Attitudes and practices of physicians and nurses regarding physical activity promotion in the Catalan primary health-care system

BACKGROUND

In Catalonia a high percentage of the population remains inactive. General practices are an ideal setting to advise on physical activity (PA). However, there is a lack of evidence regarding practices, barriers and predictors of such promotion in the Catalan primary health-care system. This study set out to establish descriptive baseline data for PA promotion in Catalan general practices, and to explore the experiences of doctors/nurses in promoting PA in their day-to-day professional lives.

METHODS

A mixed-method approach was adopted. A survey was conducted with 245 physicians/nurses (58% response rate). Subsequently, focus groups (n = 5) and semi-structured interviews (n = 7) were conducted with 18 physicians and 15 nurses. After coding for important themes, the final interpretation was confirmed by contributors.

RESULTS

Eighty-eight percent of physicians/nurses promoted PA at least infrequently. However, work conditions were perceived as unfavourable, with the main barriers being lack of (i) time, (ii) training and (iii) protocols. Qualitative data showed that PA promotion was opportunistic, focused on selected patients, used generalized messages and was highly dependent on personal interests. Regular promotion was encouraged by direct experiences of the benefits of regular exercising, knowing patients well, being supported by medical colleagues and creating links with other community institutions. PA promotion was especially hindered by seeing PA promotion as a secondary task, and patients ignoring recommendations.

CONCLUSIONS

PA promotion in Catalonia remains to be integrated into practice consultations. Therefore, strategies should be developed within public health. Using a mixed-method approach provided a broader range of evidence than most studies, which rely on quantitative methods.

How general practitioners promote 'lifestyle' physical activity

We investigated how General Practitioners (GPs) promote lifestyle physical activity (PA) ('accumulate 30 min of at least moderate PA on 5 or more days per week': PA30 x 5) to patients in the different stages of change, using a range of counselling strategies. These strategies included six 'A' factors (Ask, Assess, Advise, Assure, Arrange a follow-up, and Applaud). In a postal questionnaire (68% return rate), 47% of GPs from a single UK health district reported regularly promoting PA30 x 5. A stepwise logistic regression identified three counselling strategies that predicted regularly promoting PA30 x 5: (1) arrange follow-ups for patient pre-contemplators (OR=4.93), (2) patient contemplators passed to GP exercise referral scheme (OR=2.34), and (3) asking relapsers about their PA30 x 5 (OR=2.61). GPs who regularly promote PA30 x 5 base their counselling on patients' pre-existing PA behaviour, using 'effortful', 'stage-matched' approaches. Since these are acceptable to GPs, in-service training may build on using these three factors.

A survey to assess physical activity promotion by Registered Dietitians

BACKGROUND

Convincing evidence has emerged in recent years for the role of physical activity (PA) in the prevention and treatment of many chronic diseases. These include both physical and mental health problems, which are likely to be encountered by practicing dietitians. This study aimed to identify whether NHS based Registered Dietitians (RDs) currently promote PA to their patients and if so, how they do it and with which patients.

METHOD

An anonymous questionnaire sent to 516 RDs in NHS teaching hospitals achieved a 77% (n = 397) return rate.

RESULTS

Ninety-three per cent of respondents reported regularly promoting PA particularly with new patients. Among active PA promoters, 87% reported encouraged daily accumulation of PA, 50% focused on sport and exercise and 52% referred patients to GPs or Physiotherapists for advice. Distinctive levels and styles of PA promotion were found to be related to levels of recent training in the field although fewer than one in four had actually received any formal training.

CONCLUSIONS

A high interest in further PA-specific training (95% of all respondents), together with high variability in the type and quality of advice suggests the need to develop further in-service training specifically for RDs.

Total ankle replacement

29 patients underwent 30 Scandinavian Total Ankle Replacements (STAR) by a single surgeon, over a four year period (1997 to 2001). There were 12 primary osteo arthritic patients with 6 post traumatic. The mean age of these 18 patients was 73. Eleven patients had rheumatoid arthritis and these had a mean age of 58 years at the time of surgery. One patient had bilateral replacements giving a total of 30 prostheses inserted. On review dorsiflexion had increased from a mean of 7 to 11 degrees while plantar flexion from 15 to 24 degrees. The American Orthopaedic Foot and Ankle hindfoot score was 95 (maximum 100) and the Kofoed ankle score revealed 17 excellent, 5 good and 4 fair. No patients had radiological evidence of loosening. Our intermediate term result for the STAR (W. Link GmbH & Co., Hamburg, Germany) ankle replacement has yielded 90% excellent and good functional outcomes in a mixed osteo arthritic and rheumatoid population which mirrors the results of those published from Scandinavia.

Adhesion of Staphylococcus to orthopaedic metals, an in vivo study

This study describes a new model of biofilm study in rabbits. The primary focus of this study was to assess biofilm adhesion to orthopaedic metals in their first 48 h in a femoral intramedullary implantation model. Two previous inoculation methods i.e. that of pre- and direct inoculation were studied with two bacterial isolates namely Staphylococcus aureus and epidermidis, on titanium and stainless steel metallic implants. A method of sonication and log dilution/plating was used to assess biofilm bacteria adhering to implants. Silver coated metals were then compared with their respective control metals in the new model. The direct inoculation model gave larger and more reproducible biofilm adhesion to implanted metals. Staphylococcus epidermidis shows lower adhesion ability to metals, and biofilms adhere in greater numbers to stainless steel over titanium. Silver coated metals show no statistical difference over control metals when exposed to orthopaedic biofilms.

Time-lapse 3-D seismic imaging of shallow subsurface contaminant flow

This paper presents a physical modelling study outlining a technique whereby buoyant contaminant flow within water-saturated unconsolidated sand was remotely monitored utilizing the time-lapse 3-D (TL3-D) seismic response. The controlled temperature and pressure conditions, along with the high level of acquisition repeatability attainable using sandbox physical models, allow the TL3-D seismic response to pore fluid movement to be distinguished from all other effects. TL3-D seismic techniques are currently being developed to monitor hydrocarbon reserves within producing reservoirs in an endeavour to improve overall recovery. However, in many ways, sandbox models under atmospheric conditions more accurately simulate the shallow subsurface than petroleum reservoirs. For this reason, perhaps the greatest application for analogue sandbox modelling is to improve our understanding of shallow groundwater and environmental flow mechanisms. Two fluid flow simulations were conducted whereby air and kerosene were injected into separate water-saturated unconsolidated sand models. In both experiments, a base 3-D seismic volume was recorded and compared with six later monitor surveys recorded while the injection program was conducted. Normal incidence amplitude and P-wave velocity information were extracted from the TL3-D seismic data to provide visualization of contaminant migration. Reflection amplitudes displayed qualitative areal distribution of fluids when a suitable impedance contrast existed between pore fluids. TL3-D seismic reflection tomography can potentially monitor the change in areal distribution of fluid contaminants over time, indicating flow patterns. However, other research and this current work have not established a quantifiable relationship between either normal reflection amplitudes and attenuation and fluid saturation. Generally, different pore fluids will have unique seismic velocities due to differences in compressibility and density. The predictable relationships that exist between P-wave velocity and fluid saturation can allow a quantitative assessment of contaminant migration.

The discovery of RPR 200765A, a p38 MAP kinase inhibitor displaying a good oral anti-arthritic efficacy

RPR132331, a 2-(2-dioxanyl)imidazole, was identified as an inhibitor of tumour necrosis factor (TNF)alpha release from lipopolysaccharide (LPS)-stimulated human monocytes. An intensive programme of work exploring the biology, toxicity and physical chemistry of a novel series of inhibitors, derived from RPR132331, has led to the identification of RPR200765A, a development candidate for the treatment of rheumatoid arthritis (RA). RPR200765A is a potent and selective inhibitor of p38 MAP kinase (IC50 = 50 nM). It inhibits LPS-stimulated TNFalpha release both in vitro, from human monocytes (EC50 = 110 nM), and in vivo in Balb/c mice (ED50 = 6 mg/kg). At oral doses between 10 and 30 mg/kg/day it reduces the incidence and progression in the rat streptococcal cell wall (SCW) arthritis model when administered in either prophylactic or therapeutic dosing regimens. The compound, which is a mesylate salt and exists as a stable monohydrate, shows good oral bioavailabiltiy (F = 50% in the rat) and excellent chemical stability. The data from the SCW disease model suggests that RPR200765A could exhibit a profile of disease modifying activity in rheumatoid arthritis (RA) patients which is not observed with current drug therapies.

A grasp-related deficit in tactile discrimination following dorsal column lesion in the rat

The dorsal columns of the spinal cord are a major source of haptic (sense of active touch) and proprioceptive input to the brainstem and sensory-motor cortex. Following injury in primates, there are impairments in two-point discrimination, direction of movement across the skin, and frequency of vibration, and qualitative control of the digits, but simple spatial discriminations recover. In the rat there are qualitative deficits in paw control in skilled reaching, but no sensory deficits have been reported. Because recent investigations of sensory control suggest that sensory functions may be related to specific actions, the present study investigated whether the dorsal columns contribute to hapsis during food grasping in the rat. Adult female Long-Evans rats were trained to reach with a single forepaw for a piece of uncooked pasta or for equivalent sized but tactually different nonfood items. One group was given lesions of the dorsal column ipsilateral to their preferred paw, while the second group served as a control. Postlesion, both groups were tested for skilled reaching success and force application as well as adhesive dot removal and forepaw placing. Performance levels on these tests were normal. Nevertheless, the rats with dorsal column lesions were unable to discriminate a food item from a tactually distinctive nonfood item as part of the reaching act, suggesting that the dorsal columns are important for on-line tactile discriminations, or "haptic actions," which contribute to the normal performance of grasping actions.

What is the magnitude of blood pressure response to a programme of moderate intensity exercise? Randomised controlled trial among sedentary adults with unmedicated hypertension

BACKGROUND

Current guidelines for the management of hypertension recommend regular, moderate intensity aerobic exercise such as brisk walking as a means of blood pressure reduction. However, there is a lack of consistent evidence regarding the magnitude of blood pressure response to such a prescription. In particular, no well designed studies have investigated the efficacy of a programme of exercise meeting current guidelines.

AIM

To investigate the effect of a six-week programme of moderate intensity exercise on daytime ambulatory blood pressure (10.00 am to 10.00 pm) among unmedicated, sedentary adults aged 25 years to 63 years with office blood pressure of 150 mmHg to 180 mmHg systolic and/or 91 mmHg to 110 mmHg diastolic.

METHOD

Randomised controlled trial of participants carrying out 30 minutes of moderate intensity exercise (brisk walking or equivalent) five days per week for six weeks compared with controls who maintained existing levels of physical activity.

RESULTS

Compliance with the exercise programme was high. The reduction in mean daytime ambulatory blood pressure between baseline and six-week follow-up was greater in the intervention group than in the control group for both systolic and diastolic blood pressure. However, this net hypotensive effect was not statistically significant (systolic = -3.4 mmHg, 95% CI = -7.4 to 0.6; diastolic = -2.8 mmHg, 95% CI = -5.8 to 0.2). Adjusting for baseline differences in mean ambulatory blood pressure in an analysis of covariance led to a reduction in the estimated magnitude of the effect (systolic = -1.9 mmHg, 95% CI = -5.4 to 1.7, P = 0.31; diastolic = -2.2 mmHg, 95% CI = -4.9 to 0.5, P = 0.11).

CONCLUSION

Despite high compliance with the exercise programme, the magnitude of the hypotensive effect of moderate intensity exercise was not as great as that found in studies of higher intensity exercise among hypertensives. Expectations of general practitioners and patients that a programme of moderate intensity exercise will lead to a clinically important reduction in the individual's blood pressure are unlikely to be realised.

Analysis of the functional role of a G.A sheared base pair by in vitro genetics

A classical genetic strategy has been combined with an in vitro selection method to search for functional interactions between the two domains of the hairpin ribozyme. G(21) is located within internal loop B; it is proposed to form a sheared base pair with A(43) across loop B and to bind a Mg(2+) ion. Both nucleotides are important for ribozyme function, and G.A sheared base pairs are a very widespread motif in structured RNA. We took advantage of its presence in the hairpin ribozyme to study its functional role. Pseudorevertants, in which the loss of G(21) was compensated by mutations at other positions, were isolated by in vitro selection. The vast majority of G(21) revertants contained substitutions within domain A, pointing to functional communication between specific sites within the two domains of the hairpin ribozyme. The possibility of a direct or redundant contacts is supported by electrophoretic mobility shift studies showing that a complex formed between domain B of the ribozyme and the substrate was disrupted and restored by base substitutions that have analogous effects on catalytic activity. The functional significance of this complex, the role of the nucleotides involved, and the basis for magnesium ion requirement is discussed.

External fixation of distal radial fractures

From February 1995 until December 1997 we treated 48 patients aged between 26 and 79 years for distal radial fractures with external fixation. They were treated in an Arbeitsgemeinschaft fur Osteosynthestragen (A.O.) construct for periods of 5-10 weeks, the mean being 6 weeks. Forty patients were available for follow up. Our indications for this procedure were: severe comminuted displaced intra-articular fracture, severe shortening and inability to achieve fixation with other methods. The majority of patients had A.O. Classification type C fractures. Patients at follow up had objective clinical and radiological assessment as well as a subjective functional evaluation. Results were calculated using Stewart's modification of Gartland and Werley's assessment criteria. Functionally 90% achieved an excellent or good result. Radiographically 95% had an excellent or good result.

A randomized control trial of new tailored walking campaigns in an employee sample

Public health groups use mass media communications to address the problem of sedentary behaviour. However, these campaigns are poorly evaluated and lack tailoring. Campaigns and questionnaires were developed based on existing theoretical, cross-sectional, and qualitative data regarding how to promote walking with people who are not regularly active. Subjects were volunteer white-collar employees (n = 181) randomly allocated by quota to the campaigns, or control, for one week. One-hundred-thirty-eight subjects (76.2%) completed pre- and postcampaign questionnaires. This study successfully (1) developed four new tailored campaigns to promote walking according to a formalized process that health promoters can adapt and refine, (2) developed a complimentary measure of outcomes, and (3) compared the new campaigns with the English Health Education Authority (HEA) "Active for Life" campaign (control).

Strategies for an effective youth counter-marketing program: recommendations from commercial marketing experts

Intensive and sustained efforts to "counter-market" tobacco among teenagers are necessary to negate the "friendly familiarity" created by tobacco advertising and to communicate the true health and social costs of tobacco use. Counter-marketing campaigns should: highlight a tobacco-free lifestyle as the majority lifestyle of diverse and interesting individuals; explain the dangers of tobacco in a personal, emotional way; offer youth empowerment and control; use multiple voices, strategies, and executions; offer constructive alternatives to tobacco use; and portray smoking as unacceptable and undesirable for everyone. Counter-marketing activities should work in concert with other interventions to alter social norms regarding tobacco.

A multicentre trial of ropivacaine 7.5 mg x ml(-1) vs bupivacaine 5 mg x ml(-1) for supra clavicular brachial plexus anesthesia

PURPOSE

To compare the efficacy of ropivacaine 7.5 mg x ml(-1) with bupivacaine 5.0 mg x ml(-1) for subclavian perivascular brachial plexus block.

METHODS

After informed consent, 104 ASA I-III adults participated in a randomized, double-blind, multi-center trial to receive 30 ml of either ropivacaine 7.5 mg x ml(-1) or bupivacaine 5.0 mg x ml(-1) for subclavian perivascular brachial plexus block prior to upper limb surgery. Onset and duration of sensory and motor block in the distribution of the axillary, median, musculo-cutaneous, radial and ulnar nerves were assessed.

RESULTS

Onset times and duration of sensory and motor block were similar between groups. Mean duration of analgesia for the five nerves was between 11.3 and 14.3 hr with ropivacaine and between 10.3 and 17.1 hr with bupivacaine. Quality of muscle relaxation judged as excellent by the investigators was not significantly different (ropivacaine - 35/49, bupivacaine - 30/49). The median time to first request for analgesia was comparable between the two groups (11-12 hr). One patient developed a grand mal seizure shortly after receiving bupivacaine and recovered consciousness within 30 min. There were no serious adverse events in the ropivacaine group.

CONCLUSIONS

Thirty ml ropivacaine 7.5 mg x ml(-1) (225 mg) produced effective and well tolerated brachial plexus block of long duration by the subclavian perivascular route. In this study, the results were similar to those of 30 ml bupivacaine 5.0 mg x ml(-1).

Delusional ideation in religious and psychotic populations

OBJECTIVES

Previous research into schizotypy has shown that certain groups of people have similar experiences to the positive symptoms of schizophrenia but remain functioning members of society, such as those with profound religious experiences (Jackson & Fulford, 1997).

METHOD

The focus of the present study was to explore the incidence of delusional ideation in New Religious Movements (NRMs). Hare Krishnas and Druids were compared to two control groups (non-religious and Christian), and to deluded, psychotic in-patients on two delusions measures.

RESULTS

As predicted, individuals from the NRMs scored significantly higher than the control groups on all the delusional measures apart from levels of distress. They did not show as much florid symptomatology as the psychotic patients, but could not be differentiated from the deluded group on the number of delusional items endorsed on the Peters et al. Delusions Inventory (PDI; Peters, Day & Garety, 1996), or on levels of conviction. However, they were significantly less distressed and preoccupied by their experiences. No differences were found between the two control groups on any of the delusional measures, suggesting that religious beliefs per se do not account for the NRMs members' scores.

DISCUSSION

These findings provide further support for, first, the notion of a continuum between normality and psychosis and, second, for the necessity to consider the multidimensionality of delusional beliefs.

Comparison of epidural anaesthesia with ropivacaine 0.5% and bupivacaine 0.5% for caesarean section

PURPOSE

To compare ropivacaine 0.5% with bupivacaine 0.5% for epidural anaesthesia for Caesarean section.

METHODS

Healthy pregnant women, scheduled for elective Caesarean section were enrolled into this randomized, double-blind, parallel-group study. Epidural block was obtained with 20-30 ml of ropivacaine (group R) or bupivacaine (group B) and surgery started when anaesthesia was reached T6. Maternal heart rate and blood pressure and fetal heart rate were assessed before the test dose and at five minute intervals until the end of surgery. At the same intervals, sensory and motor block characteristics were determined. Apgar scores and Neurologic and Adaptive Capacity Scores (NACS) were determined after delivery. Adverse events were recorded.

RESULTS

Sixty-five patients were enrolled and data from 61 were available for analysis; 30 ropivacaine and 31 bupivacaine. Time from the end of the last injection to the start of surgery was 46 +/- 13 min (mean +/- SD) in gp R and 53 +/- 25 min in gp B (P:NS). The median duration of analgesia varied between 1.7 and 4.2 hr in gp R and between 1.8 and 4.4 hr in gp B (P:NS). In patients who developed Bromage 4 block, it persisted longer in those in gp B (2.5 hr) than in gp R (0.9 hr) (P < 0.05). The quality of analgesia was satisfactory in 27/29 patients (93%) in gp R and 27/31 patients (87%) in gp B (P:NS), although supplemental i.v. opioid was required in ten and seven patients, respectively. The most common adverse events in the mother were hypotension (63% gp R and 61% in gp B) (NS) and nausea (30% and 58%, in group R and B, respectively) (P = 0.05). Apgar scores were 7 after five minutes in all neonates.

CONCLUSION

Ropivacaine 0.5% and bupivacaine 0.5% provided effective epidural anaesthesia for Caesarean section although supplementation with i.v. opioid was commonly required.