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Many school-based interventions for obesity prevention have been proposed with positive changes in behaviour, but with unsatisfactory results on weight change. The objective was to verify the effectiveness of a combined school- and home-based obesity prevention programme on excessive weight gain in adolescents. Teachers delivered the school-based primary prevention programme to fifth- and sixth-graders (nine schools, forty-eight control classes, forty-nine intervention classes), which included encouraging healthy eating habits and physical activity. A subgroup of overweight or obese adolescents also received a home-based secondary prevention programme delivered by community health professionals. Schools were randomised to intervention or control group. Intent-to-treat analysis used mixed models for repeated continuous measures and considered the cluster effect. The main outcomes were changes in BMI and percentage body fat (%body fat) after one school-year of intervention and follow-up. Against our hypothesis, BMI increased more in the intervention group than in the control group (Δ = 0·3 kg/m2; P = 0·05) with a greater decrease in %body fat among boys (Δ = –0·6 %; P = 0·03) in the control group. The intervention group increased physical activity by 12·5 min per week compared with the control group. Female adolescents in the intervention group ate healthier items more frequently than in the control group. The subgroup that received both the school and home interventions had an increase in %body fat than in the control group (Δ = 0·89 %; P = 0·01). In the present study, a behavioural change led to a small increase in physical activity and healthy eating habits but also to an overall increase in food intake.
Shiga toxin-producing Escherichia coli (STEC) infection can cause serious illness including haemolytic uraemic syndrome. The role of socio-economic status (SES) in differential clinical presentation and exposure to potential risk factors amongst STEC cases has not previously been reported in England. We conducted an observational study using a dataset of all STEC cases identified in England, 2010–2015. Odds ratios for clinical characteristics of cases and foodborne, waterborne and environmental risk factors were estimated using logistic regression, stratified by SES, adjusting for baseline demographic factors. Incidence was higher in the highest SES group compared to the lowest (RR 1.54, 95% CI 1.19–2.00). Odds of Accident and Emergency attendance (OR 1.35, 95% CI 1.10–1.75) and hospitalisation (OR 1.71, 95% CI 1.36–2.15) because of illness were higher in the most disadvantaged compared to the least, suggesting potential lower ascertainment of milder cases or delayed care-seeking behaviour in disadvantaged groups. Advantaged individuals were significantly more likely to report salad/fruit/vegetable/herb consumption (OR 1.59, 95% CI 1.16–2.17), non-UK or UK travel (OR 1.76, 95% CI 1.40–2.27; OR 1.85, 95% CI 1.35–2.56) and environmental exposures (walking in a paddock, OR 1.82, 95% CI 1.22–2.70; soil contact, OR 1.52, 95% CI 2.13–1.09) suggesting other unmeasured risks, such as person-to-person transmission, could be more important in the most disadvantaged group.
Over the past decade, health technology assessment (HTA) agencies have become interested in improving the patient-centeredness of their assessments. A common approach has been to prioritize patient-reported outcomes (PROs), often describing PROs as patient-relevant or patient-oriented. However, it is often unclear whether and to what degree PRO measures (PROMs) truly reflect what is important to patients. This review examined the pedigree of a sample of measures used as primary or secondary endpoints in trials and discussed in Food and Drug Administration (FDA) approved product labels between 2003 and 2014.
We examined all 26 PROs included in chapters 1 (Office of Microbial Products) and 2 (Office of Drug Evaluation I) of the FDA's Pilot Clinical Outcome Assessment (COA) Compendium. Three reviewers independently searched PubMed and Google to identify publications or other relevant materials related to method and stage of measure development where patient engagement took place.
Among 26 evaluated PROMs, we were unable to locate any information on development or validation for 12 (patient diary=9; rating scale=3). Among the remaining 14 PROMs, 5 did not include any evidence of patient engagement (questionnaire=1; patient diary=2; rating scale=2); 3 engaged patients during concept elicitation or psychometric validation only (disease-specific questionnaires=3); and 6 engaged patients during both concept elicitation and cognitive interviewing (disease-specific questionnaires=6). PROMs either previously qualified or submitted for qualification by FDA were more likely to include patient engagement.
PROs can provide patient-centered data useful for HTA; however, patient-reported information is not inherently patient-centered. This study found that only a minority of sampled PROMs engaged patients during both concept elicitation and cognitive interviewing. To facilitate patient-centered HTA, manufacturers should ensure that PROMs incorporated into clinical trials measure concepts important to patients. Similarly, HTAs should request data on development and validation of all outcome measures incorporated into trials.
Firefighters represent an important population for understanding the consequences of exposure to potentially traumatic stressors.
The researchers were interested in the effects of pre-employment disaster exposure on firefighter recruits’ depression and posttraumatic stress disorder (PTSD) symptoms during the first three years of fire service and hypothesized that: (1) disaster-exposed firefighters would have greater depression and PTSD symptoms than non-exposed overall; and (2) depression and PTSD symptoms would worsen over years in fire service in exposed firefighters, but not in their unexposed counterparts.
In a baseline interview, 35 male firefighter recruits from seven US cities reported lifetime exposure to natural disaster. These disaster-exposed male firefighter recruits were matched on age, city, and education with non-exposed recruits.
A generalized linear mixed model revealed a significant exposure×time interaction (ecoef =1.04; P<.001), such that depression symptoms increased with time for those with pre-employment disaster exposure only. This pattern persisted after controlling for social support from colleagues (ecoefficient=1.05; P<.001), social support from families (ecoefficient=1.04; P=.001), and on-the-job trauma exposure (coefficient=0.06; ecoefficient=1.11; P<.001). Posttraumatic stress disorder symptoms did not vary significantly between exposure groups at baseline (P=.61).
Depression symptoms increased with time for those with pre-employment disaster exposure only, even after controlling for social support. Posttraumatic stress disorder symptoms did not vary between exposure groups.
PenningtonML, CarpenterTP, SynettSJ, TorresVA, TeagueJ, MorissetteSB, KnightJ, KamholzBW, KeaneTM, ZimeringRT, GulliverSB. The Influence of Exposure to Natural Disasters on Depression and PTSD Symptoms among Firefighters. Prehosp Disaster Med. 2018;33(1):102–108.
Poorer patient views of mental health inpatient treatment predict both further admissions and, for those admitted involuntarily, longer admissions. As advocated in the UK Francis report, we investigated the hypothesis that improving staff training improves patients’ views of ward care.
Cluster randomised trial with stepped wedge design in 16 acute mental health wards randomised (using the ralloc procedure in Stata) by an independent statistician in three waves to staff training. A psychologist trained ward staff on evidence-based group interventions and then supported their introduction to each ward. The main outcome was blind self-report of perceptions of care (VOICE) before or up to 2 years after staff training between November 2008 and January 2013.
In total, 1108 inpatients took part (616 admitted involuntarily under the English Mental Health Act). On average 51.6 staff training sessions were provided per ward. Involuntary patient's perceptions of, and satisfaction with, mental health wards improved after staff training (N582, standardised effect −0·35, 95% CI −0·57 to −0·12, p = 0·002; interaction p value 0·006) but no benefit to those admitted voluntarily (N469, −0.01, 95% CI −0.23 to 0.22, p = 0.955) and no strong evidence of an overall effect (N1058, standardised effect −0.18 s.d., 95% CI −0.38 to 0.01, p = 0.062). The training costs around £10 per patient per week. Resource allocation changed towards patient perceived meaningful contacts by an average of £12 (95% CI −£76 to £98, p = 0.774).
Staff training improved the perceptions of the therapeutic environment in those least likely to want an inpatient admission, those formally detained. This change might enhance future engagement with all mental health services and prevent the more costly admissions.
Capturing service users’ perspectives can highlight additional and different concerns to those of clinicians, but there are no up to date, self-report psychometrically sound measures of side effects of antipsychotic medications.
To develop a psychometrically sound measure to identify antipsychotic side effects important to service users, the Maudsley Side Effects (MSE) measure.
An initial item bank was subjected to a Delphi exercise (n = 9) with psychiatrists and pharmacists, followed by service user focus groups and expert panels (n = 15) to determine item relevance and language. Feasibility and comprehensive psychometric properties were established in two samples (N43 and N50). We investigated whether we could predict the three most important side effects for individuals from their frequency, severity and life impact.
MSE is a 53-item measure with good reliability and validity. Poorer mental and physical health, but not psychotic symptoms, was related to side-effect burden. Seventy-nine percent of items were chosen as one of the three most important effects. Severity, impact and distress only predicted ‘putting on weight’ which was more distressing, more severe and had more life impact in those for whom it was most important.
MSE is a self-report questionnaire that identifies reliably the side-effect burden as experienced by patients. Identifying key side effects important to patients can act as a starting point for joint decision making on the type and the dose of medication.
There is limited evidence for effective interventions in the treatment of post-traumatic stress symptoms within individuals diagnosed with schizophrenia. Clinicians have concerns about using exposure treatments with this patient group. The current trial was designed to evaluate a 16-session cognitive restructuring programme, without direct exposure, for the treatment of post-traumatic stress symptoms specifically within individuals diagnosed with schizophrenia.
A multicentre randomized controlled single-blinded trial with assessments at 0 months, 6 months (post-treatment) and 12 months (follow-up) was conducted. A total of 61 participants diagnosed with schizophrenia and exhibiting post-traumatic stress symptoms were recruited. Those randomized to treatment were offered up to 16 sessions of cognitive–behaviour therapy (CBT, including psychoeducation, breathing training and cognitive restructuring) over a 6-month period, with the control group offered routine clinical services. The main outcome was blind rating of post-traumatic stress symptoms using the Clinician Administered PTSD Scale for Schizophrenia. Secondary outcomes were psychotic symptoms as measured by the Positive and Negative Symptom Scale and the Psychotic Symptom Rating Scale.
Both the treatment and control groups experienced a significant decrease in post-traumatic stress symptoms over time but there was no effect of the addition of CBT on either the primary or secondary outcomes.
The current trial did not demonstrate any effect in favour of CBT. Cognitive restructuring programmes may require further adaptation to promote emotional processing of traumatic memories within people diagnosed with a psychotic disorder.
To determine the typical microbial bioburden (overall bacterial and multidrug-resistant organisms [MDROs]) on high-touch healthcare environmental surfaces after routine or terminal cleaning.
Prospective 2.5-year microbiological survey of large surface areas (>1,000 cm2).
MDRO contact-precaution rooms from 9 acute-care hospitals and 2 long-term care facilities in 4 states.
Samples from 166 rooms (113 routine cleaned and 53 terminal cleaned rooms).
Using a standard sponge-wipe sampling protocol, 2 composite samples were collected from each room; a third sample was collected from each Clostridium difficile room. Composite 1 included the TV remote, telephone, call button, and bed rails. Composite 2 included the room door handle, IV pole, and overbed table. Composite 3 included toileting surfaces. Total bacteria and MDROs (ie, methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci [VRE], Acinetobacter baumannii, Klebsiella pneumoniae, and C. difficile) were quantified, confirmed, and tested for drug resistance.
The mean microbial bioburden and range from routine cleaned room composites were higher (2,700 colony-forming units [CFU]/100 cm2; ≤1–130,000 CFU/100 cm2) than from terminal cleaned room composites (353 CFU/100 cm2; ≤1–4,300 CFU/100 cm2). MDROs were recovered from 34% of routine cleaned room composites (range ≤1–13,000 CFU/100 cm2) and 17% of terminal cleaned room composites (≤1–524 CFU/100 cm2). MDROs were recovered from 40% of rooms; VRE was the most common (19%).
This multicenter bioburden summary provides a first step to determining microbial bioburden on healthcare surfaces, which may help provide a basis for developing standards to evaluate cleaning and disinfection as well as a framework for studies using an evidentiary hierarchy for environmental infection control.
The Francis report highlights perceptions of care that are affected by
different factors including ward structures.
To assess patient and staff perceptions of psychiatric in-patient wards
Patient and staff perceptions of in-patient psychiatric wards were
assessed over 18 months. We also investigated whether the type of ward or
service structure affected these perceptions. We included triage and
routine care. The goal was to include at least 50% of eligible patients
The most dramatic change was a significant deterioration in all
experiences over the courseof the study. Systems of care or specific
wards did not affect patient experience but staff were more dissatisfied
in the triage system.
This is the first report of deterioration in perceptions of the
therapeutic in-patient environment that has been captured in a rigorous
way. It may reflect contemporaneous experiences across the National
Health Service of budget reductions and increased throughput. The ward
systems we investigated did not improve patient experience and triage may
have been detrimental to staff.
Introduction: Point of care ultrasound (PoCUS) provides invaluable information during resuscitation efforts in cardiac arrest by determining presence/absence of cardiac activity and identifying reversible causes such as pericardial tamponade. There is no agreed guideline on how to safely and effectively incorporate PoCUS into the advanced cardiac life support (ACLS) algorithm. We consider that a consensus-based priority checklist using a “4 F’s” approach (Fluid; Form; Function; Filling), would provide a better algorithm during ACLS. Methods: The ultrasound subcommittee of the Australasian College for Emergency Medicine (ACEM) drafted a checklist incorporating PoCUS into the ACLS algorithm. This was further developed using the input of 24 international experts associated with five professional organizations led by the International Federation of Emergency Medicine. A modified Delphi tool was developed to reach an international consensus on how to integrate ultrasound into cardiac arrest algorithms for emergency department patients. Results: Consensus was reached following 3 rounds. The agreed protocol focuses on the timing of PoCUS as well as the specific clinical questions. Core cardiac windows performed during the rhythm check pause in chest compressions are the sub-xiphoid and parasternal cardiac views. Either view should be used to detect pericardial fluid, as well as examining ventricular form (e.g. right heart strain) and function, (e.g. asystole versus organized cardiac activity). Supplementary views include lung views (for absent lung sliding in pneumothorax and for pleural fluid), and IVC views for filling. Additional ultrasound applications are for endotracheal tube confirmation, proximal leg veins for DVT, or for sources of blood loss (AAA, peritoneal/pelvic fluid). Conclusion: The authors hope that this process will lead to a consensus-based SHoC-cardiac arrest guideline on incorporating PoCUS into the ACLS algorithm.
Topographic and morphologic models based on detailed Digital Elevation Models (DEM) of the Rur Graben, in particular a 33 km section of the Rurrand Fault, proved to be essential in preliminary investigations for the site selection of a trench for detailed paleoseismological investigations. The entire DEM in the 33 km Jülich-Düren area displayed as a color-shaded terrain map clearly illustrates the main features of the eastern border fault of the Rur Graben. As investigations concentrated on the 8x6 km Stetternich-Hambach section of the Rurrand fault, the use of contoured topographic, gray-shaded terrain and terrain slope maps helped delineate the main features of the surface fault expression. On the basis of topographic profiles constructed from the DEM, no fault scarp could be identified; however, the detailed surveying results from two geophysical profiles correlated well with the topographic data.
Recently, large-scale trials of behavioural interventions have failed to show improvements in pregnancy outcomes. They have, however, shown that lifestyle support improves maternal diet and physical activity during pregnancy, and can reduce weight gain. This suggests that pregnancy, and possibly the whole periconceptional period, represents a ‘teachable moment’ for changes in diet and lifestyle, an idea that was made much of in the recent report of the Chief Medical Officer for England. The greatest challenge with all trials of diet and lifestyle interventions is to engage people and to sustain this engagement. With this in mind, we propose a design of intervention that aims simultaneously to engage women through motivational conversations and to offer access to a digital platform that provides structured support for diet and lifestyle change. This intervention design therefore makes best use of learning from the trials described above and from recent advances in digital intervention design.
Few records in the alpine landscape of western North America document the geomorphic and glaciologic response to climate change during the Pleistocene–Holocene transition. While moraines can provide snapshots of glacier extent, high-resolution records of environmental response to the end of the Last Glacial Maximum, Younger Dryas cooling, and subsequent warming into the stable Holocene are rare. We describe the transition from the late Pleistocene to the Holocene using a ~ 17,000-yr sediment record from Swiftcurrent Lake in eastern Glacier National Park, MT, with a focus on the period from ~ 17 to 11 ka. Total organic and inorganic carbon, grain size, and carbon/nitrogen data provide evidence for glacial retreat from the late Pleistocene into the Holocene, with the exception of a well-constrained advance during the Younger Dryas from 12.75 to 11.5 ka. Increased detrital carbonate concentration in Swiftcurrent Lake sediment reflects enhanced glacial erosion and sediment transport, likely a result of a more proximal ice terminus position and a reduction in the number of alpine lakes acting as sediment sinks in the valley.