London Health Research Articles

Children’s Health in London and Luton (CHILL) cohort: a 12-month natural experimental study of the effects of the Ultra Low Emission Zone on children’s travel to school

BackgroundThe Ultra-Low Emission Zone (ULEZ), introduced in Central London in April 2019, aims to enhance air quality and improve public health. The Children's Health in London and Luton (CHILL) study evaluates the impact of the ULEZ on children's health. This analysis focuses on the one-year impacts on the shift towards active travel to school.MethodsCHILL is a prospective parallel cohort study of ethnically diverse children, aged 6–9 years attending 84 primary schools within or with catchment areas encompassing London’s ULEZ (intervention) and Luton (non-intervention area). Baseline (2018/19) and one-year follow-up (2019/20) data were collected at school visits from 1992 (58%) children who reported their mode of travel to school ‘today’ (day of assessment). Multilevel logistic regressions were performed to analyse associations between the introduction of the ULEZ and the likelihood of switching from inactive to active travel modes, and vice-versa. Interactions between intervention group status and pre-specified effect modifiers were also explored.ResultsAmong children who took inactive modes at baseline, 42% of children in London and 20% of children in Luton switched to active modes. For children taking active modes at baseline, 5% of children in London and 21% of children in Luton switched to inactive modes. Relative to the children in Luton, children in London were more likely to have switched from inactive to active modes (OR 3.64, 95% CI 1.21–10.92). Children in the intervention group were also less likely to switch from active to inactive modes (OR 0.11, 0.05–0.24). Moderator analyses showed that children living further from school were more likely to switch from inactive to active modes (OR 6.06,1.87–19.68) compared to those living closer (OR 1.43, 0.27–7.54).ConclusionsImplementation of clean air zones can increase uptake of active travel to school and was particularly associated with more sustainable and active travel in children living further from school.

Community integration, quality of life, thriving, and mental health among refugees and asylum seekers. A London service provider perspective.

This article explores how systemic injustices and social inequalities affect refugee and asylum seeker integration, thriving, and mental health in London. This is pertinent as the United Kingdom currently operates a 'broken' asylum system with unfair policies and a 'tough' immigration rhetoric which makes it extraordinarily difficult for asylum seekers and refugees to achieve community integration, have a good quality of life, be able to thrive, and have good health including mental health. Paradoxically, the United Kingdom Home Office also features an Indicators for Integration Framework to provide practical ways to design more effective strategies, monitor services and evaluated integration interventions. This study employed a qualitative research design including semi-structured interviews with 19 mental health and psychosocial support service providers working in third-sector organizations in London. The study results show that the current asylum system severely undermines efforts to support asylum seekers and refugees with their integration. All participants highlighted that asylum seekers and refugees lacked experienced poor quality of life and faced structural challenges to build meaningful social connections; to have access education, fair employment and good work; to achieve good mental health and wellbeing; and to be able to thrive. To improve community integration, quality of life, thriving, and mental health for asylum seekers and refugees in London and, beyond, the United Kingdom, four recommendations are made on structural and service-levels: (1) reform of the current asylum system by centering human rights; (2) implement and carry out needs assessments among asylum seekers and refugees focussing on key social determinants; (3) ensure asylum seekers and refugees benefit from the NHS Inclusion Health framework; and (4) extend the NHS Patient and Carer Race Equality framework beyond England. To be effective, all four initiatives need to be grounded in a participatory approach that meaningfully involves diverse groups of stakeholders including asylum seekers and refugees.

Ultrasound-guided wire localisation: a GPS for hidden head and neck tumours? A case series.

Ultrasound-guided wire (USGW) localisation for small non-palpable tumours before a revision head and neck surgery is an attractive pre-operative option to facilitate tumour identification and decrease potential complications. We describe five cases of pre-operative USGW localisation of non-palpable head and neck lesions to facilitate surgical localisation and resection. All patients undergoing pre-operative USGW localisation for non-palpable tumours of the head and neck region at London Health and Sciences Center, London, Ontario, Canada, were included. All the USGW localisations were performed by the same interventional radiologist, and the surgeries were performed by fellowship trained head and neck surgeons. Five patients were included. All patients were undergoing revision surgery for recurrent or persistent disease. All successfully underwent a pre-operative USGW localisation of the non-palpable lesion before revision surgery. All lesions were localised intra-operatively with no peri-operative complications. USGW localisation is a safe and effective pre-operative technique for the identification of small non-palpable head and neck tumours.

Investigating the impact of London’s ultra low emission zone on children’s health: children’s health in London and Luton (CHILL) protocol for a prospective parallel cohort study

BackgroundAir pollution harms health across the life course. Children are at particular risk of adverse effects during development, which may impact on health in later life. Interventions that improve air quality are urgently needed both to improve public health now, and prevent longer-term increased vulnerability to chronic disease. Low Emission Zones are a public health policy intervention aimed at reducing traffic-derived contributions to urban air pollution, but evidence that they deliver health benefits is lacking. We describe a natural experiment study (CHILL: Children’s Health in London and Luton) to evaluate the impacts of the introduction of London’s Ultra Low Emission Zone (ULEZ) on children’s health.MethodsCHILL is a prospective two-arm parallel longitudinal cohort study recruiting children at age 6–9 years from primary schools in Central London (the focus of the first phase of the ULEZ) and Luton (a comparator site), with the primary outcome being the impact of changes in annual air pollutant exposures (nitrogen oxides [NOx], nitrogen dioxide [NO2], particulate matter with a diameter of less than 2.5micrograms [PM2.5], and less than 10 micrograms [PM10]) across the two sites on lung function growth, measured as post-bronchodilator forced expiratory volume in one second (FEV1) over five years. Secondary outcomes include physical activity, cognitive development, mental health, quality of life, health inequalities, and a range of respiratory and health economic data.DiscussionCHILL’s prospective parallel cohort design will enable robust conclusions to be drawn on the effectiveness of the ULEZ at improving air quality and delivering improvements in children’s respiratory health. With increasing proportions of the world’s population now living in large urban areas exceeding World Health Organisation air pollution limit guidelines, our study findings will have important implications for the design and implementation of Low Emission and Clean Air Zones in the UK, and worldwide.ClinicalTrials.govNCT04695093 (05/01/2021).

Impact of rapid near-patient STI testing on service delivery outcomes in an integrated sexual health service in the United Kingdom: a controlled interrupted time series study

ObjectivesTo evaluate the impact of a new clinic-based rapid sexually transmitted infection testing, diagnosis and treatment service on healthcare delivery and resource needs in an integrated sexual health service.DesignControlled interrupted...

Improving health in London: reflections from three mini case studies (HIV, mental health, healthcare estate)

ABSTRACT Global health will increasingly be determined by cities and therefore city-wide transformation of health and care is crucially important. Reflections from our experiences in London suggest some critical ingredients for city-wide transformation, including: having a shared aim; robust engagement with the citizens, service users and providers of services; setting aside organisational priorities and effective incentives to do so; a focus on enablers; strong city-wide leadership. Rather than working ‘together but separately’, health and care partners must work ‘together, together’ if cities are to meet the health and care challenges of the next decade.

A retrospective cohort study describing characteristics of those repeatedly detained under Section 136 of the Mental Health Act over a 5-year period and the association with past abuse.

Individuals repeatedly detained under Section 136 (S136) of the Mental Health Act account for a significant proportion of all detentions. This study provides a detailed analysis of those repeatedly detained ('repeat attenders') to a London Mental Health Trust, identifying key demographic profiles when compared to non-repeat attenders, describing core clinical characteristics and determining to what degree a past history of abuse might be associated with these.All detentions to the S136 suite at South West London and St George's Mental Health NHS Trust over a 5-year period (2015-2020) were examined. Data were collected retrospectively from electronic records. A total of 1767 patients had been detained, with 81 patients identified as being a 'repeat attenders' (having had > = 3 detentions to the S136 suite during the study period). Repeat attenders accounted for 400 detentions, 17.7% of all detentions.Repeat attenders included a higher proportion of females (49.4%, p = 0.0001), compared to non-repeat attenders, and a higher proportion of them were of white ethnicity (85.2%, p = 0.001). 52 (64%) patients reported being a victim of past abuse or trauma. Of repeat attenders who reported past abuse or trauma, a high proportion had diagnoses of personality disorders, with deliberate self-harm as the most common reason for detention. They were more commonly discharged home with community support, rather than considered for hospital admission. In light of these findings, this paper discusses support potential strategies for those most vulnerable to repeated S136 detention, thereby minimising the ever-growing number of S136 detentions in the UK.

Prevalence of conduct problems and social risk factors in ethnically diverse inner-city schools

BackgroundIn the UK, around 5% of 11–16-year olds experience conduct problems of clinical importance. However, there are limited data on prevalence of conduct problems by ethnic group, and how putative social risk factors may explain any variations in prevalence. This study has two main aims: (1) to estimate the prevalence and nature of conduct problems overall, and by ethnic group and gender, among adolescents in diverse inner-city London schools; (2) to assess the extent to which putative risk factors - racial discrimination, socioeconomic status, parental control, and troublesome friends - explain any observed differences in prevalence of conduct problems between ethnic groups.MethodsThis study uses baseline data from REACH, an accelerated cohort study of adolescent mental health in inner-city London. Self-report questionnaire data were collected on conduct problems and a range of distinct putative social risk factors (including racial discrimination, free school meals, troublesome friends, and parental care and control). A total of 4353 pupils, 51% girls, aged 11–14 participated. We estimated prevalence of conduct problems and used multilevel logistic regression to examine differences by ethnicity and gender and associations with putative risk factors.ResultsPrevalence of conduct problems in inner-city schools was around three times higher than reported in national studies (i.e., 16% [95%CI: 15·2–17·5] vs. 5% [95%CI 4·6–5·9]). Compared with overall prevalence, conduct problems were lower among Indian/Pakistani/Bangladeshi (RR: 0.53 [95% CI:0.31–0.87]) and white British (RR: 0.65 [0.51–0.82]) groups, and higher among black Caribbean (RR: 1.39 [95%CI:1.19–1.62]) and mixed white and black (RR: 1.29 [95% CI: 1.02–1.60]) groups. Risk of conduct problems was higher among those who were exposed to racial discrimination compared with those who were not (RR: 1.95 [95% CI: 1.59–2.31]).ConclusionsConduct problems are markedly more common in inner-city schools, and variations in the prevalence of conduct problems are, to some extent, rooted in modifiable social contexts and experiences, such as experiences of racial discrimination.

‘Test Now, Stop HIV’: COVID-19 and the idealisation of quarantine as the ‘end of HIV’

The emergence of COVID-19 precipitated varied responses from public health officials in London, England. In April 2020, clinicians at 56 Dean Street sexual health and advice clinic in central London described social isolation as ‘a unique window of opportunity’ to ‘break the chain’ in HIV transmission. This was followed by critical responses within HIV prevention circles. Drawing from these responses, this article examines the implications of the clinic’s ‘Test Now, Stop HIV’ campaign by asking how has the early COVID-19 pandemic reshaped institutional responses and strategies to end HIV transmission in England? We assess how campaign messages developed between April and May 2020. We analyse materials related to the campaign, including the clinic’s Twitter account, the campaign website, and journalism in mainstream media. Based on this information, we discuss three themes: testing and issues of access; the biopolitics of testing; and the idealism of quarantine. We draw on sociology, cultural theory and science and technology studies to describe how the ‘end of HIV’ was constructed through the link between COVID-19 and HIV. We suggest the campaign reinscribes historical perceptions of abstinence and quarantine as idealised HIV prevention strategies, and thus fails to address safer sex in the time of Coronavirus.

Unhuman Entities that Shaped a Century: Non- Anthropocentric Analysis of the Case of Great Stink and Pandemic, Victorian London

The history of architectural and urban design has expanded its scope and started adopting new philosophical approaches from other disciplines to explore the built environment. Theorist discusses whether we still live in a humanist world where a human being has more priority over the unhuman things or not to answer that; should we design architecture and urban within an anthropocentric approach. As a recent pandemic show, things that are not human, like animals or viruses, could control and navigate a new style of living. This research will introduce Bruno Latour's ANT and Graham Harman's Object-Oriented Ontology (OOO) as a new constructive method to analyse how human and unhuman bodies are equally the affective actors of daily practices in the urban realm. 19th-century Great Stink and epidemic in Victorian London will be a case study to picture urban dwellers of London that shaped determined the destiny of health and hygiene of London in 1858.

Novel Linkage of Administrative Health and Family Court Data to Examine Mental Health Need Among Women Whose Children Enter Care

IntroductionAn estimated 23% of children in England are exposed to maternal mental health problems, with growing concern around how maternal mental health affects parenting capacity and entries into public care for their children. There is limited evidence on the prevalence of mental health service need among women whose children enter care and on whether these needs are sufficiently met. With England’s family justice system and children’s social care sector increasingly overstretched, there is a need to identify opportunities for an improved response to maternal mental health.
 Objectives and ApproachWe linked administrative family court data for women (n = 5463) involved in public family court proceedings (care proceedings) across eight London boroughs between 2007 and 2019, with patient records from South London and Maudsley NHS mental health trust (SLaM). Work is ongoing to (1) describe the frequency, type and timing of mental health service use among women who link and (2) compare these findings to general population trends.
 Results2843 (52%) women linked to a SLaM patient record via deterministic linkage. Matches had better recording of identifiers and were more likely to have returned to court than non-matches (36% vs 26%). The majority of women (75.0%) were referred for treatment before the start of their (first) care proceeding, while 34.8% had a diagnosis recorded in a structured field. To appraise linkage quality, we manually reviewed de-identified clinician notes for 100 randomly selected women who linked; we confirmed ‘true’ match status for 95 women and found no evidence contradicting match status for the remainder.
 Conclusion / ImplicationsThis novel linkage between mental health and family court data supports growing evidence that women whose children enter care in England have high prevalence of mental health problems. Research using this linkage will help to inform strategies to improve maternal mental health and outcomes for vulnerable women and their children.

Montenegro makes important strides towards achievement of the SDGs.

In 2018, Montenegro took an important step towards ratification of the Protocol on Water and Health to the 1992 Convention on the Protection and Use of Transboundary Watercourses and International Lakes. A multisectoral national consultation provided a forum where national stakeholders could assist in related decision-making. The Protocol is the first and only multilateral legal agreement linking sustainable water management and the prevention, control and reduction of water-related diseases in the pan-European region. It was adopted in 1999 at the Third Ministerial Conference on Environment and Health in London and entered into force in 2005 as legally binding for the ratifying countries. To date, 26 countries have ratified it, covering about 60% of the population of the pan-European region. Montenegro is on the way to becoming the next country to ratify it and has used it as an instrument to strengthen national action towards progressively reaching regional and global WASH-related commitments, specifically in relation to SDG 3 (good health and well-being), SDG 6 (clean water and sanitation) and the Ostrava Declaration on Environment and Health (2017).

PM2.5 on the London Underground

IntroductionDespite the London Underground (LU) handling on average 2.8 million passenger journeys per day, the characteristics and potential health effects of the elevated concentrations of metal-rich PM2.5 found in this subway system are not well understood. MethodsSpatial monitoring campaigns were carried out to characterise the health-relevant chemical and physical properties of PM2.5 across the LU network, including diurnal and day-to-day variability and spatial distribution (above ground, depth below ground and subway line). Population-weighted station PM2.5 rankings were produced to understand the relative importance of concentrations at different stations and on different lines. ResultsThe PM2.5 mass in the LU (mean 88 μg m−3, median 28 μg m−3) was greater than at ambient background locations (mean 19 μg m−3, median 14 μg m−3) and roadside environments in central London (mean 22 μg m−3, median 14 μg m−3). Concentrations varied between lines and locations, with the deepest and shallowest submerged lines being the District (median 4 μg m−3) and Victoria (median 361 μg m−3 but up to 885 μg m−3). Broadly in agreement with other subway systems around the world, sampled LU PM2.5 comprised 47% iron oxide, 7% elemental carbon, 11% organic carbon, and 14% metallic and mineral oxides. Although a relationship between line depth and air quality inside the tube trains was evident, there were clear influences relating to the distance from cleaner outside air and the exchange with cabin air when the doors open. The passenger population-weighted exposure analysis demonstrated a method to identify stations that should be prioritised for remediation to improve air quality. ConclusionPM2.5 concentrations in the LU are many times higher than in other London transport Environments. Failure to include this environment in epidemiological studies of the relationship between PM2.5 and health in London is therefore likely to lead to a large exposure misclassification error. Given the significant contribution of underground PM2.5 to daily exposure, and the differences in composition compared to urban PM2.5, there is a clear need for well-designed studies to better understand the health effects of underground exposure.

Linking two administrative datasets about looked after children: testing feasibility and enhancing understanding

Background with rationaleEvery year all 32 local authorities in Scotland provide information on looked after children in their area to the Scottish Government. This forms the basis for the annual Children Looked After Statistics (CLAS). Information is also collected by Scottish Children’s Reporter Administration (SCRA) on all children who are involved in the Children’s Hearings System. Until now these two data sets had never been linked.
 Main Aim To test the feasibility and success of the linkage on the basis that these datasets had not previously been linked, and if linkage was possible, use this data to enhance our understanding of the child and process factors associated with pathways to permanence or lack of permanence.
 Methods/ApproachVeterans were identified using the South London and Maudsley Biomedical Research Centre (SLaM) case register – a database holding secondary mental health care electronic records for the South London and Maudsley National Health Service Trust of 300,000 patients. We developed two methods. An NLP and machine learning tool were developed to automatically evaluate personal history statements written by clinicians.
 ResultsFor the first time, as part of the Permanently Progressing? Building secure futures for children in Scotland study, these two data sets were linked safely and successfully for 1,000 children who became looked after in 2012-13 when they were aged five and under.
 The linkage provided important new information for practitioners and policymakers. In this presentation we will focus on the key findings, such as what it told us about previous referrals and methodological insights regarding these data sets and their linkage.
 ConclusionThe data linkage process was complex and time-consuming but possible. The data we were able to link provided valuable information that enhanced our understanding of child and process factors.

Childhood cognitive ability and the use of long-term care in later life

Background As the population ages the demand for care is predicted to increase. Previous studies have reported that individuals with poorer post-morbid cognitive ability are at higher risk of entering long-term care, both institutionalised care and home-based care. Given that post-morbid cognitive ability is sensitive to the type and severity of morbidity, it remains unclear whether higher cognitive ability, as a trait-level measure of individual differences, contributes to care usage. Some success has been observed using non-cognitive early-life circumstances such as socioeconomic circumstances as pre-morbid predictors of care risk. However, the contribution of early-life cognitive ability has yet to be examined.
 Main Aim We investigate the association between early-life circumstances, particularly cognitive ability, and the risk of entry into long-term care in later life (age 65+).
 Methods Veterans were identified using the South London and Maudsley Biomedical Research Centre (SLaM) case register – a database holding secondary mental health care electronic records for the South London and Maudsley National Health Service Trust of 300,000 patients. We developed two methods. An NLP and machine learning tool were developed to automatically evaluate personal history statements written by clinicians.
 Results This study uses a large sample of individuals born in Scotland in 1936 and who took part in the Scottish Mental Survey 1947. It links research data from childhood to routinely-collected administrative and healthcare records from across the life course.
 Conclusion We demonstrate the importance of early-life factors for predicting care usage in later life and how this role differs between types of long-term care. The implications of the results for research and policy will be discussed.

Identifying Military Veterans in a Clinical Research Database using Natural Language Processing

BackgroundThere is a lack of quantitative evidence concerning United Kingdom veterans who access secondary mental health care. This is mainly due to a person’s veteran status not being routinely collected when they enter the health care system.
 Main AimThe study aimed to develop an NLP approach for identifying veterans accessing secondary mental health care services using National Health Service electronic health records.
 MethodsVeterans were identified using the South London and Maudsley Biomedical Research Centre (SLaM) case register – a database holding secondary mental health care electronic records for the South London and Maudsley National Health Service Trust of 300,000 patients. We developed two methods. An NLP and machine learning tool were developed to automatically evaluate personal history statements written by clinicians.
 ResultsThis study showed that it was possible to identify veterans using the NLP and machine learning approach on a sub-set of 4,200 patients. The automatic machine learning method was able to identify 270 veterans representing an accuracy of 97.2%. It is estimated to take between 6 to 16 minutes to manually search patient history statements whereas the automatic machine learning method took only one minute to run.
 ConclusionWe have shown that it is possible to identify veterans using NLP combined with machine learning. This work contributes towards the development of a more comprehensive picture of veterans who are accessing secondary mental health care services in the UK. It represents a first step in identifying veterans from one dataset and we hope that future research can inform the possibility of deploying the methods nationally. Despite our success in the current work, the tools are tailored to the SLaM dataset and future work is needed to develop a more agnostic framework.
 FundingForces in Mind Trust

MicroEnv: A microsimulation model for quantifying the impacts of environmental policies on population health and health inequalities

The Sustainable Development Goals (SDGs) recognise the critical need to improve population health and environmental sustainability. This paper describes the development of a microsimulation model, MicroEnv, aimed at quantifying the impact of environmental exposures on health as an aid to selecting policies likely to have greatest benefit. Its methods allow the integration of morbidity and mortality outcomes and the generation of results at high spatial resolution. We illustrate its application to the assessment of the impact of air pollution on health in London. Simulations are performed at Lower Layer Super Output Area (LSOA), the smallest geographic unit (population of around 1500 inhabitants) for which detailed socio-demographic data are routinely available in the UK. The health of each individual in these LSOAs is simulated year-by-year using a health-state-transition model, where transition probabilities from one state to another are based on published statistics modified by relative risks that reflect the effect of environmental exposures. This is done through linkage of the simulated population in each LSOA with 1 × 1 km annual average PM2.5 concentrations and area-based deprivation indices. Air pollution is a leading cause of mortality and morbidity globally, and improving air quality is critical to the SDGs for Health (Goal 3) and Cities (Goal 11). The evidence of MicroEnv is aimed at providing better understanding of the benefits for population health and health inequalities of policy actions that affect exposure such as air quality, and thus to help shape policy decisions. Future work will extend the model to integrate other environmental determinants of health.

History of the International Association of Paediatric Dentistry: A 50-year perspective.

This paper demonstrates how the International Association of Paediatric Dentistry (IAPD) arose from small beginnings in 1967. What started as an International Forum on Child Dental Health in London grew to become first the International Association of Dentistry for Children and then the outstanding IAPD with biennial Congresses, regional meetings, cooperation with other children's organizations, Teach the Teachers programmes, a wonderful website, and this International Journal of Paediatric Dentistry. There are now 70 national member societies worldwide representing over 16000 members with a single interest: to further the oral health care of children. It is a truly remarkable achievement.

Brivaracetam in adults with drug-resistant epilepsy and psychiatric comorbidities

This is a case series of 25 patients with drug-resistant epilepsy and psychiatric comorbidities who started on brivaracetam (BRV) at St George's University Hospitals and Frimley Health in London. Median BRV dose was 150 mg for a median follow-up period of 8 months. Twenty had focal epilepsy, four had generalized epilepsies, and one had unclassified epilepsy; 76% had mood disorders (either depression or bipolar disorder), 12% intellectual disabilities with autism spectrum disorder and challenging behavior, and 12% psychoses. Forty percent of patients presented at least 50% seizure reduction, but none of them became seizure-free. A total of 44% of patients discontinued BRV, 20% because of adverse events, 20% because of inefficacy, and 4% because of both. Depression was reported by 8%, aggressive behavior by 8%, while 4% reported both. A total of 91.6% had received levetiracetam (LEV) before, in whom LEV was discontinued because of psychiatric adverse events (PAEs) in half. Seventy-seven percent of patients who developed PAEs with LEV did not do so on BRV suggesting that BRV is better tolerated than LEV in complex patients with psychiatric comorbidities and that the synaptic vesicle glycoprotein 2A (SV2A) protein modulation is unlikely to be implicated in LEV-related PAEs.

The Allegory of the Iron Fist: Transnational Ecofeminism in Monica Ali’s Brick Lane

ABSTRACTThis article argues that Monica Ali makes extensive use of ecologically themed parallelism in her novel Brick Lane (2003). Ali uses this parallel structure to engage ecological, health, and social problems in East Pakistan, Bangladesh, and London. The parallelism serves to construct a larger ecological framework within which the migrant experience in London is brought into relief critically, complicating the assumption that Brick Lane focuses on the heroine’s “private world”. The article suggests that the novel is an allegory of development, within which images of metallic-projectile force against the female body are metonymic of the text’s ecofeminist practice.