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1.  Incidence of diabetic retinopathy in people with type 2 diabetes mellitus attending the Diabetic Retinopathy Screening Service for Wales: retrospective analysis  
Objectives To determine the incidence of any and referable diabetic retinopathy in people with type 2 diabetes mellitus attending an annual screening service for retinopathy and whose first screening episode indicated no evidence of retinopathy.
Design Retrospective four year analysis.
Setting Screenings at the community based Diabetic Retinopathy Screening Service for Wales, United Kingdom.
Participants 57 199 people with type 2 diabetes mellitus, who were diagnosed at age 30 years or older and who had no evidence of diabetic retinopathy at their first screening event between 2005 and 2009. 49 763 (87%) had at least one further screening event within the study period and were included in the analysis.
Main outcome measures Annual incidence and cumulative incidence after four years of any and referable diabetic retinopathy. Relations between available putative risk factors and the onset and progression of retinopathy.
Results Cumulative incidence of any and referable retinopathy at four years was 360.27 and 11.64 per 1000 people, respectively. From the first to fourth year, the annual incidence of any retinopathy fell from 124.94 to 66.59 per 1000 people, compared with referable retinopathy, which increased slightly from 2.02 to 3.54 per 1000 people. Incidence of referable retinopathy was independently associated with known duration of diabetes, age at diagnosis, and use of insulin treatment. For participants needing insulin treatment with a duration of diabetes of 10 years or more, cumulative incidence of referable retinopathy at one and four years was 9.61 and 30.99 per 1000 people, respectively.
Conclusions Our analysis supports the extension of the screening interval for people with type 2 diabetes mellitus beyond the currently recommended 12 months, with the possible exception of those with diabetes duration of 10 years or more and on insulin treatment.
PMCID: PMC3284424  PMID: 22362115
2.  Effects on patients with asthma of eradicating visible indoor mould: a randomised controlled trial 
Thorax  2007;62(9):767-772.
It is not clear whether associations between respiratory symptoms and indoor mould are causal. A randomised controlled trial was conducted to see whether asthma improves when indoor mould is removed.
Houses of patients with asthma were randomly allocated into two groups. In one group, indoor mould was removed, fungicide was applied and a fan was installed in the loft. In the control group, intervention was delayed for 12 months. Questionnaires were administered and peak expiratory flow rate was measured at baseline, 6 months and 12 months.
Eighty‐one houses were allocated to the intervention group and 83 to the control group; 95 participants in 68 intervention houses and 87 in 63 control houses supplied follow‐up information. Peak expiratory flow rate variability declined in both groups, with no significant differences between them. At 6 months, significantly more of the intervention group showed a net improvement in wheeze affecting activities (difference between groups 25%, 95% CI 3% to 47%; p = 0.028), perceived improvement of breathing (52%, 95% CI 30% to 74%; p<0.0001) and perceived reduction in medication (59%, 95% CI 35% to 81%; p<0.0001). By 12 months the intervention group showed significantly greater reductions than the controls in preventer and reliever use, and more improvement in rhinitis (24%, 95% CI 9% to 39%; p = 0.001) and rhinoconjunctivitis (20%, 95% CI 5% to 36%; p = 0.009).
Although there was no objective evidence of benefit, symptoms of asthma and rhinitis improved and medication use declined following removal of indoor mould. It is unlikely that this was entirely a placebo effect.
PMCID: PMC2117320  PMID: 17389753
3.  Asthma prevalence in 1973, 1988 and 2003 
Thorax  2006;61(4):296-299.
A study was undertaken to see whether the prevalence of asthma has changed since a survey was conducted in 1988, using the same methods that showed an increase during the previous 15 years.
A survey of 12 year old children was conducted in schools in South Wales where surveys had taken place in 1973 and 1988. The survey comprised a parentally completed questionnaire and an exercise challenge test, performed when no bronchodilator had been recently used.
In 1973, 1988, and 2003, questionnaires were obtained for 817, 965 and 1148 children, respectively; the exercise test was performed by 812, 960 and 1019 children, respectively. The prevalence of reported wheeze in the last year rose during each 15 year period (9.8%, 15.2%, 19.7%), with an even steeper rise in reported asthma ever (5.5%, 12.0%, 27.3%). There was a continued increase in wheeze attributed to running, in terms of all children (5.8%, 10.5%, 16.0%) and also as the proportion of those with a history of wheeze (34.1%, 47.0%, 57.3%). The use of inhaled corticosteroids (not available in 1973) increased fourfold between 1988 and 2003. The prevalence of exercise induced bronchoconstriction rose between 1973 and 1988 but had declined by 2003.
The rise in the prevalence of asthmatic symptoms has continued since 1988. This appears to conflict with a reported recent decline, unless asthma prevalence peaked in the 1990s. The decline in exercise induced bronchoconstriction is probably attributable to better control of the disease as more children are now using inhaled corticosteroids as preventive treatment.
PMCID: PMC2104617  PMID: 16396947
asthma; children; epidemiology; wheeze
4.  Variability of antiepileptic medication taking behaviour in sudden unexplained death in epilepsy: hair analysis at autopsy 
Variable compliance with antiepileptic drugs (AEDs) is a potentially preventable cause of sudden unexplained death in epilepsy (SUDEP). Hair AED concentrations provide a retrospective insight into AED intake variability.
We compared hair AED concentration variability in patients with SUDEP (n = 16), non‐SUDEP epilepsy related deaths (n = 9), epilepsy outpatients (n = 31), and epilepsy inpatients (n = 38). AED concentrations were measured in 1 cm hair segments using high performance liquid chromatography. Individual patient hair AED concentration profiles were corrected for “washout” using linear regression analysis. The coefficient of variation (CV) of the corrected mean hair AED concentration provided an index of variability of an individual's AED taking behaviour. Hair sample numbers varied between subjects, and so weighted regression estimates of the CV were derived for each group.
The CV regression estimates for each group were: SUDEP 20.5% (standard error 1.9), non‐SUDEP 15.0% (3.9), outpatients 9.6% (1.4), and inpatients 6.2% (2.7). The SUDEP group therefore showed greater hair AED concentration variability than either the outpatient or the inpatient groups (p<0.0001).
Observed variability of hair AED concentrations, reflecting variable AED ingestion over time, is greater in patients dying from SUDEP than in either epilepsy outpatients or inpatients. SUDEP, at least in a proportion of cases, appears preventable.
PMCID: PMC2077527  PMID: 16543526
antiepileptic drugs; compliance; epilepsy; hair; SUDEP
5.  Are abused babies protected from further abuse? 
Archives of Disease in Childhood  2004;89(9):845-846.
PMCID: PMC1763201  PMID: 15321863
6.  Heterozygosity for the haemochromatosis mutation HFE C282Y is not a risk factor for angina 
Heart  2004;90(8):939-940.
PMCID: PMC1768358  PMID: 15253976
HFE C282Y; angina; haemochromastosis; iron
7.  Head injury and limb fracture in modern playgrounds 
Archives of Disease in Childhood  2004;89(2):152-153.
PMCID: PMC1719792  PMID: 14736633
8.  Are mobile speed cameras effective? A controlled before and after study 
Injury Prevention  2003;9(4):302-306.
Objective: To identify the most appropriate metric to determine the effectiveness of mobile speed cameras in reducing road traffic related injuries.
Design: Controlled before and after study which compares two methods for examining the local effectiveness of mobile speed cameras—a circular zone around the camera and a route based method to define exposure at various distances from sites.
Setting: South Wales, UK.
Subjects: Persons injured by road traffic before and after intervention.
Intervention: Use of mobile speed cameras at 101 sites.
Main outcome measures: Rate ratio of injurious crashes at intervention and control sites.
Results: Camera sites had lower than expected numbers of injurious crashes up to 300 metres using circles and up to 500 metres using routes. Routes methods indicated a larger effect than the circles method except in the 100 metres nearest sites. A 500 metre route method was used to investigate the effect within strata of time after intervention, time of day, speed limit, and type of road user injured. The number of injurious crashes after intervention was substantially reduced (rate ratio 0.49, 95% confidence interval 0.42 to 0.57) and sustained throughout two years after intervention. Significant decreases occurred in daytime and night time, on roads with speed limits of 30 and 60–70 miles/hour and for crashes that injured pedestrians, motorcycle users, and car occupants.
Conclusions: The route based method is the better method of measure effectiveness at distances up to 500 metres. This method demonstrates a 51% reduction in injurious crashes.
PMCID: PMC1731028  PMID: 14693888
9.  A scoring system for bruise patterns: a tool for identifying abuse 
Archives of Disease in Childhood  2002;86(5):330-333.
Aims: To determine whether abused and non-abused children differ in the extent and pattern of bruising, and whether any differences which exist are sufficiently great to develop a score to assist in the diagnosis of abuse.
Methods: Total length of bruising in 12 areas of the body was determined in 133 physically abused and 189 control children aged 1–14 years.
Results: Our method of recording bruises by site, maximum dimension, and shape was easy to use. There were clear differences between cases and controls in the total length of bruises. These differences were at their greatest in the head and neck and were less notable in the limbs. A scoring system was developed using logistic regression analysis using total lengths of bruising in five regions of the body. Good discrimination between the two sets of children was achieved using this score; by including a variable that indicates whether a bruise had a recognisable shape the discrimination could be made even better. Given a prior probability of abuse the score can be used to give posterior odds of abuse, given a particular bruising pattern.
Conclusions: The scoring system provides a measure that discriminates between abused and non-abused children, which should be straightforward to implement, though the results must be interpreted carefully. We do not see this score as replacing the complex qualitative analysis of the diagnosis of abuse. This clearly includes history as well as examination, but rather as the beginning of the development of an important aid in this process.
PMCID: PMC1751094  PMID: 11970921
10.  Social deprivation and the causes of stillbirth and infant mortality 
Archives of Disease in Childhood  2001;84(4):307-310.
AIMS—To investigate the relation between social deprivation and causes of stillbirth and infant mortality.
METHODS—Stillbirths and infant deaths in 6347 enumeration districts in Wales were linked with the Townsend score of social deprivation. In 1993-98 there were 211 072 live births, 1147 stillbirths, and 1223 infant deaths. Poisson regression analysis was used to estimate the magnitude of effect for associations between the Townsend score and categories of death by age and the causes of death. The relative risk of death between most and least deprived enumeration districts was derived.
RESULTS—Relative risk of combined stillbirth and infant death was 1.53 (95% CI 1.35 to 1.74) in the most deprived compared with the least deprived enumeration districts. The early neonatal mortality rate was not significantly associated with deprivation. Sudden infant death syndrome showed a 307% (95% CI 197% to 456%) increase in mortality across the range of deprivation. Deaths caused by specific conditions and infection were also associated with deprivation, but there was no evidence of a significant association with deaths caused by placental abruption, intrapartum asphyxia, and prematurity.
CONCLUSIONS—Collaborative public health action at national and local level to target resources in deprived communities and reduce these inequalities in child health is required. Early neonatal mortality rates and deaths from intrapartum asphyxia and prematurity are not significantly associated with deprivation and may be more appropriate quality of clinical care indicators than stillbirth, perinatal, and neonatal mortality rates.

PMCID: PMC1718731  PMID: 11259227
12.  Inflammatory bowel disease and predisposition to osteopenia 
Archives of Disease in Childhood  1997;76(4):325-329.
Accepted 13 December 1996

The prevalence of osteopenia in children with inflammatory bowel disease (IBD) is unknown. The effect of nutritional state, disease activity, and steroid therapy on bone mineral content (BMC) of whole body, lumbar spine, and left femoral neck measured by dual energy x ray absorptiometry in 32 children with IBD was assessed by comparison with 58 healthy local school children. Using the control data, a predicted BMC was calculated taking into account bone area, age, height, weight, and pubertal stage. The measured BMC in children with IBD was expressed as a percentage of this predicted value (% BMC). Mean (SD) % BMC was significantly reduced for the whole body and left femoral neck in the children with IBD (97.0 (4.5)% and 93.1 (12.0)% respectively, p<0.05). Of the children with IBD, 41% had a % BMC less than 1 SD below the mean for the whole body and 47% at the femoral neck. Reduction in % BMC was associated with steroid usage but not with the magnitude of steroid dose, disease activity, or biochemical markers of bone metabolism. In conclusion, osteopenia is relatively common in childhood IBD and may be partly related to the previous use of steroids.

PMCID: PMC1717165  PMID: 9166024
15.  Attitudes of general practitioners to caring for people with learning disability. 
BACKGROUND: The views of general practitioners on their increasing role in caring for people with learning disability in the community are not known. AIM: A study was carried out to assess the views of general practitioners with regard to providing routine care, organizing health promotion and specific health checks for people with learning disability and the role of specialists. METHOD: A postal questionnaire was sent to all 242 general practitioners in Gwent, south Wales. Participants had to mark their level of agreement with 20 attitude statements regarding learning disability. RESULTS: A total of 126 general practitioners (52%) responded. Respondents generally agreed that general practitioners were responsible for the medical care of people with learning disability. Respondents tended to be opposed to providing regular structured health promotion for people with learning disability, such as annual health checks and assessing hearing and eyesight. Specialist services were generally valued by respondents. CONCLUSION: General practitioners largely accepted their role as primary health care providers for people with learning disability. In contrast, their role as providers of health promotion for this patient group was not generally accepted. Further research into the appropriateness and opportunity costs of health screening for people with learning disability is needed.
PMCID: PMC1239537  PMID: 8855015

Results 1-16 (16)