD prevention (JBS2) are...

‘It's the bread and butter of our practice’: experiencing the Early Years Foundation Stage

This article presents the experiences of nursery and primary head teachers (n=12) on the English Early Years Foundation Stage (EYFS) after its first year of implementation in 2010. Findings are drawn from a subset of data (head teachers of primary and nursery schools) which forms part of a larger Department for Children, Schools and Families funded project entitled Practitioners' Experiences of the EYFS. To reflect a breadth of experience, interviews were conducted in six geographical regions in England. The results suggest that the EYFS served to validate the existing child-led early years approach adopted by most schools. Nonetheless, a pedagogic tension was noted in reception classes between the child-led play based EYFS approach and the knowledge-led National Curriculum. Additionally, a perceived lack of consistency was noted in the quality provided within and between the PVI (private, voluntary and independent) sector and maintained sector staff. Despite these shortcomings, several primary head teachers are extending the principles of the EYFS into Key Stage One.

Regional variation in the efficacy of Entry Level Stewardship in England

The Entry Level Stewardship scheme, introduced in 2005, is the first non-competitive, broad-uptake scheme designed to deliver simple but effective environmental management on farms throughout England. While previous analysis suggests that the benefits of the scheme at the national scale may be limited thus far, efficacy may vary on a regional basis because of spatial differences in the uptake of individual options, in local environmental resource gaps or in the population status of key species. We assessed the influence of Entry Level Stewardship on regional population changes between 2005 and 2008 of farmland bird species. Trends were derived from standardised surveys carried out across eight geographical regions in England in more than 2000 lowland farmland 1 km squares. Birds showed apparent region-specific population trends and responses to Stewardship options. Boundary management had a positive association with the population trends of several species in both Yorkshire and the North West. Neither grass field margins nor the provision of winter foraging resources appeared to have any substantial benefits across any regions. An important influence of regional context was suggested by contrasting effect of management on some species, such as linnet, across regions. This study suggests that there are regional differences in the efficacy of options and responses of bird populations, although the number of tests conducted means that some of the apparent results may represent statistical artefacts. Nevertheless, this study suggests that agri-environment schemes like Entry Level Stewardship would be improved by greater consideration of regionality in biodiversity responses and efficacy than is currently common in standard schemes.

118 ASPIRE-2-PREVENT: lifestyle and risk factor management in people at high risk of developing cardiovascular disease in the UK

Introduction The first ASPIRE survey, conducted by the British Cardiovascular Society in 1994–1995 showed a high prevalence of modifiable risk factors in coronary patients in the UK. The second ASPIRE-2-PREVENT survey included people at high cardiovascular risk in general practice. The aim was to determine in high risk individuals whether the JBS2 and NICE guidance on cardiovascular disease prevention are being followed in clinical practice. Methods ASPIRE-2-PREVENT survey was undertaken in 2008–2009 in 18 randomly selected general practices in 12 geographical regions in England, Northern Ireland, Wales, and Scotland. Consecutive patients, men and women Results A total of 943 high risk individuals were identified and 446 (47.5% females) were interviewed (participation rate 48.5%). Overall, 13.3% smoked cigarettes, 85.5% were overweight (BMI≥30 kg/m 2 ), 50.2% obese (BMI≥30 kg/m 2 ) and 76.4% centrally obese (waist circumference≥94 cm in men (≥90 cm in Asian men) or≥80 cm in women), 51.3% had blood pressure ≥ 140/85 mmHg (≥130/80 in people with diabetes mellitus), 78.7% had total cholesterol≥4.0 mmol/l, 43.8% reported a history of diabetes and 1.4% had newly diagnosed diabetes. Risk factor control was poor, with only 47.4% of those patients using antihypertensive medication at blood pressure goal ( Conclusions The ASPIRE-2-PREVENT survey shows the lifestyle of high risk patients is a major cause for concern with high prevalences of smoking, obesity and central obesity. Blood pressure, lipid and glucose control are inadequate with most patients not achieving the targets defined in the JBS2 prevention guidelines. Primary prevention needs a systematic, comprehensive, multidisciplinary approach, which addresses lifestyle and risk factor management by general practitioners, nurses and other allied health professionals.

115 ASPIRE-2-PREVENT: a British cardiovascular society survey on the lifestyle and risk factor management and use of cardioprotective medication in coronary patients in the UK

Introduction The first ASPIRE survey, conducted by the British Cardiovascular Society in 1994–1995 showed a high prevalence of modifiable risk factors in coronary patients in the UK and a real potential to further reduce coronary heart disease morbidity and mortality. The aim of the ASPIRE-2-PREVENT survey was to determine in patients with established coronary disease whether JBS2 and NICE guidance on cardiovascular disease prevention are being followed in everyday clinical practice. Methods ASPIRE-2-PREVENT survey was undertaken in 2008–2009 in 18 randomly selected hospitals in 12 geographical regions in England, Northern Ireland, Wales, and Scotland. Consecutive patients, men and women Results A total of 1522 medical records (26.1% women) were reviewed and 676 patients were interviewed on average 13.0 (10.3, 16.2) months following their index event (participation rate 47.2%). At interview, 14.1% of patients smoked cigarettes and 47.1% were persistent smokers, 78.4% were overweight (BMI≥25 kg/m 2 ), 38.0% obese (BMI≥30 kg/m 2 ), 76.4% had central obesity (waist circumference ≥ 94 cm in men (≥90 cm in Asian men) or ≥ 80 cm in women), 46.9% raised blood pressure (BP≥130/80 mmHg), 52.6% elevated total cholesterol ≥ 4 mmol/l, 17.8% self-reported diabetes and 4.4% newly diagnosed diabetes (fasting plasma glucose≥7 mmol/l). Cardioprotective drug therapies: aspirin or other anti-platelets drugs 95.4%, β-blockers 74.8%, ACE inhibitors/ARBs 78.9%, statins 92.8%, anticoagulants 3.9%. 53.2% of patients on blood pressure lowering medication were controlled (BP Conclusions ASPIRE-2-PREVENT shows the lifestyle of coronary patients continues to be a major challenge with high prevalences of persistent smoking, obesity and central obesity and many patients not achieving the blood pressure, lipid and diabetes targets. So, a gap continues to exist in the implementation of evidence-based preventive medicine in cardiological practice. Prevention and rehabilitation of coronary, and other patients with atherosclerotic vascular disease, needs a systematic, comprehensive, multidisciplinary approach, which addresses all aspects of lifestyle, risk factor and therapeutic management.

Distribution and antimicrobial susceptibility patterns of Clostridium difficile PCR ribotypes in English hospitals, 2007-08

A surveillance study designed to provide a representative sample of the strains of Clostridium difficile causing infections in hospitals in England was in operation from April 2007 to the end of March 2008. Six hundred and seventy-seven isolates were obtained from 186 hospitals in the nine geographical regions of England as recognised by the Health Protection Agency's Regional Microbiology Network. Typing studies revealed that PCR ribotype 027 is now the most common strain isolated from symptomatic patients, accounting for over 41.3% of isolates in English hospitals. Type 106 was the second most common strain (20.2%) and Type 001, which was once the most common strain associated with hospital outbreaks, has now been reduced to only 7.8% of the total. A mixture of 44 other PCR ribotypes accounted for the remaining 28.9% of isolates. This represents a changing distribution of strains when compared to a previous study performed two years earlier which showed roughly equal proportions of types 106, 001 and 027. Antimicrobial susceptibility testing by the E test method revealed significantly lower susceptibility to metronidazole in the more common strains when compared to the less common ribotypes, although none were classified as clinically resistant. Similarly, no resistance to vancomycin was detected. However, common PCR ribotypes were more resistant to moxifloxacin and erythromycin than the less common strains, which may indicate a selective advantage for resistance to these agents, and combined resistance to these two agents was a good indicator of a common ribotype.

Regional genetic variation in Caucasians

When evaluating DNA evidence, the necessary calculations are often carried out using databases drawn from broad populations; for example, the Forensic Science Service (FSS) maintains genetic databases for the 3 major racial groups of England and Wales—Caucasian, Afro-Caribbean and Asian (from the Indian subcontinent). The resulting figures may be challenged in court on the premise that they are not based on data from the population of most relevance in the particular case under consideration. One important factor might be the location of the crime. Since the recent establishment of a National DNA Intelligence Database, data have been made available from a wide range of geographical regions in England and Wales. This paper gives details of analyses conducted to measure the differentiation between white Caucasian populations from these regions and from other areas of the UK and abroad using a Bayesian approach.