Background - Heart failure (HF) is a major disease with high mortality despite many therapeutic options. Little is known on the epidemiology and prognosis of HF in Leicestershire, which includes a large proportion of South Asians. Hypotheses - The epidemiology of heart failure in Leicestershire is different to that of published national and international cohorts. South Asians have more severe coronary disease compared to Caucasians, and will have more severe HF and increased mortality. Simple clinical data on admission can be used to predict survival. Methods - Matched cohort design with retrospective data collection on 528 patients - 176 South Asians age and sex matched to 352 Caucasians admitted with a validated new diagnosis of HF between April 1998 and March 2001. Cox proportional hazards modelling to test variables associated with outcome and develop a prognostic model. Results - The majority of HF is secondary to ischaemic heart disease or hypertension. Two-thirds of patients undergo echocardiography. Only 60% of patients are discharged with an ACE inhibitor, just 17% receive a beta blocker. 11% died during admission, and by the end of follow up 45% had died. South Asians have higher rates of hypertension and diabetes and present earlier with less severe impairment of systolic function. South Asians have lower mortality - odds ratio of 0.71 (95% CI 0.53 – 0.96, p=0.02) compared to Caucasians. A prognostic score based on five simple variables stratifies patients into low or high risk with a sensitivity 78% of and specificity of 57%. Conclusion - The epidemiology of patients admitted with HF in Leicestershire is not significantly different to published cohorts. South Asian patients present with less severe ventricular dysfunction and survive for longer with no differences in the investigations or treatment given compared to Caucasians. A pragmatic risk prediction model using easily available clinical variables can identify high risk individuals.

Heart failure is a growing cause of morbidity in an ageing population. Despite increasing use of clinically proven therapies its overall prognosis remains poor, and our knowledge of outcomes in some patient groups is still very limited. Most of existing evidence is based on clinical trial populations, which often exclude ethnic minorities, women or sicker elderly patients. UK’s South Asian population has been shown to suffer from particularly high rates of cardiovascular disease but data on their clinical outcomes have been lacking. This study aimed to evaluate heart failure outcomes in an unselected population and to test a hypothesis of poorer prognosis among South Asians. Using population-based historical cohort design, this thesis evaluates the longterm survival in a large unselected cohort of 5,789 patients with an initial heart failure admission between 1998 and 2001, on a background of the overall trends in heart failure hospitalisation and fatality between 1993 and 2001. The relative risks linked to main patient groups are estimated using logistic regression and survival modelling and a prognostic model is proposed. The results show a plateau in the rates of hospitalisation in the late 1990s. Despite a 50% improvement in survival between 1993 and 2001, outcomes remain poor with a 40% one year fatality. South Asian patients tend to be younger at first admission (by 8 years) and with higher rates of comorbidity, however, their survival appears to be similar to other groups. The developed models indicate high prognostic value of concomitant conditions, such as stroke and renal failure, but only a moderate effect of diabetes. This is the first large study to describe heart failure outcomes in a multi-ethnic contemporary population with an almost complete follow-up of patients. On a background of higher cardiovascular risk, younger age at first admission and higher rate of hospitalisation among South Asians, their clinical outcomes appear to be similar to white patients. Despite the clear limitations inherent in routine data sources, this study shows clear benefits in developing routine risk assessment models for public health research and health care evaluation.

Executive Summary: Type 2 Diabetes Mellitus (T2DM) is a chronic multi factorial disorder linked to obesity that is associated with increased morbidity and mortality. T2DM poses a major public health problem with the prevalence expecting to reach 4 million in the United Kingdom by the year 2025. Upto 50% of people may have established complications at the time of diagnosis of T2DM. However, T2DM is preceded by a latent phase of Prediabetes (PDM) which provides a window of opportunity for primary prevention. PDM is often known as impaired glucose metabolism (IGM) or impaired glucose regulation (IGR). PDM is a collective term for impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and those with combined IFG and IGT. The reported prevalence of these conditions is variable throughout the world. This thesis seeks to address key questions on identification of IGR, determine factors predicting progression to T2DM and thus propose prevention strategies in a mixed ethnic population in the UK using data from the ADDITION Leicester and ADDITION PLUS studies. ADDITION Leicester is a sub study of the multinational multi centre study-ADDITION Europe. ADDITION study is a randomised controlled trial evaluating the benefits of a multi factorial cardiovascular disease risk factor intervention in a cohort of patients with screen detected T2DM. The prevalence of PDM was 16% in the study population with IFG, IGT and combined IFG and IGT being 2.8%, 11% and 2.2% respectively. People of South Asian (SA) origin have a significantly higher adjusted prevalence of PDM compared to those of White European (WE) origin (OR: 1.57; 95% CI: 1.24 to 1.98). A risk score tailored to the local population (Leicester risk assessment score) was robust in identifying those at risk of developing T2DM and PDM as well those progressing from PDM to T2DM at 12 months. Subjects with PDM have a unique phenotype placing their cardiovascular disease (CVD) risks between T2DM and normal glucose tolerance. Novel markers of CVD such as Interleukin 6, Adiponectin, Leptin and C-reactive protein are also raised in those with PDM compared to normal. The risk of progression from PDM to T2DM at 12 months is higher for SA compared to WE (OR: 3.09, 95% CI- 1.58 to 6.02). The diabetes progression rate (cases/100 person-years) for IFG, IGT and combined IFG and IGT were 5.51, 3.13 and 14.46 respectively. The risk of progression for SA people occurs at a lower cut off for BMI and waist circumference. A meta analysis of 13,314 patients from 22 studies with PDM revealed a pooled progression rate (cases per 100 person-years) (95% CI) to be 6.29 (4.29- 9.22), 7.48 (5.00-11.18) and 7.86 (5.51- 11.20) for people with IFG, IGT and combined IFG+IGT respectively. Presence of CVD, central obesity measured both by waist circumference and BMI, triglycerides, fasting plasma glucose (FPG) and HbA1c significantly predict progression to T2DM at 12 months. Presence of metabolic syndrome with more than 2 additional criteria significantly predicts progression to T2DM. In terms of adipocytokines, TNFα is the only marker, after adjusting for confounders that is significantly associated with progression to T2DM. In terms of follow up of this cohort, we propose a two step method using FPG >6 mmol/L as a screening tool to identify people who can subsequently be screened using an OGTT, reducing the number of OGTT needed to 23.5%. Our findings suggest using a structured screening programme with a risk score used in parallel to the recommended opportunistic screening for T2DM. The need for ethnic specific cut-off for obesity has been established. Factors such as presence of metabolic syndrome, HbA1c >6%, presence of a single diabetes range glucose value and pre-existing CVD may be used in risk stratification of individuals with PDM. These factors may also be used to guide those who may benefit from Metformin in addition to established life style interventions for PDM. Our findings provide a contemporary and prospective data on the prevalence of PDM in a multi ethnic UK population and factors predicting progression from PDM to T2DM. A robust strategy using a self assessed risk score is proposed to identify those at risk of developing PDM and T2DM. A step wise ethnic specific algorithm using anthropometric measures is also recommended to enable follow up of those with PDM. These findings have important implications for public health in informing strategies to address the emerging pandemic of T2DM.

The studies conducted in this thesis have explored the physical activity levels (PAL) and temporal patterning of school children using a combination of objective and subjective measures. The primary objective of the work presented in this thesis was to develop a novel computer-based tool, which would permit an enhanced quality of data, and provide a convenient, accurate and precise method for assessing physical activity behaviour in large-scale population studies of primary school-aged children.

No description available.

Exercising in greenspaces, referred to as 'green exercise' provides an ideal way of improving the nation's health. This research quantitatively analyses the psychological health benefits of engaging in a range of green exercise activities and assesses its therapeutic properties for those experiencing mental ill-health. A series of four studies was conducted comprising one laboratory study, one observational field study, one intervention field study and a six-week nature-based intervention programme for people with mental health problem. Results were analysed using multivariate statistics. Key findings showed that participating in all types of green exercise activities, of different durations, intensities and exposure time enhanced mood (p<0.001) and improved self-esteem (p<0.001). blood pressure significantly reduced when viewing rural pleasant pictures (p<0.05) and exercise alone could not explain the improved health outcomes. Introducing a nature-based intervention programme for people with mental ill-health led to improvements in self-esteem (p<0.001), indicating its therapeutic properties. The findings have important implications for individual and community health, environmental protection and national and international policies. There are many areas of policy reform that could help increase participation in green exercise activities, although it is clear that there is a need for more comprehensive economic analyses to place a monetary value on avoided health costs. Participating in green exercise activities could offer a more sustainable option in maintaining long-term activity levels. However, in order to take advantage of these opportunities, a wide range of policy reform to increase the health and greenspace dividend is still required.

Objective: The Washington Panel on Cost-effectiveness in Health and Medicine recommends that economic evaluation of healthcare technologies uses values for health states elicited from the general population rather than patients. However, general population respondents do not necessarily recognize the possibility of adapting to the impaired state. This thesis examines how informing the general population about disease adaptation influences their values. Rheumatoid arthritis (RA) states are used as an illustration. Methods: This work employed a sequential mixed-methods design using three components. First, Rasch and cluster analyses were used to construct RA states. Simultaneously, a novel adaptation exercise consisting of audio-recordings of patients discussing disease adaptation was developed. Second, semi-structured interviews were conducted with 12 general population respondents to identify the effect of adaptation information on their perceptions of RA. Finally, the influence of this information on health state values from a random sample of the general population (n = 200) was assessed quantitatively and the factors contributing to this change were identified. Results: The first component of this study defined three RA states. In the second, the qualitative interviews revealed that the adaptation exercise encouraged the general population to empathize with the messages in the audio-recordings. Finally, the third component showed that the adaptation exercise was effective at changing health state values; for example, for the severe RA state, a mean (standard deviation) change of 0.17 (0.34) (p < 0.01) was observed. Individuals who were younger, were healthier, recognized the importance of coping strategies, and comprehended the valuation task were more likely to increase their values. Conclusions: The results from this thesis demonstrate a novel method of informing the general population about disease adaptation. After undertaking the adaptation exercise, most respondents increased their values for the given health states. Thus, important contributions are made to an emerging field of developing better informed general population values.

This study centres around the work of a regional Accident and Emergency department. It first considers the previous literature on accidents and accident services, noting the problem of finding a uniform definition and the lack of sociological research in this area. It then describes the organisation of the particular accident department under study, and looks in detail at the different rules and routines applied in the everyday situations from reception to discharge. Together these chapters comprise a description of the processing of those who attend the A & E department. The thesis continues with a discussion of the recording procedures which form an intrinsic part of the departmental routines. From a study of these activities it postulates that a reflexive relationship exists between the actual and recorded events and argues that this relationship should be explored when using records for certain kinds of research. Some examples of the indexical nature of such records is given. Finally, the study returns to the definition of accidents and concludes that because such definitions appear to be situational, comparisons between different studies of the subject, particularly those where organisational records are involved, should be approached with caution.

This thesis reports an ethnographic study of undergraduate medical students at Edinburgh University, in their first year of clinical studies. It explores various aspects of their 'clinical experience' in the course of that year. The thesis is organized in four parts. Part I provides the context for the research. The conduct of the study is reported, and the methods used (participant observation, interviews and self-administered questionnaire) are discussed. The medical school, the undergraduate curriculum and the work of the fourth (first clinical) year are also outlined. Part II examines two major concepts - 'student culture' and 'professional segmentation'. The variety of medical and educational experiences that students encounter, and the students' understandings of segmentation within the medical school are examined. This part of the thesis also explores how students use their understanding of such diversity in organizing their own careers in the medical school. The argument is also illustrated with case studies of individual clinical attachments. Part III is focused on the social interaction of clinical teaching - between doctors, students and patients. The management of clinical information in such encounters is discussed. The argument proceeds with a consideration of the conditions for the successful accomplishment of bedside teaching, and of contingencies which can undermine such accomplishment. Part IV develops the analysis begun in Parts II and III. The management of medical knowledge is analysed further: the 'classic case', 'clinical experience' and clinicians' appeals to indeterminate knowledge are documented. These topics are linked with the theme of Part II, as it is argued that divergencies in personal knowledge are grounded in processes of segmentation in the medical profession and the medical school. Thus the themes of 'professional segmentation' and 'clinical experience' are reunited in the concluding section of the thesis.

No description available.