Non-legislative interventions for the promotion of cycle helmet wearing by children

BACKGROUND

Helmets reduce bicycle-related head and facial injuries for bicyclists of all ages in all types of crash. We aimed to identify non-legislative interventions that are effective in promoting helmet use among children, so future campaigns can be designed on a firm evidence base.

OBJECTIVES

to assess the effectiveness of non-legislative interventions (compared to a lack of interventions) in increasing helmet use among children; to identify possible reasons for differences in the effectiveness of interventions; to evaluate effectiveness with respect to social group; to identify any adverse consequences of interventions.

SEARCH STRATEGY

We searched 11 electronic databases and manually searched other sources of potentially relevant data.

SELECTION CRITERIA

We included randomised controlled trials, cluster randomised controlled trials and controlled before and after studies. Studies included participants aged 0 to 18 years and described interventions to promote helmet use not requiring enactment of legislation. Studies had to report at least one of the following outcomes: observed helmet wearing; self-reported helmet ownership; self-reported helmet wearing.

DATA COLLECTION AND ANALYSIS

Data were extracted by two reviewers working independently. Study results were adjusted to account for clustering. A random-effects model was used to pool data in meta-analyses. Heterogeneity was explored with sub-group analyses.

MAIN RESULTS

Twenty-two studies were included. The odds of observed helmet wearing were significantly greater amongst those receiving non-legislative interventions (OR 2.30, 95% CI 1.37 to 3.85). Sub-group analysis indicated the effect may be greater for community-based studies (OR 4.30, 95% CI 2.24 to 8.25) and those providing free helmets (OR 4.35, 95% CI 2.13 to 8.89) than for those providing subsidised helmets (OR 2.02, 95% CI 0.98 to 4.17) and for those set in schools (OR 1.82, 95% CI 0.94 to 3.52). We found no significant effect of non-legislative interventions in increasing self-reported helmet ownership, but they were associated with a significant increase in self-reported helmet wearing (OR 3.90, 95% CI 1.42 to 10.69), particularly amongst interventions set in schools (OR 4.73, 95% CI 1.09 to 20.49) but there was significant unexplained heterogeneity between effect sizes for these two outcomes.

AUTHORS' CONCLUSIONS

Community-based studies that include the provision of free helmets alongside an educational component increase observed helmet wearing in the areas in which they are set. There is some evidence that interventions in schools and those providing subsidised helmets may increase observed helmet wearing, but possibly to a lesser extent than those set in communities and those providing free helmets.

A cluster of leptospirosis cases in canoeists following a competition on the River Liffey

On 6 November 2001, a possible case of leptospirosis was notified in a canoeist following a white-water event on the River Liffey. It emerged that a second race participant was also a possible case. An outbreak control team coordinated the epidemiological investigation, laboratory investigation, environmental assessment, communication and control measures. A cluster of six laboratory-confirmed cases of leptospirosis, serologically Leptospira interrogans serogroup Icterohaemorrhagiae was found. The attack rate was 9.2% (6/65). Fever, chills, red eyes and shortness of breath were significantly associated with being a confirmed case. Five cases were hospitalized. Swallowing more than one mouthful of water was associated with an increased risk of developing leptospirosis. Increased rainfall and release of hydroelectric water may have contributed to this outbreak. A multidisciplinary approach and use of the Internet and e-mail facilitated rapid and effective communication.

[ABC of smoking cessation. Use of simple advice and behavioural support]

The most effective methods of helping smokers to quit smoking combine pharmacotherapy (such as nicotine or bupropion) with advice and behavioural support. These two components contribute about equally to the success of the intervention. Doctors and other health professionals should therefore be familiar with what these strategies offer, encourage smokers to use them, and be able at least to provide simple advice and behavioural support to smokers. They also need to be familiar with other sources of support, such as written materials, telephone help-lines, and strategies for preventing relapses. This article focuses on non-pharmacological interventions.

Impact of UK National Health Service smoking cessation services: variations in outcomes in England

OBJECTIVES

To determine the extent to which UK National Health Service (NHS) smoking cessation services in England reach smokers and support them to quit at four weeks, and to identify which service and area characteristics contribute to observed outcomes.

DESIGN

Ordinary least squares regression was used to investigate local smoking outcomes in relation to characteristics of health authorities and their smoking cessation services.

SETTING

76 health authorities (from a total of 99) in England from April 2000 to March 2001.

MAIN OUTCOME MEASURES

REACH--number of smokers attending cessation services and setting a quit date as a percentage of the adult smoking population in each health authority. ABSOLUTE SUCCESS--number of smokers setting a quit date who subsequently reported quitting at four weeks (not having smoked between two and four weeks after quit date). CESSATION RATE--number of smokers who reported quitting at four weeks as a percentage of those setting a quit date. LOSS--percentage lost to follow up.

RESULTS

A range of service and area characteristics was associated with each outcome. For example, group support proved more effective than one to one interventions in helping a greater proportion of smokers to quit at four weeks. Services based in health action zones were reaching larger numbers of smokers. However, services operating in deprived communities achieved lower cessation rates than those in more prosperous areas.

CONCLUSIONS

Well developed, evidence based NHS smoking cessation services, reflecting good practice, are yielding positive outcomes in England. However, most of the data are based on self reported smoking status at four weeks. It will be important to obtain validated data about continuous cessation over one year or more in order to assess longer term impact.

How should laboratories communicate with primary care? Obtaining general practitioners' views

AIMS

Recognising the importance of communication with our primary care colleagues, focus groups were held with GPs to determine how they perceived the current lines of communication with their local microbiology laboratory and the PHLS, and how they could be improved.

METHODS

Focus groups were held in Plymouth, Gloucester, Bristol and Hereford. Between four and 10 GPs and/or PCG Board members attended each workshop. The modes of communication i.e. websites, face-to-face contact, laboratory reporting, telephone advice, newsletters, guidance and surveillance were discussed.

RESULTS

Microbiology websites should be user friendly, with clear labelling as to whom the page is directed. They should contain locally relevant data, antibiotic guidance and information leaflets. Despite great variation in laboratory reporting protocols GPs were mostly happy with reports received. Results, especially serology, should contain a clear conclusion and could refer to a website for further information. Electronic reporting was enthusiastically awaited. All GPs felt they had excellent access to telephone advice. GPs would value data and guidance on their use of diagnostic tests.

CONCLUSION

These workshops highlight the variation in laboratory reporting protocols that should be addressed. Website development for GPs should include locally relevant data. GPs would value details of their laboratory use and costs.

How do microbiology consultants undertake their jobs? A survey of consultant time and tasks in South West England

AIMS

To measure the total consultant medical microbiologist (CMM) weekly workload, to identify time spent on different activities, and to differentiate those tasks that were viewed by a consensus of consultants as core activities from those that could be accorded a lower priority.

METHODS

A self administered questionnaire completed by consultant medical microbiologists in the Public Health Laboratory Service South West Group.

RESULTS

Reported hours worked by respondents ranged from 41 to 65 hours each week, excluding on call activities. Eleven of 20 respondents reported working in excess of 48 hours each week. There was no correlation between hours worked and laboratory workload as measured by numbers of specimens. Clinical liaison, result authorisation, infection control, and management activities took up most time. Working practices varied widely between individuals, partly reflecting their differing roles in the laboratory. A consensus was reached regarding the relative importance and priority of many regular CMM activities.

CONCLUSIONS

Consultant microbiologists can identify, with consensus, both high and lower priority activities in their daily practice. If such clinical priorities can be more widely agreed across the profession, this would provide a rational approach to workload control.

Six-year follow-up study of cognitive and functional status across the lifespan in schizophrenia: a comparison with Alzheimer's disease and normal aging

OBJECTIVE

Follow-up studies of cognitive functions of poor-outcome (long-term institutionalized) elderly patients with schizophrenia have demonstrated deterioration over time, while stable cognitive functions over time have been reported for younger, better-outcome schizophrenic patients. This study examined whether cognitive changes in elderly schizophrenic patients with a history of long-term institutional stay extended to institutionalized younger patients. The rate of decline was compared to changes associated with Alzheimer's disease.

METHOD

Patients with schizophrenia (N=107) age 20-80 years were followed over 6 years and assessed with the Clinical Dementia Rating and the Mini-Mental State Examination. The schizophrenic subjects age 50 and older were compared to 136 healthy comparison subjects and 118 Alzheimer's disease patients age 50 and older who were assessed over a similar follow-up period.

RESULTS

There was a significant age group effect on the magnitude of cognitive decline for the schizophrenic subjects, with older subjects experiencing greater levels of decline over the follow-up. Neither the healthy individuals nor the Alzheimer's disease patients demonstrated similar age-related differences in the magnitude of cognitive change over the follow-up, with healthy comparison subjects showing no change and Alzheimer's disease patients manifesting decline regardless of age at the initiation of the follow-up.

CONCLUSIONS

Institutionalized schizophrenic patients demonstrated an age-related pattern of cognitive change different from that observed for Alzheimer's disease patients and healthy individuals. The cognitive and functional status of these schizophrenic patients was fairly stable until late life, suggesting that cognitive change may not be occurring in younger patients over an interval as long as 6 years.

Qualitative study of pilot payment aimed at increasing general practitioners' antismoking advice to smokers

OBJECTIVES

To elicit general practitioners' and practice nurses' accounts of changes in their clinical practice or practice organisation made to claim a pilot health promotion payment. To describe attitudes towards the piloted and previous health promotion payments.

DESIGN

Qualitative, semistructured interview study.

SETTING

13 general practices in Leicester.

PARTICIPANTS

18 general practitioners and 13 practice nurses.

RESULTS

Health professionals did not report substantially changing their clinical practice to claim the new payments and made only minimal changes in practice organisation. The new health promotion payment did not overcome general practitioners' resistance towards raising the issue of smoking when they felt that doing so could cause confrontation with patients. General practitioners who made the largest number of claims altered the way in which they recorded patients' smoking status rather than raising the topic of smoking more frequently with patients. PARTICIPANTS had strong negative views on the new payment, feeling it would also be viewed negatively by patients. They were, however, more positive about health promotion payments that rewarded "extra" effort-for example, setting up practice based smoking cessation clinics.

CONCLUSIONS

General practitioners and practice nurses were negative about a new health promotion payment, despite agreeing to pilot it. Health promotion payments do not automatically generate effective health promotion activity, and policymakers should consider careful piloting and evaluation of future changes in health promotion payments.

Smoking cessation: integrating recent advances into clinical practice

Smoking remains a prevalent habit with serious consequences for public health. There are now effective treatments for nicotine addiction and, in the UK, specialist services for the treatment of smoking cessation are becoming available in all areas. This paper reviews the role of treatments for nicotine addiction in the management of smoking cessation. Recommendations are made for the judicious use of these therapies and also for the rational use of the new UK smoking cessation services.

PPARalpha deficiency reduces insulin resistance and atherosclerosis in apoE-null mice

PPARalpha is a ligand-dependent transcription factor expressed at high levels in the liver. Its activation by the drug gemfibrozil reduces clinical events in humans with established atherosclerosis, but the underlying mechanisms are incompletely defined. To clarify the role of PPARalpha in vascular disease, we crossed PPARalpha-null mice with apoE-null mice to determine if the genetic absence of PPARalpha affects vascular disease in a robust atherosclerosis model. On a high-fat diet, concentrations of atherogenic lipoproteins were higher in PPARalpha(-/-)apoE(-/-) than in PPARalpha(+/+)apoE(-/-) mice, due to increased VLDL production. However, en face atherosclerotic lesion areas at the aortic arch, thoracic aorta, and abdominal aorta were less in PPARalpha-null animals of both sexes after 6 and 10 weeks of high-fat feeding. Despite gaining as much or more weight than their PPARalpha(+/+)apoE(-/-) littermates, PPARalpha(-/-)apoE(-/-) mice had lower fasting levels of glucose and insulin. PPARalpha-null animals had greater suppression of endogenous glucose production in hyperinsulinemic clamp experiments, reflecting less insulin resistance in the absence of PPARalpha. PPARalpha(-/-)apoE(-/-) mice also had lower blood pressures than their PPARalpha(+/+)apoE(-/-) littermates after high-fat feeding. These results suggest that PPARalpha may participate in the pathogenesis of diet-induced insulin resistance and atherosclerosis.

Anti-smoking advice from general practitioners: is a population-based approach to advice-giving feasible?

General practitioners' (GPs') advice against smoking has a small, beneficial effect on patients' smoking. Consequently, GPs have been urged to adopt a population-based approach to advice-giving that involves discussing smoking repeatedly with the maximum possible number of smokers. This discussion paper assesses how far GPs' current clinical practice is from a population-based approach to advice-giving and finds that GPs prefer a problem-orientated approach to advising those who present with smoking-related problems. Discussion focuses on the feasibility of suggesting that GPs adopt a population-based approach instead.

Skeletal muscle respiratory uncoupling prevents diet-induced obesity and insulin resistance in mice

To determine whether uncoupling respiration from oxidative phosphorylation in skeletal muscle is a suitable treatment for obesity and type 2 diabetes, we generated transgenic mice expressing the mitochondrial uncoupling protein (Ucp) in skeletal muscle. Skeletal muscle oxygen consumption was 98% higher in Ucp-L mice (with low expression) and 246% higher in Ucp-H mice (with high expression) than in wild-type mice. Ucp mice fed a chow diet had the same food intake as wild-type mice, but weighed less and had lower levels of glucose and triglycerides and better glucose tolerance than did control mice. Ucp-L mice were resistant to obesity induced by two different high-fat diets. Ucp-L mice fed a high-fat diet had less adiposity, lower levels of glucose, insulin and cholesterol, and an increased metabolic rate at rest and with exercise. They were also more responsive to insulin, and had enhanced glucose transport in skeletal muscle in the setting of increased muscle triglyceride content. These data suggest that manipulating respiratory uncoupling in muscle is a viable treatment for obesity and its metabolic sequelae.

Using content analysis of video-recorded consultations to identify smokers' "readiness" and "resistance" towards stopping smoking

Although physicians' brief advice against smoking is effective in helping smokers to stop, very little is known about the process of counseling smokers. We describe the development of a coding system for describing smokers' motivation to stop smoking as judged by their behaviour when discussing smoking with their family physician. We analysed video-recordings of consultations between 47 self-reported smokers and 29 family physicians where smoking was discussed. By a process of observing recordings, reading transcripts and discussion, we developed a coding system for describing smokers' levels of motivation to stop smoking. This consists of four behaviours thought to indicate "readiness" (higher motivation to stop) and four "resistance" (lower motivation to stop). Interobserver reliability between two observers was good (Kappa = 0.71 for readiness, 0.73 for resistance behaviours). We discuss the relevance of our descriptions for clinicians and the possibility of developing this work further to enable systematic research into doctor-patient interactions where smokers are counseled to stop.

Using video-recorded consultations for research in primary care: advantages and limitations

BACKGROUND

Video-recording primary care consultations is an established technique for primary care research. Despite the widespread use of video-recording to help answer a variety of research questions, little is known about how this recording technique influences the findings of studies in which it is employed.

OBJECTIVE

This article investigates how video-recorded consultations have been used in research and discusses how this technique may influence both the internal and external validity of studies.

CONCLUSION

Using video-recorded consultations for research purposes may cause bias in the characteristics of doctors and patients who agree to participate in research. There is little evidence, however, that video-recording influences the behaviour of either GPs or patients. Recommendations are made for researchers who are considering using video-recorded consultations in their research.

The 1'-hydroxylation of Rac-bufuralol by rat brain microsomes

The 1'-hydroxylation of rac-bufuralol, which is catalyzed by polymorphic CYP2D6 in humans, was studied in brain microsomes from male and female Wistar rats and from the female Dark Agouti rat, a model of the CYP2D6 poor metabolizer phenotype. The kinetics of the 1'-hydroxylation of bufuralol (1-1500 microM) by brain microsomes were biphasic. The activity of the high-affinity site of metabolism was consistent with Michaelis-Menten kinetics (apparent K(m1) = 0. 61-1.42 microM, V(max1) = 4.3-4.8 fmol/min/mg of protein), whereas the low-affinity activity was better described by a Hill function (K(50%(2)) = 253-258 microM, V(max2) = 817-843 fmol/min/mg of protein, n = 1.2-1.3). Values for kinetic constants were similar in all rat strains. Quinine was only a weak inhibitor of both the high- (apparent K(i) = 90 microM) and low-affinity (210 microM) sites of metabolism. In contrast, the kinetics of 1'-hydroxylation of bufuralol by rat liver microsomes were best described by a two-site Michaelis-Menten function. V(max) values were 3 to 5 orders of magnitude greater compared with those for brain microsomes (male and female Wistar), and liver microsomes from female Dark Agouti rats were significantly less active than those from Wistar rats. These data, together with the known potent inhibitory effect of quinine on bufuralol 1'-hydroxylation by rat liver microsomes, indicate tissue-specific differences in the enzymology of this reaction. The role of brain CYP2D enzymes remains to be clarified.

Cloning and expression in Escherichia coli of an azoreductase gene from Clostridium perfringens and comparison with azoreductase genes from other bacteria

A genomic library of Clostridium perfringens ATCC 3626 was constructed in phage lambda gt11 and screened with an antibody against the C. perfringens azoreductase, which catalyzes the reduction of azo dyes to aromatic amines. A positive recombinant phage, containing a 3.8 kb DNA fragment insert was selected and purified. Lytic and lysogenic Escherichia coli cultures infected with the recombinant phage had higher azoreductase activity than cultures infected only with the vector lambda gt11. The 3.8 kb DNA fragment was amplified by PCR and found to hybridize with one band from C. perfringens DNA digested with EcoR1, indicating the presence of a single copy of the azoreductase gene. The fragment also hybridized with DNA from other azoreductase-producing Clostridium species, a Eubacterium sp., Enterobacter cloacae, Citrobacter amalonaticus and E. coli, but not with DNA from some other species of anaerobic bacteria capable of reducing azo dyes. The data indicate that the sequence of the azoreducatse gene of C. perfringens is conserved in some anaerobes and facultative anaerobes, but not in others, and that different types of azoreductase genes must be found in other anaerobic bacteria.

Factors influencing discussion of smoking between general practitioners and patients who smoke: a qualitative study

BACKGROUND

Anti-smoking advice from general practitioners (GPs) is effective and recent evidence-based guidelines urge GPs to advise all patients against smoking at every opportunity. GPs do not exploit many opportunities to discuss smoking with patients and the reasons for this are unclear.

AIM

To elicit, relate, and interpret GPs' accounts of why they discuss smoking with some patients and not others.

METHOD

Thirty-nine Leicestershire GPs were purposively selected so as to have a range of attitudes towards discussing smoking with patients. Each GP had one surgery session video-recorded and afterwards participated in a qualitative, semi-structured interview. Prior to each interview, GPs were shown a video-recording of one of their consultations with a smoker to enhance their recall of events.

RESULTS

Being aware of patients' smoking status did not necessarily result in GPs discussing smoking with patients. GPs were keen to preserve good doctor-patient relationships and avoid negative responses from patients once the topic of smoking had been raised, and this was felt to be best achieved by restricting most discussions about smoking to situations where patients presented with smoking-related problems and in circumstances where the doctors perceived the doctor-patient relationship was strong. Doctors also thought it important to address patients' agendas relating to the current consultation before discussing smoking.

CONCLUSIONS

General practitioners have strong reasons for preferring to discuss smoking when patients present with smoking-related problems. Those wishing to increase the amount of advice-giving by GPs might be more successful if they encouraged GPs to make greater use of problem-orientated opportunities to discuss smoking.

Relative hypoglycemia and hyperinsulinemia in mice with heterozygous lipoprotein lipase (LPL) deficiency. Islet LPL regulates insulin secretion

Lipoprotein lipase (LPL) provides tissues with fatty acids, which have complex effects on glucose utilization and insulin secretion. To determine if LPL has direct effects on glucose metabolism, we studied mice with heterozygous LPL deficiency (LPL+/-). LPL+/- mice had mean fasting glucose values that were up to 39 mg/dl lower than LPL+/+ littermates. Despite having lower glucose levels, LPL+/- mice had fasting insulin levels that were twice those of +/+ mice. Hyperinsulinemic clamp experiments showed no effect of genotype on basal or insulin-stimulated glucose utilization. LPL message was detected in mouse islets, INS-1 cells (a rat insulinoma cell line), and human islets. LPL enzyme activity was detected in the media from both mouse and human islets incubated in vitro. In mice, +/- islets expressed half the enzyme activity of +/+ islets. Islets isolated from +/+ mice secreted less insulin in vitro than +/- and -/- islets, suggesting that LPL suppresses insulin secretion. To test this notion directly, LPL enzyme activity was manipulated in INS-1 cells. INS-1 cells treated with an adeno-associated virus expressing human LPL had more LPL enzyme activity and secreted less insulin than adeno-associated virus-beta-galactosidase-treated cells. INS-1 cells transfected with an antisense LPL oligonucleotide had less LPL enzyme activity and secreted more insulin than cells transfected with a control oligonucleotide. These data suggest that islet LPL is a novel regulator of insulin secretion. They further suggest that genetically determined levels of LPL play a role in establishing glucose levels in mice.

Factors associated with the provision of anti-smoking advice by general practitioners

The acceptability of advice about smoking in the consultation has recently been questioned. We report a study that explored patients' attitudes to general practitioners' (GPs) anti-smoking advice and the characteristics of patients with whom GPs chose to discuss smoking. Patients who recalled the advice were generally positive about stopping smoking. This could be explained by the observation that GPs were more likely to advise smokers who perceived their problems to be smoking-related and were more motivated to stop smoking. The implications of this finding are discussed.