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1.  Ascertaining the size of the symptom iceberg in a UK-wide community-based survey 
Background
The symptom iceberg describes the phenomenon that most symptoms are managed in the community without people seeking professional health care. The size of the iceberg for many symptoms is unknown, as is their association with personal characteristics, including history of a chronic disease.
Aim
To ascertain the size of the symptom iceberg in the UK.
Design of study
A UK-wide community-based postal survey.
Setting
Urban and rural communities across the UK.
Method
A postal survey was sent to an age- and sex-stratified random sample of 2474 adults, aged 18–60 years, drawn from 20 practices around the UK. Questions were aimed at investigating adults' experiences of 25 different symptoms in the previous 2 weeks.
Results
The number of symptoms experienced by one individual in the previous 2 weeks ranged from 0 to 22 (mean 3.66). Of the symptoms examined, the three most common were: feeling tired/run down; headaches; and joint pain. Univariate analysis found symptom prevalence to be significantly associated with a wide range of participant characteristics. However, after adjustment, many of these associations no longer remained significant for a number of the symptoms. Presence of a chronic condition, age, and employment status were the three factors most commonly associated with the 2-week prevalence of symptoms. Reported symptom characteristics (severity, duration, interference, and time off work) varied little by sex or age.
Conclusion
Symptoms in the UK community are common. Symptom prevalence was associated with a number of participant characteristics, although the extent of this association was less than has been reported in previous research. This study provides an important current baseline prevalence of 25 symptoms in the community for those who do, and do not, have a chronic condition.
doi:10.3399/bjgp11X548910
PMCID: PMC3020067  PMID: 21401979
community-based; epidemiology; prevalence; signs and symptoms; symptom iceberg
2.  Impact of lifestyle in middle-aged women on mortality: evidence from the Royal College of General Practitioners' Oral Contraception Study 
Background
Although many individuals have multiple lifestyle risk factors, few studies have investigated the impact of lifestyle risk factor combinations among women.
Aim
To investigate the relationship between individual and combinations of lifestyle risk factors in middle-aged women with subsequent mortality, and to estimate the associated population attributable risks.
Design of study
Prospective cohort study.
Setting
Royal College of General Practitioners' (RCGP) Oral Contraception Study, UK.
Method
In 1994–1995, women remaining under follow-up in the RCGP Oral Contraception Study were sent a lifestyle survey, from which modifiable risk factors were identified: pack-years smoked, physical inactivity, never drinking versus consuming at least 7 units of alcohol weekly, and being underweight, overweight, or obese. The cohort was followed to December 2006 or death. Population attributable risks were calculated.
Results
Of 10 059 women studied, 896 died. Pack-years smoked (11–20 years: adjusted hazard ratio [HR] = 1.82, 95% confidence interval [CI] = 1.46 to 2.27; >20 years: adjusted HR = 2.34, 95% CI = 2.00 to 2.74); never drinking alcohol (adjusted HR = 1.66, 95% CI = 1.34 to 2.05); being underweight (adjusted = HR 1.66, 95% CI = 1.03 to 2.68); and physical inactivity (<15 hours/week: adjusted HR = 1.73, 95% CI = 1.46 to 2.04) were significantly associated with mortality compared with their respective reference group. Women with multiple lifestyle risk factors had higher mortality risks than those reporting one factor. The population attributable risk of the combination of smoking, physical inactivity, body mass index outside normal range, and alcohol (never drinking or excess intake) was 59% (95% CI = 31% to 78%).
Conclusion
Assuming a causal relationship between lifestyle and mortality, avoidance of four lifestyle risk factors would have prevented 60% of the deaths. The importance of avoiding smoking and undertaking physical inactivity during midlife should continue to be emphasised.
doi:10.3399/bjgp10X515052
PMCID: PMC2913736  PMID: 20822689
epidemiology; follow-up studies; lifestyle; mortality; women
3.  Effects of maternal and infant co-infections, and of maternal immunisation, on the infant response to BCG and tetanus immunisation 
Vaccine  2010;29(2-2):247-255.
Some vaccines show poor efficacy in tropical countries. Within a birth cohort in Uganda, we investigated factors that might influence responses to BCG and tetanus immunisation. Whole blood assay responses to crude culture filtrate proteins of Mycobacterium tuberculosis (cCFP)) and tetanus toxoid (TT) were examined among 1506 and 1433 one-year-olds, respectively. Maternal Mansonella perstans infection was associated with higher interleukin (IL)-10 responses to both immunogens but no reduction in gamma interferon (IFN-γ), IL-5 and IL-13 responses; other maternal helminth infections showed little effect. Tetanus immunisation during pregnancy was associated with higher infant responses to TT; maternal BCG scar (from past immunisation) with lower infant IL-5 and IL-13 responses to cCFP. IFN-γ, IL-5 and IL-13 to TT were reduced in HIV-exposed-uninfected infants; infant malaria and HIV were associated with lower IFN-γ, IL-5 and IL-13 responses to both immunogens. We conclude that maternal helminth infections are unlikely to explain poor vaccine efficacy in the tropics. Effects of maternal immunisation on infant responses to vaccines should be explored. Prevention of infant malaria and HIV could contribute to effectiveness of immunisation programmes.
doi:10.1016/j.vaccine.2010.10.047
PMCID: PMC3021124  PMID: 21040693
BCG; Tetanus; Immunisation
4.  Mortality among contraceptive pill users: cohort evidence from Royal College of General Practitioners’ Oral Contraception Study 
Objective To see if the mortality risk among women who have used oral contraceptives differs from that of never users.
Design Prospective cohort study started in 1968 with mortality data supplied by participating general practitioners, National Health Service central registries, or both.
Setting 1400 general practices throughout the United Kingdom.
Participants 46 112 women observed for up to 39 years, resulting in 378 006 woman years of observation among never users of oral contraception and 819 175 among ever users.
Main outcome measures Directly standardised adjusted relative risks between never and ever users for all cause and cause specific mortality.
Results 1747 deaths occurred in never users of oral contraception and 2864 in ever users. Compared with never users, ever users of oral contraception had a significantly lower rate of death from any cause (adjusted relative risk 0.88, 95% confidence interval 0.82 to 0.93). They also had significantly lower rates of death from all cancers; large bowel/rectum, uterine body, and ovarian cancer; main gynaecological cancers combined; all circulatory disease; ischaemic heart disease; and all other diseases. They had higher rates of violent deaths. No association between overall mortality and duration of oral contraceptive use was observed, although some disease specific relations were apparent. An increased relative risk of death from any cause between ever users and never users was observed in women aged under 45 years who had stopped using oral contraceptives 5-9 years previously but not in those with more distant use. The estimated absolute reduction in all cause mortality among ever users of oral contraception was 52 per 100 000 woman years.
Conclusion Oral contraception was not associated with an increased long term risk of death in this large UK cohort; indeed, a net benefit was apparent. The balance of risks and benefits, however, may vary globally, depending on patterns of oral contraception usage and background risk of disease.
doi:10.1136/bmj.c927
PMCID: PMC2837145  PMID: 20223876

Results 1-4 (4)