Screening for health risks: A social science perspective

Health screening promises to reduce risks to individuals via probabilistic sifting of populations for medical conditions. The categorisation and selection of 'conditions' such as cardiovascular events, dementia and depression for screening itself requires prior interpretive labour which usually remains unexamined. Screening systems can take diverse organisational forms and varying relationships to health status, as when purported disease precursors, for example 'pre-cancerous' polyps, or supposed risk factors, such as high cholesterol themselves, become targets for screening. Screening at best yields small, although not necessarily unworthwhile, net population health gains. It also creates new risks, leaving some individuals worse-off than if they had been left alone. The difficulties associated with attempting to measure small net gains through randomised controlled trials are sometimes underestimated. Despite endemic doubts about its clinical utility, bibliometric analysis of published papers shows that responses to health risks are coming to be increasingly thought about in terms of screening. This shift is superimposed on a strengthening tendency to view health through the lens of risk. It merits further scrutiny as a societal phenomenon

Routine data linkage to identify and monitor diabetes in clozapine-treated patients with schizophrenia

No abstract available

Viewpoint – Pouring money down the drain: Can we break the habit by reconceiving wastes as resources?

As water-sector professionals re-discover the value in the 'waste' conveyed in 'waste'water, this Viewpoint argues that the theory of plural rationality (also known as Cultural Theory) may accelerate the switch from waste management to resource recovery. Accordingly, it extends the framing of plural rationality, from its traditional applications in matters of governance and social and economic analysis, to the beginnings of a set of plural schools of engineering thought. This sounds controversial. Indeed, we hope it is. For all too often ways to resolve water issues end up in the impasse of two deeply entrenched positions: the 'technocratic reductionism' of the 'quick engineering fix' to problem solving; and the 'participatory holism' of the 'local, socially sensitive, integrationist' approach. Plural rationality sees this is an impoverished duopoly. Our very strong preference is to find ways of promoting the creative interplay among plural (more than two), mutually opposed, contending ways of framing a problem and resolving it. This, we argue, should not only expand the portfolio of possible alternatives for technology-policy interventions, but also lead to the chosen alternative being preferable — in social, economic, and environmental terms — to what might otherwise have happened. Such solutions are called 'clumsy' in plural rationality theory. We use a synopsis of a case history of restoring water quality in the River Rhine in Europe, within a wider account of the sweep of resource recovery spanning two centuries (late 18th Century through early 21st Century), to illustrate how clumsiness works. This, however, does not extend to our elaborating our proposed set of plural schools of engineering thought beyond just its very beginnings. Our Viewpoint allows us merely to start framing the challenge of developing, and eventually applying, such a notion

The development of an approach to assess critical loads of acidity for woodland habitats in Great Britain

International audienceAlongside other countries that are signatories to the UNECE Convention Long Range Transboundary on Air Pollution, the UK is committed to reducing the impact of air pollution on the environment. To advise and guide this policy in relation to atmospheric emissions of sulphur and nitrogen, a critical load approach has been developed. To assess the potential impact of these pollutants on woodland habitats a steady state, simple mass balance model has been parameterised. For mineral soils, a Ca:Al ratio in soil solution has been used as the critical load indicator for potential damage. For peat and organic soils critical loads have been set according to a pH criterion. Together these approaches have been used with national datasets to examine the potential scale of acidification in woodland habitats across the UK. The results can be mapped to show the spatial variability in critical loads of the three principal woodland habitat types (managed coniferous, managed broadleaved/ mixed woodland and unmanaged woodland). The results suggest that there is a wide range of critical loads. The most sensitive (lowest) critical loads are associated with managed coniferous followed by unmanaged woodland on peat soils. Calculations indicate that at steady state, acid deposition inputs reported for 1995?1997 result in a large proportion of all the woodland habitats identified receiving deposition loads in excess of their critical load; i.e. critical loads are exceeded. These are discussed in relation to future modelled depositions for 2010. Whilst significant widespread negative impacts of such deposition on UK woodland habitats have not been reported, the work serves to illustrate that if acid deposition inputs were maintained and projected emissions reductions not achieved, the long-term sustainability of large areas of woodland in the UK could be compromised. Keywords: critical loads, acid deposition, acidification, woodland, simple mass balance model, sustainabilit

Hypertension in autosomal dominant polycystic kidney disease: a meta-analysis

CONTEXT: Autosomal dominant polycystic kidney disease (ADPKD) is a common disorder that can cause hypertension during childhood, but the true prevalence of hypertension during childhood is not known. OBJECTIVE: We undertook a systematic review and meta-analysis to determine the prevalence of hypertension in children with ADPKD. DATA SOURCES: Systematic review of articles published between 1980 and 2015 in MEDLINE and EMBASE. STUDY SELECTION: Studies selected by two authors independently if reporting data on prevalence of hypertension in children and young persons aged 15 children. Articles were excluded if inadequate diagnostic criteria for hypertension were used. Studies with selection bias were included but analysed separately. DATA EXTRACTION: Data extracted on prevalence of hypertension, proteinuria and reduced renal function using standardised form. Meta-analysis was performed to calculate weighted mean prevalence. RESULTS: 903 articles were retrieved from our search; 14 studies met the inclusion criteria: 1 prospective randomised controlled trial; 8 prospective observational studies; and 5 retrospective cross-sectional studies. From 928 children with clinically confirmed ADPKD, 20% (95% CI 15% to 27%) were hypertensive. The estimated prevalence of proteinuria in children with ADPKD is 20% (8 studies; 95% CI 9% to 40%) while reduced renal function occurred in 8% (5 studies; 95% CI 2% to 26%). LIMITATIONS: Studies showed a high degree of methodological heterogeneity (I(2)=73.4%, τ(2)=0.3408, p<0.0001). Most studies did not use ambulatory blood pressure (BP) monitoring to diagnose hypertension. CONCLUSIONS: In this meta-analysis we estimate 20% of children with ADPKD have hypertension. In the population, many children with ADPKD are not under regular follow-up and remain undiagnosed. We recommend that all children at risk of ADPKD have regular BP measurement

Zoster vaccination is associated with a reduction of zoster in elderly patients with chronic kidney disease.

BACKGROUND: Growing epidemiological evidence demonstrates increased zoster risks in people with chronic kidney disease (CKD). Study objectives were to determine zoster vaccine effectiveness in individuals with CKD in pragmatic use. METHODS: A population-based cohort study was undertaken in a 5% random sample of US Medicare from 2007 to 2009 involving 766 330 eligible individuals aged ≥65 years who were (29 785) and were not (736 545) exposed to the zoster vaccine. Incidence rates for zoster in vaccinated and unvaccinated individuals and hazard ratios for zoster comparing vaccinated with unvaccinated were determined for individuals with CKD. Time-updated Cox proportional hazards models were used, adjusting for relevant confounders. RESULTS: CKD was present in 183 762 (24%) of individuals (15% of vaccinees). Adjusted vaccine effectiveness [95% confidence intervals (CIs)] in individuals with CKD was 0.49 (0.36-0.65). The adjusted vaccine effectiveness in participants with both CKD and diabetes mellitus was 0.46 (95% CI 0.09-0.68). Vaccine effectiveness estimates were similar to those previously reported for the general population [vaccine effectiveness 0.48 (95% CI 0.39-0.56)]. CONCLUSIONS: Zoster vaccine is effective against incident zoster in older individuals with CKD. Extra efforts are warranted to increase vaccine uptake in individuals with CKD given the known low uptake in these higher risk individuals

The effects of H2SO4 and (NH4)2SO4 treatments on the chemistry of soil drainage water and pine seedlings in forest soil microcosms

International audienceAn experiment comparing effects of sulphuric acid and reduced N deposition on soil water quality and on chemical and physical growth indicators for forest ecosystems is described. Six H2SO4 and (NH4)2SO4 treatment loads, from 0 ? 44 and 0 ? 25 kmolc ha-1 yr-1, respectively, were applied to outdoor microcosms of Pinus sylvestris seedlings in 3 acid to intermediate upland soils (calc-silicate, quartzite and granite) for 2 years. Different soil types responded similarly to H2SO4 loads, resulting in decreased leachate pH, but differently to reduced N inputs. In microcosms of calc-silicate soil, nitrification of NH4 resulted in lower pH and higher cation leaching than in acid treatments. By contrast, in quartzite and granite soils, (NH4)2SO4 promoted direct cation leaching, although leachate pH increased. The results highlighted the importance of soil composition on the nature of the cations leached, the SO4 adsorption capacities and microbial N transformations. Greater seedling growth on calc-silicate soils under both treatment types was related to sustained nutrient availability. Reductions in foliar P and Mg with higher N treatments were observed for seedlings in the calc-silicate soil. There were few treatment effects on quartzite and granite microcosm tree seedlings since P limitation precluded seedling growth responses to treatments. Hence, any benefits of N deposition to seedlings on quartzite and granite soils appeared limited by availability of co-nutrients, exacerbated by rapid depletion of soil exchangeable base cations. Keywords: acidification, manipulation, nitrogen, ammonium, deposition, soil, drainage, pine, microcosms, fores

Phosphodiesterase Type 5 Inhibitors and Risk of Malignant Melanoma: Matched Cohort Study Using Primary Care Data from the UK Clinical Practice Research Datalink.

BACKGROUND: Laboratory evidence suggests that reduced phosphodiesterase type 5 (PDE5) expression increases the invasiveness of melanoma cells; hence, pharmacological inhibition of PDE5 could affect melanoma risk. Two major epidemiological studies have investigated this and come to differing conclusions. We therefore aimed to investigate whether PDE5 inhibitor use is associated with an increased risk of malignant melanoma, and whether any increase in risk is likely to represent a causal relationship. METHODS AND FINDINGS: We conducted a matched cohort study using primary care data from the UK Clinical Practice Research Datalink. All men initiating a PDE5 inhibitor and with no prior cancer diagnosis were identified and matched on age, diabetes status, and general practice to up to four unexposed controls. Ever use of a PDE5 inhibitor and time-updated cumulative number of PDE5 inhibitor prescriptions were investigated as exposures, and the primary outcome was malignant melanoma. Basal cell carcinoma, solar keratosis, and colorectal cancer were investigated as negative control outcomes to exclude bias. Hazard ratios (HRs) were estimated from Cox models stratified by matched set and adjusted for potential confounders. 145,104 men with ≥1 PDE5 inhibitor prescription, and 560,933 unexposed matched controls were included. In total, 1,315 incident malignant melanoma diagnoses were observed during 3.44 million person-years of follow-up (mean 4.9 y per person). After adjusting for potential confounders, there was weak evidence of a small positive association between PDE5 inhibitor use and melanoma risk (HR = 1.14, 95% CI 1.01-1.29, p = 0.04). A similar increase in risk was seen for the two negative control outcomes related to sun exposure (HR = 1.15, 95% CI 1.11-1.19, p < 0.001, for basal cell carcinoma; HR = 1.21, 95% CI 1.17-1.25, p < 0.001, for solar keratosis), but there was no increased risk for colorectal cancer (HR = 0.91, 95% CI 0.85-0.98, p = 0.01). There was no evidence that risk increased with number of prescriptions received (p-trend = 0.83). In a post hoc analysis, there was strong evidence that solar keratosis was associated with future PDE5 inhibitor use (odds ratio = 1.28, 95% CI 1.23-1.34, p < 0.001), suggesting that men with higher sun exposure were more likely to become PDE5 inhibitor users. However, a limitation of our study was that we did not have individual-level data on sun exposure, so we could not directly control for this in the primary analysis. CONCLUSIONS: Our results were not consistent with PDE5 inhibitors being causally associated with melanoma risk, and strongly suggest that observed risk increases are driven by greater sun exposure among patients exposed to a PDE5 inhibitor

Effectiveness of herpes zoster vaccination in an older United Kingdom population.

BACKGROUND: Vaccination against herpes zoster was introduced in the United Kingdom in 2013 for individuals aged 70 years, with a phased catch-up campaign for 71-79 year olds. Vaccine introduction has resulted in a marked fall in incident herpes zoster and in post-herpetic neuralgia (PHN), but formal evaluation of vaccine effectiveness is needed. METHODS: In a population-based cohort study of older individuals born between 1933 and 1946, we used linked UK anonymised primary care health records for the first three years of the vaccination programme (01/09/2013-31/08/2016) and multivariable Poisson regression to obtain incidence rates and vaccine effectiveness (VE) against zoster and PHN. RESULTS: Among 516,547 individuals, 21% were vaccinated. Incidence of zoster was 3.15/1000 person-years in vaccinees and 8.80/1000 person-years in unvaccinated individuals. After adjustment, VE was 64% (95%CI = 60-68%) against incident zoster and 81% (95%CI = 61-91%) against PHN, with very similar VE estimates in the routine and catch-up cohorts. VE against zoster was lower in those with a previous history of zoster: 47% (95%CI = 31-58%) versus 64% (95%CI = 60-68%) in those without previous zoster. There was evidence of waning VE over time, from 69% (95%CI = 65-74%) in the first year after vaccination to 45% (95%CI = 29-57%) by the third year. CONCLUSION: This first formal assessment of VE in the UK zoster vaccination programme demonstrates good effectiveness of zoster vaccine, and very good protection against PHN. The findings provide evidence that VE is similar across the age groups targeted for vaccination in the UK, and on duration of protection of the vaccine in public health use. The study provides key information for decision-makers about the future direction of UK zoster vaccination programme, indicating that the live zoster vaccine may be more cost-effective than estimated previously. It also supports efforts to communicate the benefits of zoster vaccination to address the declining coverage observed across the UK