Involvement of deprivation and environmental lead in neural tube defects: a matched case-control study

OBJECTIVE: To analyse the prevalence of neural tube defects in small geographical areas and seek to explain any spatial variations with reference to environmental lead and deprivation. SETTING: The Fylde of Lancashire in the north west of England. DESIGN: Cases were ascertained as part of a prospective survey of major congenital malformations in babies born in the Fylde to residents there between 1957 and 1981. A matched case-control analysis used infants with cardiovascular system, alimentary tract, and urinary system malformations as controls. Conditional logistic regression was used to assess the effects of more than 10 micrograms/l lead in drinking water and the Townsend deprivation score. RESULTS: The prevalence of neural tube defects in 1957-73 was higher in Blackpool, Fleetwood, and North Fylde, whereas the three control groups showed no significant spatial variation. In 1957-81 mothers living in electoral wards with either a higher proportion of houses with more than 10 micrograms/l lead in the water or a higher deprivation score had a greater risk of having a baby with a neural tube defect. For spina bifida and cranium bifidum alone, this was also true. For anencephaly, deprivation was less important although the effect of lead was still seen. In some neural tube defects, lead may act independently of other possible factors associated with deprivation. It seemed unlikely that lead levels changed significantly during the survey. The percentage of houses with 10 micrograms/l or more of lead in the water in 1984-5 was similar to that found in Great Britain 10 years previously. CONCLUSION: There is evidence to suggest that lead is one cause of neural tube defects, especially anencephaly. This could link the known preventive actions of hard water and folic acid. Calcium is a toxicological antagonist of lead. One cause of a deficiency of folic acid is impaired absorption secondary to zinc deficiency, which may be produced or exacerbated by lead.     

Variations in use of tertiary cardiac services in part of North-West England

We assess the extent to which the need for tertiary cardiac care is being met uniformly within two Health Authorities in North-West England. We analyse small-area data from 1993-1996 on standardised rates of investigation (angiography) and surgery (bypass grafts and angioplasty). Utilisation by electoral ward is shown to be related to material deprivation. Small areas in which the Asian population is high have significantly fewer angiograms and angioplasties than might be expected according to need, while there is some evidence that women do not receive the levels of bypass surgery that might be expected.     

Digging deep: using diary techniques to explore the place of health and well-being amongst older people

To date, solicited diaries have been relatively neglected as a social science research method. This is particularly true within the field of health research. Yet, these narrative approaches can provide invaluable insights into the health behaviours of individuals and how these are played out across time and space. To illustrate this, we draw on recent research in the north west of England that investigated the potential benefits of communal gardening as opposed to other social activities in maintaining the health and emotional well-being of older people. As part of a wider study using largely qualitative techniques, our analysis revealed that, contrary to the findings of earlier studies, diaries can be used effectively over relatively long periods of time and are equally effective in exploring health issues amongst both older men and women. With the benefit of good researcher support, we argue that diary techniques can offer some unique insights into the ongoing health routines and coping strategies of older people and can prove invaluable in uncovering those, often hidden, aspects of their daily lives and routines that impact on their health histories. Through the gathering of chronologically organised data about daily activities, diaries can act as both a record and reflection of the health experiences, activities and life-worlds inhabited by older people.     

Mapping the determinants of health inequalities in social space: can Bourdieu help us?

Considerable research effort has been devoted to describing and explaining, at a variety of spatial scales, geographical inequalities in health outcomes within the developed world. Following Bourdieu, we argue that structures of the social world may be revealed in different kinds of 'social' space. We outline the relational thinking that underlies these ideas. We then 'map', using correspondence analysis (on which Bourdieu himself drew), the structure of social space according to the differential availability of some forms of capital, across four study areas in north-west England. We use logistic regression analysis to explain variation in psychological morbidity (GHQ-score) and then portray the significant predictors of morbidity using multiple correspondence analysis. The area of residence of the survey respondents is used to associate them with particular locations in these social spaces.     

Beyond ‘beer,fags, egg and chips’? Exploring lay understandings of social inequalities in health

This paper seeks to contribute to the limited body of work that has directly explored lay understandings of the causes of health inequalities. Using both quantitative and qualitative methodology, the views of people living in contrasting socio-economic neighbourhoods are compared. The findings support previous research in suggesting that lay theories about causality in relation to health inequalities, like lay concepts of health and illness in general, are multi-factorial. The findings, however, also illustrate how the ways in which questions about health and illness are asked shape people's responses. In the survey reported on here people had no problem offering explanations for health inequalities and, in response to a question asking specifically about area differences in health experience, people living in disadvantaged areas 'constructed' explanations which included, but went beyond, individualistic factors to encompass structural explanations that gave prominence to aspects of 'place'. In contrast, within the context of in-depth interviews, people living in disadvantaged areas were reluctant to accept the existence of health inequalities highlighting the moral dilemmas such questions pose for people living in poor material circumstances. While resisting the notion of health inequalities, however, in in-depth interviews the same people provided vivid accounts of the way in which inequalities in material circumstances have an adverse impact upon health. The paper highlights ways in which different methodologies provide different and not necessarily complementary understandings of lay perspectives on the causes of inequalities in health.     

Place of death: analysis of cancer deaths in part of North West England

BACKGROUND: Relatively little work of a detailed geographical nature has been undertaken on the distribution of place of death. In particular, given evidence that most cancer patients would prefer to die at home there is a need to examine the extent to which this preference is met differentially from place to place. METHODS: Using data on cancer deaths for a single Health Authority in North West England we conducted both small area and individual analyses of place of death, using binomial and binary logistic regression models, respectively. RESULTS: Results from the small area analysis show that in more deprived areas cancer patients are more likely to die in hospital or hospice, and less likely to die at home, but that the effect disappears for home and hospice deaths once other factors are controlled for. At the individual level, the probability of death at home decreases among those living in deprived areas, whereas the probability of death in hospital increases as area deprivation increases. Age, gender, type of cancer, and proximity to hospital or hospice all have some effect on the probability of dying in a particular setting. CONCLUSION: There is significant place-to-place variation in place of death among cancer patients in part of North West England. However, studies of place of death among cancer patients need to consider the full range of settings and, if examining the impact of deprivation or social class, need to adjust for other factors, including proximity to different settings.     

Contacting your GP when the surgery is closed: issues of location and access

This paper examines spatial variation in the delivery of out of hours care through general practice, in two Health Authorities in northwest England. It demonstrates considerable variations in the type of care provided to patients in different parts of the region. These differences are not due primarily to either the geographical or socio-economic characteristics of the areas. Rather, the type of out of hours care delivered depends much more on variations in the structure and organization of service delivery. These factors, in turn, largely reflect the history of service development in each area and the ethos of individual general practitioners instrumental in establishing the service.     

The Dewey Monitor: Pulse Oximetry can Warn of Hypoxia in an Immersed Rebreather Diver in Multiple Scenarios

Annals of Biomedical Engineering - Divers who wish to prolong their time underwater while carrying less equipment often use devices called rebreathers, which recycle the gas expired after each...     

Spontaneous rupture of the spleen in initial presentation of Hodgkin's disease

A 46-year-old man presented with a four-week history of fevers, occasional chills, and a two-week history of sweats and poor appetite. He also complained of progressive weakness and lethargy. After initial evaluation, while awaiting further consultation, the patient developed rapidly progressing abdominal pain and light-headedness. He was moved immediately into the emergency treatment area. He was noted to have an acute abdomen and was taken to surgery. An enlarged Hodgkin's-infiltrated spleen with an actively bleeding hematoma was removed. The patient denied any history of trauma.