Ecological study of social fragmentation,poverty, and suicide

ObjectivesTo investigate the association between suicide and area based measures of deprivation and social fragmentation.DesignEcological study.Setting633 parliamentary constituencies of Great Britain as defined in 1991.ResultsMortality from suicide and all other causes increased with increasing Townsend deprivation score, social fragmentation score, and abstention from voting in all age and sex groups. Suicide mortality was most strongly related to social fragmentation, whereas deaths from other causes were more closely associated with Townsend score. Constituencies with absolute increases in social fragmentation and Townsend scores between 1981 and 1991 tended to have greater increases in suicide rates over the same period. The relation between change in social fragmentation and suicide was largely independent of Townsend score, whereas the association with Townsend score was generally reduced after adjustment for social fragmentation.ConclusionsSuicide rates are more strongly associated with measures of social fragmentation than with poverty at a constituency level.

Key messages

• Place of residence may affect health, and mortality from most common diseases tends to be higher in areas characterised by low socioeconomic position
• Research dating back over 100 years suggests that social fragmentation may influencesuicide
• In the 1980s and 1990s, parliamentary constituencies with high levels of social fragmentation had high rates of suicide, independent of deprivation
• Constituencies with the greatest increases in social fragmentation between 1981 and 1991 also had the greatest increases in suicide rates over the same period
• Any targeting of suicide prevention may be more effective if aimed at socially fragmented rather than deprived areas

     

Inequality in Diabetes-Related Hospital Admissions in England by Socioeconomic Deprivation and Ethnicity: Facility-Based Cross-Sectional Analysis

ObjectiveTo investigate the effect of social deprivation and ethnicity on inpatient admissions due to diabetes in England.DesignFacility-based cross-sectional analysis.SettingNational Health Service (NHS) trusts in England reporting inpatient admissions with better than 80% data reporting quality from 2010–2011 (355 facilities).ParticipantsNon-obstetric patients over 16 years old in all NHS facilities in England. The sample size after exclusions was 5,147,859 all-cause admissions.ResultsThere were 445,504 diabetes-related hospital admissions in England in 2010, giving a directly (age-sex) standardized rate of 1049.0 per 100,000 population (95% confidence interval (CI): 1046.0–1052.1). The relative risk of inpatient admission in the most deprived quintile was 2.08 times higher than that of the least deprived quintile (95% CI: 2.02–2.14), and the effect of deprivation varied across ethnicities. About 30.1% of patients admitted due to diabetes were readmitted at least once due to diabetes. South Asians showed 2.62 times (95% CI: 2.51 – 2.74) higher admission risk. Readmission risk increased with IMD among white British but not other ethnicities. South Asians showed slightly lower risk of readmission than white British (0.86, 95% CI: 0.80 – 0.94).ConclusionsMore deprived areas had higher rates of inpatient admissions and readmissions due to diabetes. South Asian British showed higher admission risk and lower readmission risk than white British. However, there was almost no difference by ethnicity in readmission due to diabetes. Higher rates of admission among deprived people may not necessarily reflect higher prevalence, but higher admission rates in south Asian British may be explained by their higher prevalence because their lower readmission risk suggests no inequality in primary care to prevent readmission. Better interventions in poorer areas, are needed to reduce these inequalities.     

Temporal changes in breast cancer incidence in South Asian women

BackgroundBreast cancer in the UK resident population of South Asian ethnicity has been lower than that in indigenous women. Leicester has a large South Asian population and a breast cancer unit with comprehensive data on diagnosed cancers. This study analysed the annual incidence of new breast cancer diagnoses in females from 1998 to 2009 to determine any changes in recent years.MethodsEthnicity was known in over 98% of cases. Population denominators were based on published figures for 2001 and 2011, projected back to 1998. Age-adjusted directly standardised incidence rates were determined by ethnicity and broken down by invasive status and screening classification. Incidence rates were analysed using logistic regression in order to identify statistically significant effects of age, ethnicity, deprivation and year of diagnosis. Interactions with invasive status and screening classification were also investigated.ResultsAt the start of the study period South Asian incidence was estimated to be 45% of that of the white population (p < 0.001); by the end of the period the difference was still significant (p = 0.022) but smaller, at 17%.ConclusionSouth Asians should no longer be considered at low risk of breast cancer.     

Ethnic differences in incidence of stroke: prospective study with stroke register

ObjectiveTo identify ethnic differences in the incidence of first ever stroke.DesignA prospective community stroke register (1995-6) with multiple notification sources. Pathological classification of stroke in all cases was based on brain imaging or necropsy data. Rates were standardised to European and world populations and adjusted for age, sex, and social class in multivariate analysis.SettingA multi-ethnic population of 234 533 in south London, of whom 21% are black.Results612 strokes were registered. The crude annual incidence rate was 1.3 strokes per 1000 population per year (95% confidence interval 1.20 to 1.41) and 1.25 per 1000 population per year (1.15 to 1.35) age adjusted to the standard European population. Incidence rates adjusted for age and sex were significantly higher in black compared with white people (P<0.0001), with an incidence rate ratio of 2.21 (1.77 to 2.76). In multivariable analysis increasing age (P<0.0001), male sex (P<0.003), black ethnic group (P<0.0001), and lower social class (P<0.0001) in people aged 35-64 were independently associated with an increased incidence of stroke.ConclusionsIncidence rates of stroke are higher in the black population; this is not explained by confounders such as social class, age, and sex. Ethnic differences in genetic, physiological, and behavioural risk factors for stroke require further elucidation to aid development of effective strategies for stroke prevention in multi-ethnic communities.

Key messages

• Incidence rates of first ever stroke adjusted for age and sex are twice as high in black people compared with white people
• This excess incidence cannot be accounted for by differences in social class in ages 35-64
• Black people tend to have their first stroke at a younger age than white people
• The excess incidence is found in all pathological types of stroke but is greatest for primary intracerebral haemorrhage
• There is no difference between ethnic groups in case fatality up to 6 months after stroke

     

Influence of maternal nutrition on outcome of pregnancy: prospective cohort study

ObjectiveTo investigate the relations of maternal diet and smoking during pregnancy to placental and birth weights at term.DesignProspective cohort study.SettingDistrict general hospital in the south of England.Participants693 pregnant nulliparous white women with singleton pregnancies who were selected from antenatal booking clinics with stratified random sampling.ResultsPlacental and birth weights were unrelated to the intake of any macronutrient. Early in pregnancy, vitamin C was the only micronutrient independently associated with birth weight after adjustment for maternal height and smoking. Each ln mg increase in vitamin C was associated with a 50.8 g (95% confidence interval 4.6 g to 97.0 g) increase in birth weight. Vitamin C, vitamin E, and folate were each associated with placental weight after adjustment for maternal characteristics. In simultaneous regression, however, vitamin C was the only nutrient predictive of placental weight: each ln mg increase in vitamin C was associated with a 3.2% (0.4 to 6.1) rise in placental weight. No nutrient late in pregnancy was associated with either placental or birth weight.ConclusionsConcern over the impact of maternal nutrition on the health of the infant has been premature. Maternal nutrition, at least in industrialised populations, seems to have only a small effect on placental and birth weights. Other possible determinants of fetal and placental growth should be investigated.

Key messages

• Placental and infant birth weights were not associated with the intake of any macronutrient early or later in pregnancy
• After adjustment for the effects of maternal height and smoking, only vitamin C independently predicted birth weight. The expected mean difference in birth weight for infants with mothers in the upper and lower thirds of intake was about 70 g
• Vitamin C was the only nutrient that independently predicted placental weight, but again this relation was of doubtful clinical significance
• Among relatively well nourished women in industrialised countries, maternal nutrition seems to have only a marginal impact on infant and placental size. Other causes of variation in the size of clinically normal infants should now be investigated

     

Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study

ObjectiveTo explore reasons for increased risk of hospital admission among south Asian patients with asthma.DesignQualitative interview study using modified critical incident technique and framework analysis.SettingNewham, east London, a deprived area with a large mixed south Asian population.Participants58 south Asian and white adults with asthma (49 admitted to hospital with asthma, 9 not admitted); 17 general practitioners; 5 accident and emergency doctors; 2 out of hours general practitioners; 1 asthma specialist nurse.ResultsSouth Asian and white patients admitted to hospital coped differently with asthma. South Asians described less confidence in controlling their asthma, were unfamiliar with the concept of preventive medication, and often expressed less confidence in their general practitioner. South Asians managed asthma exacerbations with family advocacy, without systematic changes in prophylaxis, and without systemic corticosteroids. Patients describing difficulty accessing primary care during asthma exacerbations were registered with practices with weak strategies for asthma care and were often south Asian. Patients with easy access described care suggesting partnerships with their general practitioner, had better confidence to control asthma, and were registered with practices with well developed asthma strategies that included policies for avoiding hospital admission.ConclusionsThe different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission in south Asian patients. Interventions that increase confidence to control asthma, confidence in the general practitioner, understanding of preventive treatment, and use of systemic corticosteroids in exacerbations may reduce hospital admissions. Development of more sophisticated asthma strategies by practices with better access and partnerships with patients may also achieve this.

What is already known on this topic

South Asian patients with asthma are at increased risk of hospital admission with asthma compared with white patientsNo consistent differences in severity or prevalence of asthma, prescribed drugs, or asthma education have been described, and interventions to reduce admission rates in Asian patients have met with variable success

What this study adds

Compared with white patients, south Asian patients admitted to hospital with asthma had less confidence to control asthma, were unfamiliar with the concept of preventive medication, and had less confidence in their general practitionersSouth Asian patients managed asthma attacks through family advocacy and without systematic changes in prophylaxis and without systemic corticosteroidsPatients reporting difficulty in accessing primary care during attacks were often south Asian     

Interactive effects of individual and neighborhood race and ethnicity on rates of high-grade cervical lesions

We estimated the main and interactive effects of individual race/ethnicity (black, Hispanic, white) and area race, ethnicity, and poverty (proportions of the female population black, Hispanic, and living below the federal poverty level at the census tract level, respectively) on rates of high-grade cervical lesions among young women. Using data from a statewide surveillance system during 2008–2011, we found a marginally significant interaction (P < 0.05) between individual race/ethnicity and area race, with black and Hispanic women living in areas with ≥20% of the female population black having elevated rates compared to those living in areas with <20% of the female population black. These findings indicate a possible synergistic effect between individual race/ethnicity and racial composition in neighborhoods on precancerous cervical lesions.     

Socioeconomic variation in incidence of epilepsy: prospective community based study in south east England

ObjectiveTo determine the incidence of epilepsy in a general practice population and its variation with socioeconomic deprivation.DesignProspective surveillance for new cases over an 18 or 24 month period.ParticipantsAll patients on practice registers categorised for deprivation with the Carstairs score of their postcode.Setting20 general practices in London and south east England.Results190 new cases of epilepsy were identified during 369 283 person years of observation (crude incidence 51.5 (95% confidence interval 44.4 to 59.3) per 100 000 per year). The incidence was 190 (138 to 262) per 100 000 in children aged 0-4 years, 30.8 (21.3 to 44.6) in those aged 45-64 years, and 58.7 (42.5 to 81.0) in those aged ⩾65 years. There was no apparent difference in incidence between males and females. The incidence showed a strong association with socioeconomic deprivation, the age and sex adjusted incidence in the most deprived fifth of the study population being 2.33 (1.46 to 3.72) times that in the least deprived fifth (P=0.001 for trend across fifths). Adjustment for area (London v outside London) weakened the association with deprivation (rate ratio 1.62 (0.91 to 2.88), P=0.12 for trend).ConclusionsThe incidence of epilepsy seems to increase with socioeconomic deprivation, though the association may be confounded by other factors.

What is already known on this topic

Epilepsy is associated with a wide range of markers of social and economic disadvantageA small number of epidemiological studies have confirmed this association but have not established the direction of causality

What this study adds

The incidence of epilepsy, adjusted for age and sex, in the most deprived fifth of the study population was 2.3 times that in the least deprived fifthSocioeconomic deprivation is an important risk factor for the development of epilepsy, though the results may partly reflect differences in incidence within and outside London     

Transgressing community: the case of Muslims in a twenty-first-century British city

Abstract

This paper draws on ethnographic research carried out in Birmingham, UK – a city significant for its sizeable Muslim population and its iconic role in the history of minority ethnic settlement in Britain – to consider how associations of place and ethnicity work in different ways to inform ideas about ‘Muslim community’ in twenty-first-century Britain. The paper charts happenings around a local event in an area of majority Asian settlement and how representations of the area as a place of Muslim community were used to implicate it in the ‘war on terror’. The paper goes on to show how this sensibility is disrupted by Muslims themselves through alternative engagements with space and ethnicity. The paper argues that these offer a ground for making Muslim community in ways that actively engage with histories and patterns of ethnic settlement in the city rather than being determined by them.     

Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them as they retire?

ObjectivesTo determine the number and geographical distribution of general practitioners in the NHS who qualified medically in South Asia and to project their numbers as they retire.DesignRetrospective analysis of yearly data and projection of future trends.SettingEngland and Wales.SubjectsGeneral practitioners who qualified medically in the countries of Bangladesh, India, Pakistan, and Sri Lanka and who were practising in the NHS on 1 October 1992.Results4192 of 25 333 (16.5%) of all unrestricted general practitioners practising full time on 1 October 1992 qualified in South Asian medical schools. The proportion varied by health authority from 0.007% to 56.5%. Roughly two thirds who were practising in 1992 will have retired by 2007; in some health authorities this will represent a loss of one in four general practitioners. The practices that these doctors will leave seem to be in relatively deprived areas as measured by deprivation payments and a health authority measure of population need.ConclusionMany general practitioners who qualified in South Asian medical schools will retire within the next decade. The impact will vary greatly by health authority. Those health authorities with the greatest number of such doctors are in some of the most deprived areas in the United Kingdom and have experienced the most difficulty in filling vacancies. Various responses will be required by workforce planners to mitigate the impact of these retirements.

Key messages

• Currently, one in six general practitioners practising full time in the NHS qualified medically in a South Asian medical school; two thirds are likely to retire by 2007
• It is unlikely that doctors who qualify in South Asia will be a source of general practice recruitment in the future
• The posts from which South Asian qualifiers are retiring may be more difficult to fill because they are often in practices in areas of higher need
• There is extreme variation in the proportion of total general practitioners who are South Asian qualifiers; flexibility for policy responses should be maintained

     

Population based study of social and productive activities as predictors of survival among elderly Americans

ObjectivesTo examine any association between social, productive, and physical activity and 13 year survival in older people. DesignProspective cohort study with annual mortality follow up. Activity and other measures were assessed by structured interviews at baseline in the participants’ homes. Proportional hazards models were used to model survival from time of initial interview.SettingCity of New Haven, Connecticut, United States.Participants2761 men and women from a random population sample of 2812 people aged 65 and older.ResultsAll three types of activity were independently associated with survival after age, sex, race/ethnicity, marital status, income, body mass index, smoking, functional disability, and history of cancer, diabetes, stroke, and myocardial infarction were controlled for.ConclusionsSocial and productive activities that involve little or no enhancement of fitness lower the risk of all cause mortality as much as fitness activities do. This suggests that in addition to increased cardiopulmonary fitness, activity may confer survival benefits through psychosocial pathways. Social and productive activities that require less physical exertion may complement exercise programmes and may constitute alternative interventions for frail elderly people.

Key messages

• Little is known about predictors of survival among elderly people
• Physical activity is clearly good for health, but the potential benefits of social activities have not been studied
• Social and productive activities are as effective as fitness activities in lowering the risk of death
• Enhanced social activities may help to increase the quality and length of life

     

The ghost of Christmas past: health effects of poverty in London in 1896 and 1991

ObjectivesTo compare the extent to which late 20th century patterns of mortality in London are predicted by contemporary patterns of poverty and by late 19th century patterns of poverty. To test the hypothesis that the pattern of mortality from causes known to be related to deprivation in early life can be better predicted by the distribution of poverty in the late 19th century than by that in the late 20th century.DesignData from Charles Booth''s survey of inner London in 1896 were digitised and matched to contemporary local government wards. Ward level indices of relative poverty were derived from Booth''s survey and the 1991 UK census of population. All deaths which took place within the surveyed area between 1991 and 1995 were identified and assigned to contemporary local government wards. Standardised mortality ratios for various causes of death were calculated for each ward for all ages, under age 65, and over age 65. Simple correlation and partial correlation analysis were used to estimate the contribution of the indices of poverty from 1896 and 1991 in predicting ward level mortality ratios in the early 1990s.SettingInner London.ResultsFor many causes of death in London, measures of deprivation made around 1896 and 1991 both contributed strongly to predicting the current spatial distribution. Contemporary mortality from diseases which are known to be related to deprivation in early life (stomach cancer, stroke, lung cancer) is predicted more strongly by the distribution of poverty in 1896 than that in 1991. In addition, all cause mortality among people aged over 65 was slightly more strongly related to the geography of poverty in the late 19th century than to its contemporary distribution.ConclusionsContemporary patterns of some diseases have their roots in the past. The fundamental relation between spatial patterns of social deprivation and spatial patterns of mortality is so robust that a century of change in inner London has failed to disrupt it.     

Social determinants of the changing tuberculosis prevalence in Việt Nam: Analysis of population-level cross-sectional studies

BackgroundAn ecological relationship between economic development and reduction in tuberculosis prevalence has been observed. Between 2007 and 2017, Việt Nam experienced rapid economic development with equitable distribution of resources and a 37% reduction in tuberculosis prevalence. Analysing consecutive prevalence surveys, we examined how the reduction in tuberculosis (and subclinical tuberculosis) prevalence was concentrated between socioeconomic groups.Methods and findingsWe combined data from 2 nationally representative Việt Nam tuberculosis prevalence surveys with provincial-level measures of poverty. Data from 94,156 (2007) and 61,763 (2017) individuals were included. Of people with microbiologically confirmed tuberculosis, 21.6% (47/218) in 2007 and 29.0% (36/124) in 2017 had subclinical disease. We constructed an asset index using principal component analysis of consumption data. An illness concentration index was estimated to measure socioeconomic position inequality in tuberculosis prevalence. The illness concentration index changed from −0.10 (95% CI −0.08, −0.16; p = 0.003) in 2007 to 0.07 (95% CI 0.06, 0.18; p = 0.158) in 2017, indicating that tuberculosis was concentrated among the poorest households in 2007, with a shift towards more equal distribution between rich and poor households in 2017. This finding was similar for subclinical tuberculosis. We fitted multilevel models to investigate relationships between change in tuberculosis prevalence, individual risks, household socioeconomic position, and neighbourhood poverty. Controlling for provincial poverty level reduced the difference in prevalence, suggesting that changes in neighbourhood poverty contribute to the explanation of change in tuberculosis prevalence. A limitation of our study is that while tuberculosis prevalence surveys are valuable for understanding socioeconomic differences in tuberculosis prevalence in countries, given that tuberculosis is a relatively rare disease in the population studied, there is limited power to explore socioeconomic drivers. However, combining repeated cross-sectional surveys with provincial deprivation estimates during a period of remarkable economic growth provides valuable insights into the dynamics of the relationship between tuberculosis and economic development in Việt Nam.ConclusionsWe found that with equitable economic growth and a reduction in tuberculosis burden, tuberculosis became less concentrated among the poor in Việt Nam.

Nicola Foster and colleagues examine social and economic determinants of the changing tuberculosis prevalence in Việt Nam.     

Ethnic differences in guideline-indicated statin initiation for people with type 2 diabetes in UK primary care, 2006–2019: A cohort study

BackgroundType 2 diabetes is 2–3 times more prevalent in people of South Asian and African/African Caribbean ethnicity than people of European ethnicity living in the UK. The former 2 groups also experience excess atherosclerotic cardiovascular disease (ASCVD) complications of diabetes. We aimed to study ethnic differences in statin initiation, a cornerstone of ASCVD primary prevention, for people with type 2 diabetes.Methods and findingsObservational cohort study of UK primary care records, from 1 January 2006 to 30 June 2019. Data were studied from 27,511 (88%) people of European ethnicity, 2,386 (8%) people of South Asian ethnicity, and 1,142 (4%) people of African/African Caribbean ethnicity with incident type 2 diabetes, no previous ASCVD, and statin use indicated by guidelines. Statin initiation rates were contrasted by ethnicity, and the number of ASCVD events that could be prevented by equalising prescribing rates across ethnic groups was estimated. Median time to statin initiation was 79, 109, and 84 days for people of European, South Asian, and African/African Caribbean ethnicity, respectively. People of African/African Caribbean ethnicity were a third less likely to receive guideline-indicated statins than European people (n/N [%]: 605/1,142 [53%] and 18,803/27,511 [68%], respectively; age- and gender-adjusted HR 0.67 [95% CI 0.60 to 0.76], p < 0.001). The HR attenuated marginally in a model adjusting for total cholesterol/high-density lipoprotein cholesterol ratio (0.77 [95% CI 0.69 to 0.85], p < 0.001), with no further diminution when deprivation, ASCVD risk factors, comorbidity, polypharmacy, and healthcare usage were accounted for (fully adjusted HR 0.76 [95% CI 0.68, 0.85], p < 0.001). People of South Asian ethnicity were 10% less likely to receive a statin than European people (1,489/2,386 [62%] and 18,803/27,511 [68%], respectively; fully adjusted HR 0.91 [95% CI 0.85 to 0.98], p = 0.008, adjusting for all covariates). We estimated that up to 12,600 ASCVD events could be prevented over the lifetimes of people currently affected by type 2 diabetes in the UK by equalising statin prescribing across ethnic groups. Limitations included incompleteness of recording of routinely collected data.ConclusionsIn this study we observed that people of African/African Caribbean ethnicity with type 2 diabetes were substantially less likely, and people of South Asian ethnicity marginally less likely, to receive guideline-indicated statins than people of European ethnicity, even after accounting for sociodemographics, healthcare usage, ASCVD risk factors, and comorbidity. Underuse of statins in people of African/African Caribbean or South Asian ethnicity with type 2 diabetes is a missed opportunity to prevent cardiovascular events.

In a retrospective cohort study, Sophie Eastwood and colleagues investigate the association between ethnicity and statin initiation for people with type 2 diabetes in UK.     

Coeliac disease in primary care: case finding study

ObjectivesTo provide evidence of underdiagnosis of coeliac disease and to describe the main presenting symptoms of coeliac disease in primary care.DesignCase finding in a primary care setting by testing for coeliac disease by using the endomysial antibody test.SettingNine surgeries in and around a market town in central England, serving a population of 70 000.ParticipantsFirst 1000 patients screened from October 1996 to October 1997.ResultsThe 30 patients (out of 1000 samples) with positive results on the endomysial antibody test all had histological confirmation on small intestine biopsy. The commonest mode of presentation (15/30) was anaemia of varying severity. Most patients (25/30) presented with non-gastrointestinal symptoms. Specificity of the endomysial antibody test was 30/30.ConclusionsUnderdiagnosis and misdiagnosis of coeliac disease are common in general practice and often result in protracted and unnecessary morbidity. Serological screening in primary care will uncover a large proportion of patients with this condition and should be made widely available and publicised. Coeliac disease should be considered in patients who have anaemia or are tired all the time, especially when there is a family history of the disease.

Key messages

• General practitioners currently see many people with undiagnosed coeliac disease
• The most likely presentation is a combination of microcytic anaemia, past or present, a family history of the disease, and feeling tired all the time
• Estimations of endomysial antibody and IgA are reliable diagnostic tools
• The prevalence of coeliac disease in Britain is higher than the accepted figure of 1:1000 population
• Increased awareness of the extra intestinal manifestations of coeliac disease, coupled with a low threshold for serological testing, will uncover a large portion of undiagnosed coeliac disease

     

Poverty and blindness in Pakistan: results from the Pakistan national blindness and visual impairment survey

Objective To explore the association between blindness and deprivation in a nationally representative sample of adults in Pakistan.Design Cross sectional population based survey.Setting 221 rural and urban clusters selected randomly throughout Pakistan.Participants Nationally representative sample of 16 507 adults aged 30 or above (95.3% response rate).Main outcome measures Associations between visual impairment and poverty assessed by a cluster level deprivation index and a household level poverty indicator; prevalence and causes of blindness; measures of the rate of uptake and quality of eye care services.Results 561 blind participants (<3/60 in the better eye) were identified during the survey. Clusters in urban Sindh province were the most affluent, whereas rural areas in Balochistan were the poorest. The prevalence of blindness in adults living in affluent clusters was 2.2%, compared with 3.7% in medium clusters and 3.9% in poor clusters (P<0.001 for affluent v poor). The highest prevalence of blindness was found in rural Balochistan (5.2%). The prevalence of total blindness (bilateral no light perception) was more than three times higher in poor clusters than in affluent clusters (0.24% v 0.07%, P<0.001). The prevalences of blindness caused by cataract, glaucoma, and corneal opacity were lower in affluent clusters and households. Reflecting access to eye care services, cataract surgical coverage was higher in affluent clusters (80.6%) than in medium (76.8%) and poor areas (75.1%). Intraocular lens implantation rates were significantly lower in participants from poorer households. 10.2% of adults living in affluent clusters presented to the examination station wearing spectacles, compared with 6.7% in medium clusters and 4.4% in poor cluster areas. Spectacle coverage in affluent areas was more than double that in poor clusters (23.5% v 11.1%, P<0.001).Conclusion Blindness is associated with poverty in Pakistan; lower access to eye care services was one contributory factor. To reduce blindness, strategies targeting poor people will be needed. These interventions may have an impact on deprivation in Pakistan.     

Application of Framingham risk estimates to ethnic minorities in United Kingdom and implications for primary prevention of heart disease in general practice: cross sectional population based study

ObjectiveTo compare the 10 year risk of coronary heart disease (CHD), stroke, and combined cardiovascular disease (CVD) estimated from the Framingham equations.DesignPopulation based cross sectional survey.SettingNine general practices in south London.Population1386 men and women, age 40-59 years, with no history of CVD (475 white people, 447 south Asian people, and 464 people of African origin), and a subgroup of 1069 without known diabetes, left ventricular hypertrophy, peripheral vascular disease, renal impairment, or target organ damage.ResultsPeople of African origin had the lowest 10 year risk estimate of CHD adjusted for age and sex (7.0%, 95% confidence interval 6.5 to 7.5) compared with white people (8.8%, 8.2 to 9.5) and south Asians (9.2%, 8.6 to 9.9) and the highest estimated risk of stroke (1.7% (1.5 to 1.9), 1.4% (1.3 to 1.6), 1.6% (1.5 to 1.8), respectively). The estimate risk of combined CVD, however, was highest in south Asians (12.5%, 11.6 to 13.4) compared with white people (11.9%, 11.0 to 12.7) and people of African origin (10.5%, 9.7 to 11.2). In the subgroup of 1069, the probability that a risk of CHD ⩾15% would identify risk of combined CVD ⩾20% was 91% in white people and 81% in both south Asians and people of African origin. The use of thresholds for risk of CHD of 12% in south Asians and 10% in people of African origin would increase the probability of identifying those at risk to 100% and 97%, respectively.ConclusionPrimary care doctors should use a lower threshold of CHD risk when treating mild uncomplicated hypertension in people of African or south Asian origin.     

Determinants of Circulating 25-Hydroxyvitamin D and bone Mineral Density in Young Physicians

ObjectiveTo examine determinants of serum 25-hydroxyvitamin D [25(OH)D] and bone mineral density (BMD) in young physicians, a group not well studied previously.MethodsWe analyzed data from a questionnaire completed by young physicians as well as results of serum 25(OH)D, serum parathyroid hormone, and BMD measurements.ResultsAmong 104 study subjects, 42% were white, 46% were Asian, 12% were “other” (10 Hispanic and 2 African American subjects), and 75% were women. The mean age and body mass index (BMI) were 28.1 years and 23.0 kg/m², respectively. White subjects had a higher mean serum 25(OH)D level (27.3 ng/mL) than did Asian subjects (15.9 ng/mL) and other subjects (22.3 ng/mL) (P < .0001). White subjects tended to have higher Z-scores than Asian subjects and other subjects for the hip (P = .06), trochanter (P = .08), and lumbar spine (P = .08). The serum 25(OH)D level was negatively associated with serum parathyroid hormone (r = -0.44; P < .01) but not with BMD. The prevalence of vitamin D insufficiency [serum 25(OH)D < 30 ng/mL, 77% for the entire group] was higher (P < .01) in Asian subjects (93%) than in white subjects (61%) and other subjects (73%). Significant determinants of serum 25(OH)D included age, ethnicity, exposure to sunlight, use of vitamin D supplements, and family history of osteoporosis (P < .05 for all), and together with sex, calcium supplements, exercise, and BMI, these factors explained 49% of serum 25(OH)D level variability. Significant determinants of low BMD (osteopenia plus osteoporosis, prevalence 37.5%) included sex (P = .002) and BMI (P < .0001) but not serum 25(OH)D; Asian ethnicity reached borderline significance (P = .088). Age, sex, ethnicity, smoking, and BMI explained 20% to 30% of the Z-score variations.ConclusionIn young physicians with a healthful lifestyle, determinants of low serum 25(OH)D and BMD included modifiable risk factors. Vitamin D insufficiency and low BMD could be important contributors to future osteoporotic fractures in this population. (Endocr Pract. 2012;18:219-226)     

Impact of climatic variation on populations of pine processionary moth Thaumetopoea pityocampa in a core area of its distribution

• 1 There is growing appreciation of climatic effects on insect population dynamics at the margins of distribution limits. Climatic effects might be less important and/or involve different drivers and processes near the centre of distributions.
• 2 We evaluated the effects of interannual variation in temperatures, radiation and precipitation on populations of pine processionary moth Thaumetopoea pityocampa in Central–South Portugal, a low altitude area with a relatively mild Mediterranean climate near the centre of the north–south range of the species.
• 3 We tested for effects of climate on mortality of young larvae, growth rates, final larval mass and fecundity.
• 4 Results indicated high mortality of early instars associated with low minimum and maximum daily temperatures and low precipitation. Low minimum temperatures were further associated with high parasitism by the larval parasitoid Phryxe caudata (Rondani) (Diptera, Tachinidae). Furthermore, larval growth rates were higher with high solar radiation during December and January, which was itself negatively related to precipitation and air temperature. Slow larval growth rates led to lower final mass at pupation in the spring, and smaller egg masses and smaller initial colony sizes during the next autumn.
• 5 Thus climatic factors, and temperature in particular, apparently contributed to population dynamics of T. pityocampa in the core of its distribution, as well as at its northern limits. The most specific climatic parameters of importance, however, and the connections between climate, physiology and insect demographics in the core area were clearly different from northern areas.

     

Past and present distribution of the North African–Asian lion subgroup: a review

• 1 The North African–Asian lion subgroup, which is composed of two subspecies, the Barbary lion, Panthera leo leo, and the Asian lion, P. l. persica, was nearly exterminated during the last centuries. The remaining free‐ranging population of Asian lions consists of c. 350 animals in India. The Barbary lion subsists as captive animals in zoos or circuses, all of which originate from the Moroccan Royal Collection. There have been multiple genetic hybridizations with sub‐Saharan lions.
• 2 Several incomplete distribution maps of the past occupation of lions were proposed in the literature. I examine the distribution of these lions with the help of a larger database, extracted from zoological, archaeological and historical reports. Some records are however not completely reliable. Data were collected over a long period of time (from the Epipaleolithic to the modern times) in Eurasia, North Africa and the Arabian Peninsula.
• 3 Dispersal took place in latitudes as far south as 15°N (Yemen) to 18°N (Mali; Chad) and as far north as 45–48°N (Bulgaria); and to longitudes as far west as 5.57°W (Morocco) and as far east as 84°E (India). Expansion was probably constrained by natural ecological factors northwards (higher seasonality, harsher winters) and southwards (extension of aridity after 3000 BP). At latitudes between 40 and 43°N, lions seem to have become a permanent part of the fauna during 6–8 millennia.
• 4 Lions were brought to extinction by humans through hunting, captures for exhibition in zoos and by the associated natural fragmentation of wild populations. The dates at which extinction took place varied greatly according to the geographical sites: 3000 BC for temperate Europe; 1000 BC in the south of Greece; 12–13th century in the Near East, Arabian Peninsula, Trans‐Caucasia or north of Afghanistan; and 19–20th century for North Africa, the Middle East and India.