North East Thames Regional Research Articles

John William Simmons Harris (1926-2013).

John William Simmons Harris (1926-2013).

Genetic testing in children with surfactant dysfunction

ObjectivesTo present the UK experience in genetic diagnoses of surfactant protein dysfunction disorders and develop a referral algorithm for neonates and children with persistent respiratory problems.Materials and methodsBetween 2006 and...

MICROBIAL CONTAMINATION OF NON-STERILE PHARMACEUTICAL PRODUCTS MADE IN HOSPITALS IN THE NORTH EAST THAMES REGIONAL HEALTH AUTHORITY

Non-sterile pharmaceutical products made in nine hospitals in the North East Thames Regional Health Authority were examined for microbial contamination as part of a quality assurance programme. The incidence of contamination was found to vary between hospitals, but in all cases improvements were seen during the 3-year monitoring period in the microbiological quality of products made in individual hospitals. The most common isolates were aerobic spore bearers--usually less than 10(2) colony forming units/g or ml. Gram-negative isolates were found in at least one product from each hospital. Pseudomonas spp. were isolated from several samples of peppermint water.

Moving genetics into clinical cancer care: examples from BRCA gene testing and telemedicine

The translation of genetic knowledge from the research laboratory into the clinical arena is a complex and challenging process. The skills and expertise required are different from those required by a successful laboratory scientist. Recognising the scale of the challenge, University College London has established the Institute of Human Genetics and Health; a unique, multi-disciplinary initiative examining the impact of genetic knowledge on human health and disease. The testing of the BRCA1 and 2 genes in the North East Thames region is an interesting example of the translation of genetic testing into clinical care, and the corresponding complexities relating to informed consent that can arise. The development of a remote cancer genetics service within North East Thames Regional Genetics Service, which uses live, real time teleconferencing technology, is a powerful example of the fact that the National Health Service (NHS) can adapt, and integrate new technology into its working practice.

Influence of parity on fetal mortality in prolonged pregnancy

Objective In England an estimated 50,000 inductions of labour at or beyond 41 weeks’ gestation are conducted each year. However, the published evidence on the effect of parity on stillbirth in prolonged pregnancy is limited, and has produced conflicting data. The aim of this study is to evaluate the influence of parity on fetal mortality in prolonged pregnancies. Study design Retrospective analysis of 145,695 singleton births with known parity and no malformation noted at birth to residents in the former North-East Thames Region, UK. The parity and gestation specific stillbirth risks and relative risks per 1000 ongoing pregnancies were calculated in relation to parity between 37 and 45 weeks. Results Before 41 weeks the stillbirth risk rose gradually but did not differ by parity. By 41 weeks there was a substantial increase in the stillbirth risk in nulliparous women but not in parous women. The pattern of rise is such that the stillbirth risk is 2.9 times higher (95% CI 1.06–8.19) in nulliparous women at >42 weeks’ gestation. Conclusion Being parous appears to have a protective effect on fetal mortality in prolonged pregnancy. These findings question the need for routine induction of labour at 41 weeks in parous women.

The longer patients are in hospital before Intensive Care admission the higher their mortality.

To explore the relationship between hospital mortality and time spent by patients on hospital wards before admission to the intensive care unit (ICU). Observational study of prospectively collected data. Participating intensive care units within the North East Thames Regional Database. Patients, 7,190, admitted to ICU from the hospital wards of 24 hospitals. None. Of ICU admissions from the wards, 40.1% were in hospital for more than 3 days and 11.7% for more than 15 days. ICU patients who died in hospital were in-patients longer (p=0.001) before admission (median 3 days; interquartile range 1-9) than those discharged alive (median 2 days; interquartile range 1-5). Hospital mortality increased significantly (p<0.0001) in relation to time on hospital wards before ICU: 47.1% (standardised mortality ratio 1.09) for patients in hospital 0-3 days before ICU admission up to 67.2% (standardised mortality ratio 1.39) for patients on the wards for more than 15 days before ICU. Length of stay before ICU admission was an independent predictor of hospital mortality (odds ratio per day 1.019; 95% confidence interval 1.014-1.024). There were significant differences (p<0.001) in patient age, APACHE II score and predicted mortality in relation to time on wards before ICU admission. Mortality was high among patients admitted from the wards to ICU; many were inpatients for days or weeks before admission. The longer these patients were in hospital before ICU admission, the higher their mortality. Patients with delayed admission differed in some respects compared to those admitted earlier.

The TAPS Project

The Team for the Assessment of Psychiatric Services (TAPS) was established in May 1985 with the explicit purpose of evaluating the national policy of replacing psychiatric hospitals with district based services. TAPS' remit was to mount the evaluation with respect to the closure of Friern and Claybury Hospitals in north London. Funding was provided by the Department of Health and North-East Thames Regional Health Authority (latterly North Thames Regional Health Authority) with supplements from the King's Fund and the Sainsbury Family Trusts. During 13 years of research TAPS has employed more than 50 members of staff and associated researchers. A full listing is given in Leff (1997). This summary of the research is organised by topics. However, there was very close integration of the various projects.

Survival in cerebral palsy: the role of severity and diagnostic labels

The aim of this study was to review survival and certified causes of death of 584 children on a population-based register of cerebral palsy (CP), and to assess the impact on these of an additional diagnostic label. The register, established in 1985, comprised children with CP born from 1980 to about 1987 who were resident at the time of notification in the south-east of England in a region with between 3 and 4 million population, defined by the boundaries of the regional health authority (North East Thames Regional Health Authority). The current report concerns deaths of residents born between 1980 and 1986, who had been registered but had later died, as well as of eligible children who had not been registered while alive but whose cause of death was CP. These were identified at the Office of Population Censuses and Surveys who also supplied copies of death certificates for this study. For children notified while alive, information about motor severity and other diagnostic labels was sought at entry to the register and again between 3.5 and 4 years and between 7 and 8 years. For this study, children known to have a postneonatal onset, a progressive or non-cerebral cause of motor signs, or minimal motor involvement were excluded. Thirty-nine of 584 children included in this study had died by the end of 1995. No deaths had occurred in children known to have less than four-limb involvement. Survival of the group known to have an additional diagnostic label was significantly lower (86.2%) than that of the group with no known label (96.3%; P=0.01), and remained lower, although not significantly, if only those with severe four-limb involvement were compared (75.3% versus 92.4%; P=0.2). The greater severity of limb involvement in those with an additional diagnosis may not account for this difference. Of the 37 children with death certificates available, CP was mentioned as a cause in only 24.

Socio-economic deprivation and admission rates to secure forensic psychiatry services

Annual admission rates from the North-East Thames Region to maximum- and medium-secure forensic psychiatry services demonstrated a highly significant correlation with social deprivation measured at district health authority level using the Jarman UPA 8. There were specific associations with the number of unemployed persons, overcrowded households, and persons from ethnic minorities in the districts studied. There was a 10-fold difference in treated prevalence rates across the region, indicating that certain purchasing authorities may be seriously underfunded to meet the needs of their catchment area populations for secure forensic psychiatry services. Further research is required into the nature of the association between admissions to these services and social deprivation. It is readily apparent that a new formula is required for the allocation of resources in the face of such wide disparities in demand from different geographical locations.

Monitoring fetal and infant survival using regional birth notification data in north east London.

OBJECTIVE: To demonstrate the use of aggregated, locally collected birth notification data to examine trends in birth-weight specific survival for singleton and multiple births. DESIGN: Retrospective analysis of 171,527 notified...

Melanoma excision by general practitioners in north-east Thames region, England.

A retrospective study of pathology reports of melanomas excised by general practitioners (GPs) was undertaken in the course of a population-based study of melanoma, with a telephone survey of the current practice of those GPs who had excised melanomas. The objectives of this study were to identify all cases of cutaneous melanoma excised by GPs in the North-East Thames Region between 1989 and 1993, and to review the management of those patients. The main outcome measures of the study were: (i) the patterns of distribution of GP excisions within the region; (ii) the histological subtypes of melanomas excised, the accuracy of the pre-excision clinical diagnosis and the adequacy of treatment of the GP-treated tumours compared with the control group; and (iii) the reported current practice in the management of pigmented skin lesions by the GPs who had excised melanomas. Eight hundred and nineteen melanomas were excised in the region during the study period, of which 59 were excised by GPs. The Breslow thickness of tumours was similar in both GP-excised and non-GP-excised groups. Tumours were more likely to be amelanotic in the GP-excised group (P < 0.001). Incomplete excision was significantly more likely in the GP group (P < 0.001). The GPs made a confident clinical diagnosis of melanoma in only 17% of patients prior to surgery. The reported referral rate to specialists by this subset of GPs of patients with pigmented lesions was low, and at interview half of the GPs reported that they felt confident enough to manage patients with suspected skin cancers on their own. The majority of the GPs did not routinely obtain histological examination of skin lesions they believed to be benign. In conclusion, there are problems with the accuracy of clinical diagnosis and inadequacy of excision of melanomas removed in primary care. In the majority of cases, however, patients were subsequently appropriately treated by referral to specialist units. There was an under-usage of pathological examination of samples by the GPs interviewed.

Prolonged pregnancy: evaluating gestation-specific risks of fetal and infant mortality.

To evaluate gestation-specific risks of stillbirth, neonatal and post-neonatal mortality. Retrospective analysis of 171,527 notified births (1989-1991) and subsequent infant survival at one year, from community child health records. Notifications from maternity units in the North East Thames Region, London. The incidence of births, stillbirths, neonatal and post-neonatal deaths at each gestation after 28 completed weeks. Mortality rates per 1000 total or live births and per 1000 ongoing pregnancies at each gestation were calculated. The rates of stillbirth at term (2.3 per 1000 total births) and post-term (1.9 per 1000 total births) were similar. When calculated per 1000 ongoing pregnancies, the rate of stillbirth increased six-fold from 0.35 per 1000 ongoing pregnancies at 37 weeks to 2.12 per 1000 ongoing pregnancies at 43 weeks of gestation. Neonatal and post-neonatal mortality rates fell significantly with advancing gestation, from 151.4 and 31.7 per 1000 live births at 28 weeks, to reach a nadir at 41 weeks of gestation (0.7 and 1.3 per 1000 live births, respectively), increasing thereafter in prolonged gestation to 1.6 and 2.1 per 1000 live births at 43 weeks of gestation. When calculated per 1000 ongoing pregnancies, the overall risk of pregnancy loss (stillbirth + infant mortality) increased eight-fold from 0.7 per 1000 ongoing pregnancies at 37 weeks to 5.8 per 1000 ongoing pregnancies at 43 weeks of gestation. The risks of prolonged gestation on pregnancy are better reflected by calculating fetal and infant losses per 1000 ongoing pregnancies. There is a significant increase in the risk of stillbirth, neonatal and post-neonatal mortality in prolonged pregnancy. This study provides accurate data on gestation-specific risks of pregnancy loss, enabling pregnant women and their carers to judge the appropriateness of obstetric intervention.

The association between naevi and melanoma in populations with different levels of sun exposure: a joint case-control study of melanoma in the UK and Australia.

Two case-control studies were set up to investigate the relationship between melanocytic naevi and risk of melanoma and to compare the naevus phenotype in two countries exposed to greatly different levels of sun exposure and different melanoma rates. In England 117 melanoma cases and 163 controls were recruited from the North-East Thames Region and 183 melanoma cases and 162 controls from New South Wales, Australia. Each subject underwent a whole-body naevus count performed by the same examiner in each country. Relative risks associated with melanocytic naevi in each country were calculated with comparison of naevus data in controls between Australia and England. Atypical naevi were strong risk factors for melanoma in both countries: the odds ratio (OR) for three or more atypical naevi was 4.6 (95% CI 2.0-10.7) in Australia compared with 51.7 (95% CI 6.5-408.4) in England. Common naevi were also significant risk factors in Australia and England with similar odds ratios in the two countries. Prevalence of atypical naevi was greater in Australian controls than in English controls: OR 9.7 (95% CI 1.2-81.7) for three or more atypical naevi in Australia compared with England. For young age groups, the median number of common naevi was greater in Australia than in the UK, whereas for older individuals this difference in naevi number between the two countries disappeared. The prevalence of naevi on non-sun-exposed sites in controls was not significantly different between the two countries. The atypical mole syndrome (AMS) phenotype was more prevalent in Australian controls (6%) than in English controls (2%). The results of this study support the role of sun exposure in the induction of atypical naevi in adults. There was a trend towards stronger risk factors associated with atypical naevi in England compared with Australia. The atypical mole syndrome, usually associated with a genetic susceptibility to melanoma, was more common in Australia than in England, suggesting genetic environmental interactions with the possibility of phenocopies induced by sunlight.

A needs index for mental health care.

The study aimed to develop a mental illness needs index to help local managers, district purchasers and national policy makers in allocating resources. Formulae were developed by regression analysis using 1991 census data to predict the period prevalence of acute psychiatric admission from electoral wards. Census variables used were chosen on the basis of an established association with mental illness rates. Data from one English Health Service region were analysed for patterns common to wards at hospital catchment area level and patterns common to district health authorities at regional level. The North East Thames region was chosen as the setting for the study, with 7096 patients being admitted during 1991. In most, but not all, catchment areas reasonable prediction of the pattern of admission prevalence was possible using the variables chosen. However, different population characteristics predicted admission prevalence in rural and urban areas. Prediction methods based on one or two variables are thus unlikely to work in both settings. A Mental Illness Needs Index (MINI) based on social isolation, poverty, unemployment, permanent sickness and temporary and insecure housing predicted differences in admission prevalence between wards at catchment area level better than Jarman's Underprivileged Area (UPA) score [1] and between districts at regional level better than the UPA score and comparably to the York Psychiatric Index [2] (adjusted r2 at regional level (MINI 0.82, UPA 0.53, York index 0.70). District admission prevalence rates vary by a factor of three between rural and inner city areas; this difference may not fully reflect the variation in the cost of providing care. It did not prove possible to incorporate factors related to bed availability in the models used; reasons for this are discussed. Data covering other aspects of mental health care in addition to hospital admission are needed for more satisfactory modelling.

Social deprivation and bacterial meningitis in north east thames region: three year study using small area statistics

The rates of many diseases are linked to the deprivation of the area.1 Earlier British studies have shown that lower social class and overcrowding are associated with increased risk of...

Senior house officer training: is it getting better? A questionnaire survey

A survey of senior house officer posts in north east thames region uncovered problems with workload, supervision, and education1 2 similar to those described by others.3 during the following years...

Cerebral palsy: effects of twinning, birthweight, and gestational age.

To determine the effects of birthweight and gestational age on the risk of cerebral palsy for multiple and singleton births. Children on the North East Thames Regional Health Authority Interactive Child Health System, born between 1 January 1980 and 31 December 1986, and notified as having cerebral palsy, were included. Cases of postneonatal onset, of known progressive, or non-cerebral pathology and with only mild signs were excluded. Rates and relative risks were calculated using the most complete data, which related to 1985-86, and comprised 102,059 singletons and 2367 twins. Logistic regression was used to examine the associations between being a twin, gestational age, and birthweight. The crude rate per 1000 survivors at 1 year of age was 1.0 in singletons and 7.4 in twins. The relative risk was greatest in twins weighing more than 2499 g (4.5). However, after adjusting for reduced birthweight of twins it was the relative risk of twins weighing less than 1400 g that was significantly increased. Logistic regression confirmed that lower fetal growth, lower gestational age, and being a twin are all independent risk factors for cerebral palsy. The increased risk to twins of cerebral palsy is not entirely explained by their increased risk of prematurity and low birthweight.

The current state of screening in general practice.

The aim of this study was to describe the range of screening services offered by general practitioners (GPs). A postal questionnaire survey was sent to a random sample of one in four GPs in general practices within the geographical boundaries of North (East) Thames Region. The questionnaire was divided into five sections, the first covering practice details and the other four covering screening directed at different groups of patients. Each GP in the sample was sent the general section and two other sections. The overall response rate was 67.7 per cent. There was inter-practitioner variability in screening practice in all four patient groups. A number of GPs did not undertake all screening tests required by the national GP contract or recommended by national or local policy, and some had introduced screening programmes of uncertain benefit. There was little evidence of systematic audit of screening programmes. Differences in screening provision were observed between GPs in Greater London and nonmetropolitan areas, but there was little difference between single-handed and group practice, or between fundholding and non-fundholding GPs, except in the provision of child health surveillance. Primary care teams carry out screening for a wide range of conditions but the lack of uniformity of practice and of evaluation makes it unclear to what extent the population benefits from these activities. The importance of national and international screening policies is obvious, but there is a need to go beyond publication and dissemination of guidelines to develop implementation strategies which take account of the variations in the way GPs actually address screening in their practices.

Pneumococcal meningitis in the North East Thames Region UK: epidemiology and molecular analysis of isolates.

One hundred and fourteen cases of pneumococcal meningitis were identified by prospective laboratory based surveillance during 1990-3 in the North East Thames Region. Higher rates of disease were seen in Asians (2.1/100000) than Caucasians (0.8/100000) (P = 0.002). The incidence of meningitis was higher in children than adults, while mortality rates were highest in adults over the age of 60 (48%). In 72 cases, both blood and CSF were culture positive. Serotyping of 65 isolates collected identified 22 serotypes (and one non-typable) causing disease, the most common being serotype 6 (13 cases) and serotype 14 (11 cases). Overall, 90% of serotype antigens identified were represented in the 23 valent vaccine. Ribotyping of 62 isolates identified 35 different patterns, of which 26 were single types. Different ribotypes were found among isolates of the same serotypes, with the exception of serotype 14, where 9 of 11 isolates had the same ribotype pattern. Four percent of isolates had reduced susceptibility to penicillin, but no high level penicillin resistance was found.

Management of burn injuries in children

120000 patients are seen with burns in emergency departments in the U.K. each year. Of these, 50% will be children. The average age of the children admitted to the North East Thames Regional Burns Unit (NETRBU) will be 4 years, and the size of the burn 10% body surface area. Some of the children admitted will be severely ill requiring intensive treatment. Many will be scarred, and have long-term morbidity. This paper offers a treatment protocol for burned children from first aid to management in the emergency department, and describes the regimen for treatment then followed in the NETRBU.