UK health performance: findings of the Global Burden of Disease Study 2010

Improving access to primary care for Aboriginal babies in Western Australia: study protocol for a randomized controlled trial

Background

Despite a decade of substantial investments in programs to improve access to primary care for Aboriginal mothers and infants, more than 50 % of Western Australian Aboriginal babies are still not receiving primary and preventative care in the early months of life. Western Australian hospitals now input birth data into the Western Australian electronic clinical management system within 48 hours of birth. However, difficulties have arisen in ensuring that the appropriate primary care providers receive birth notification and clinical information by the time babies are discharged from the hospital. No consistent process exists to ensure that choices about primary care are discussed with Aboriginal families.

Methods/Design

We will undertake a population-based, stepped wedge, cluster randomized controlled trial of an enhanced model of early infant primary care. The intervention is targeted support and care coordination for Aboriginal families with new babies starting as soon as possible during the antenatal period or after birth. Dedicated health professionals and research staff will consult with families about the families’ healthcare needs, provide information about healthcare in the first 3 months of life, offer assistance with birth and Medicare forms, consult with families about their choice for primary care provider, offer to notify the chosen primary care provider about the baby’s health needs, and offer assistance with healthcare coordination at the time of discharge from the hospital.

We will evaluate this model of care using a rigorous stepped wedge approach. Our primary outcome measure is a reduced hospitalization rate in infants younger than 3 months of age. Secondary outcome measures include completed Aboriginal and Torres Strait Islander child health screening assessments, immunization coverage, and satisfaction of the families about early infant primary care. We will also assess the cost effectiveness of the model of care.

Discussion

This study will be conducted over a 4-year period in partnership with birthing hospitals and primary care providers including Western Australian Aboriginal Community Controlled Health Services and the new Primary Health Networks. The results of our trial will be used to develop improved primary care models and to improve health outcomes for all Aboriginal infants. These are vital steps toward more equitable health service delivery for the Aboriginal and Torres Strait Islander children in Australia.

Trial Registration

Australian New Zealand Clinical Trials Registry

Registration number: ACTRN12615000976583 

Date registered: 17 September 2015

Prospective change in daily walking over 2 years in older adults with or at risk of knee osteoarthritis: the MOST study

OBJECTIVE

Radiographic disease and knee pain are thought to decrease physical activity in people with knee osteoarthritis (OA), but this has not been formally studied. We examined change in objectively measured daily walking over 2 years and evaluated the association of certain risk factors with reduced walking among adults with or at risk of knee OA.

DESIGN

Steps/day over 7 days were collected at baseline and 2 years later in subjects with or at risk of knee OA from the Multicenter Osteoarthritis Study using a StepWatch. We evaluated the presence of radiographic knee osteoarthritis (ROA), knee pain, worsening of ROA and pain over 2 years, obesity, depressive symptoms, living situation, catastrophizing, fatigue, widespread pain and comorbidities with 2-year change in daily walking using regression models adjusted for potential confounders.

RESULTS

1318 met inclusion criteria (age 66.9 ± 7.7, 59% women, BMI 30.6 ± 5.9) and walked 126 ± 1700 steps/day fewer steps at 2 years (95% CI [-218, -35]). People with depressive symptoms at baseline walked 455 fewer steps/day [-872, -68], and there was a trend for people with ROA worsening to walk 183 fewer steps/day [-377.5, 11.7]. No other factors met statistical significance for change in daily walking.

CONCLUSION

Adults with or at risk of knee OA experienced only minimal declines in daily walking over 2 years. Nonetheless, depressive symptoms and may be worsening ROA are associated with a decline in steps/day in adults with or at risk of knee OA.

Capsaicin and Its Role in Chronic Diseases

A significant number of experimental and clinical studies published in peer-reviewed journals have demonstrated promising pharmacological properties of capsaicin in relieving signs and symptoms of non-communicable diseases (chronic diseases). This chapter provides an overview made from basic and clinical research studies of the potential therapeutic effects of capsaicin, loaded in different application forms, such as solution and cream, on chronic diseases (e.g. arthritis, chronic pain, functional gastrointestinal disorders and cancer). In addition to the anti-inflammatory and analgesic properties of capsaicin largely recognized via, mainly, interaction with the TRPV1, the effects of capsaicin on different cell signalling pathways will be further discussed here. The analgesic, anti-inflammatory or apoptotic effects of capsaicin show promising results in arthritis, neuropathic pain, gastrointestinal disorders or cancer, since evidence demonstrates that the oral or local application of capsaicin reduce inflammation and pain in rheumatoid arthritis, promotes gastric protection against ulcer and induces apoptosis of the tumour cells. Sadly, these results have been paralleled by conflicting studies, which indicate that high concentrations of capsaicin are likely to evoke deleterious effects, thus suggesting that capsaicin activates different pathways at different concentrations in both human and rodent tissues. Thus, to establish effective capsaicin doses for chronic conditions, which can be benefited from capsaicin therapeutic effects, is a real challenge that must be pursued.

Long-term remote organ consequences following acute kidney injury

Acute kidney injury (AKI) has been a global health epidemic problem with soaring incidence, increased long-term risks for multiple comorbidities and mortality, as well as elevated medical costs. Despite the improvement of patient outcomes following the advancements in preventive and therapeutic strategies, the mortality rates among critically ill patients with AKI remain as high as 40–60 %. The distant organ injury, a direct consequence of deleterious systemic effects, following AKI is an important explanation for this phenomenon. To date, most evidence of remote organ injury in AKI is obtained from animal models. Whereas the observations in humans are from a limited number of participants in a relatively short follow-up period, or just focusing on the cytokine levels rather than clinical solid outcomes. The remote organ injury is caused with four underlying mechanisms: (1) “classical” pattern of acute uremic state; (2) inflammatory nature of the injured kidneys; (3) modulating effect of AKI of the underlying disease process; and (4) healthcare dilemma. While cytokines/chemokines, leukocyte extravasation, oxidative stress, and certain channel dysregulation are the pathways involving in the remote organ damage. In the current review, we summarized the data from experimental studies to clinical outcome studies in the field of organ crosstalk following AKI. Further, the long-term consequences of distant organ-system, including liver, heart, brain, lung, gut, bone, immune system, and malignancy following AKI with temporary dialysis were reviewed and discussed.

Trajectories of functional decline in knee osteoarthritis: the Osteoarthritis Initiative

OBJECTIVE

To describe trajectories of functional decline over 84 months and study associated risk factors among adults initially without limitation who had or were at risk of knee OA.

METHODS

We used annual measures of WOMAC physical function over 84 months from the OA Initiative. We included knees with no functional limitation (i.e. WOMAC = 0) at baseline. Knee-based trajectories of functional decline from WOMAC were identified from a group-based trajectory model (PROC TRAJ).

RESULTS

We identified five trajectories from 2110 knees (1055 participants, age 61.0 ± 9.3, BMI 27.1 ± 4.4, 52% women). Half of the knees (54%) remained free of limitation over 84 months, 26% slowly declined to a WOMAC of 1.5, 9% were limitation free for the first 36 months and declined to a WOMAC of 11.3, 6% rapidly declined over the first 12 months and gradually recovered to a WOMAC of 3.3 and 5% steadily declined to a WOMAC of 13.2. Baseline radiographic disease, knee pain, obesity and depressive symptoms at baseline were associated with trajectories of worse functional decline.

CONCLUSION

Five per cent of our sample initially without limitation was on a trajectory of progressive functional decline over 84 months later. We found worse disease and health status at baseline to be associated with faster decline over time.

Does Glass Size and Shape Influence Judgements of the Volume of Wine?

BACKGROUND

Judgements of volume may influence the rate of consumption of alcohol and, in turn, the amount consumed. The aim of the current study was to examine the impact of the size and shape of wine glasses on perceptions of wine volume.

METHODS

Online experiment: Participants (n = 360; recruited via Mechanical Turk) were asked to match the volume of wine in two wine glasses, specifically: 1. the Reference glass holding a fixed reference volume, and 2. the Comparison glass, for which the volume could be altered until participants perceived it matched the reference volume. One of three comparison glasses was shown in each trial: 'wider' (20% wider but same capacity); 'larger' (same width but 25% greater capacity); or 'wider-and-larger' (20% wider and 25% greater capacity). Reference volumes were 125 ml, 175 ml and 250 ml, in a fully factorial within-subjects design: 3 (comparison glass) x 3 (reference volume). Non-zero differences between the volumes with which participants filled comparison glasses and the corresponding reference volumes were identified using sign-rank tests.

RESULTS

Participants under-filled the wider glass relative to the reference glass for larger reference volumes, and over-filled the larger glass relative to the reference glass for all reference volumes. Results for the wider-and-larger glass showed a mixed pattern across reference volume. For all comparison glasses, in trials with larger reference volumes participants tended to fill the comparison glass less, relative to trials with smaller reference volumes for the same comparison glass.

CONCLUSIONS

These results are broadly consistent with people using the relative fullness of glasses to judge volume, and suggest both the shape and capacity of wine glasses may influence perceived volume. Perceptions that smaller glasses contain more than larger ones (despite containing the same volume), could slow drinking speed and overall consumption by serving standard portions in smaller glasses. This hypothesis awaits testing.

An Update on Nutrients and Blood Pressure

Adverse blood pressure (BP) is a major independent risk factor for epidemic cardiovascular diseases affecting almost one-quarter of the adult population worldwide. Dietary intake is a major determinant in the development and progression of high BP. Lifestyle modifications, including recommended dietary guidelines, are advocated by the American Society of Hypertension, the International Society of Hypertension, the Japanese Society of Hypertension, and many other organisations for treating all hypertensive people, prior to initiating drug therapy and as an adjunct to medication in persons already on drug therapy. Lifestyle modification can also reduce high BP and prevent development of hypertension. This review synthesizes results from the International Study of Macro/Micronutrients and Blood Pressure (INTERMAP), a cross-sectional epidemiological study of 4,680 men and women aged 40-59 years from Japan, the People's Republic of China, the United Kingdom, and the United States, published over the past few years on cross cultural BP differences. INTERMAP has previously reported that intakes of vegetable protein, glutamic acid, total and insoluble fibre, total polyunsaturated fatty acid and linoleic acid, total n-3 fatty acid and linolenic acid, phosphorus, calcium, magnesium, and non-heme iron were inversely related to BP. Direct associations of sugars (fructose, glucose, and sucrose) and sugar-sweetened beverages (especially combined with high sodium intake), cholesterol, glycine, alanine, and oleic acid from animal sources with BP were also reported by the INTERMAP Study.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution.

METHODS

Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol.

FINDINGS

All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa.

INTERPRETATION

Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

FUNDING

Bill & Melinda Gates Foundation.

Changes in health in England, with analysis by English regions and areas of deprivation, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

In the Global Burden of Disease Study 2013 (GBD 2013), knowledge about health and its determinants has been integrated into a comparable framework to inform health policy. Outputs of this analysis are relevant to current policy questions in England and elsewhere, particularly on health inequalities. We use GBD 2013 data on mortality and causes of death, and disease and injury incidence and prevalence to analyse the burden of disease and injury in England as a whole, in English regions, and within each English region by deprivation quintile. We also assess disease and injury burden in England attributable to potentially preventable risk factors. England and the English regions are compared with the remaining constituent countries of the UK and with comparable countries in the European Union (EU) and beyond.

METHODS

We extracted data from the GBD 2013 to compare mortality, causes of death, years of life lost (YLLs), years lived with a disability (YLDs), and disability-adjusted life-years (DALYs) in England, the UK, and 18 other countries (the first 15 EU members [apart from the UK] and Australia, Canada, Norway, and the USA [EU15+]). We extended elements of the analysis to English regions, and subregional areas defined by deprivation quintile (deprivation areas). We used data split by the nine English regions (corresponding to the European boundaries of the Nomenclature for Territorial Statistics level 1 [NUTS 1] regions), and by quintile groups within each English region according to deprivation, thereby making 45 regional deprivation areas. Deprivation quintiles were defined by area of residence ranked at national level by Index of Multiple Deprivation score, 2010. Burden due to various risk factors is described for England using new GBD methodology to estimate independent and overlapping attributable risk for five tiers of behavioural, metabolic, and environmental risk factors. We present results for 306 causes and 2337 sequelae, and 79 risks or risk clusters.

FINDINGS

Between 1990 and 2013, life expectancy from birth in England increased by 5·4 years (95% uncertainty interval 5·0-5·8) from 75·9 years (75·9-76·0) to 81·3 years (80·9-81·7); gains were greater for men than for women. Rates of age-standardised YLLs reduced by 41·1% (38·3-43·6), whereas DALYs were reduced by 23·8% (20·9-27·1), and YLDs by 1·4% (0·1-2·8). For these measures, England ranked better than the UK and the EU15+ means. Between 1990 and 2013, the range in life expectancy among 45 regional deprivation areas remained 8·2 years for men and decreased from 7·2 years in 1990 to 6·9 years in 2013 for women. In 2013, the leading cause of YLLs was ischaemic heart disease, and the leading cause of DALYs was low back and neck pain. Known risk factors accounted for 39·6% (37·7-41·7) of DALYs; leading behavioural risk factors were suboptimal diet (10·8% [9·1-12·7]) and tobacco (10·7% [9·4-12·0]).

INTERPRETATION

Health in England is improving although substantial opportunities exist for further reductions in the burden of preventable disease. The gap in mortality rates between men and women has reduced, but marked health inequalities between the least deprived and most deprived areas remain. Declines in mortality have not been matched by similar declines in morbidity, resulting in people living longer with diseases. Health policies must therefore address the causes of ill health as well as those of premature mortality. Systematic action locally and nationally is needed to reduce risk exposures, support healthy behaviours, alleviate the severity of chronic disabling disorders, and mitigate the effects of socioeconomic deprivation.

FUNDING

Bill & Melinda Gates Foundation and Public Health England.

"Lovely Pie in the Sky Plans": A Qualitative Study of Clinicians' Perspectives on Guidelines for Managing Low Back Pain in Primary Care in England

STUDY DESIGN

A qualitative study in south-west England primary care.

OBJECTIVE

To clarify the decision-making processes that result in the delivery of particular treatments to patients with low back pain (LBP) in primary care and to examine clinicians' perspectives on the English National Institute for Health and Care Excellence (NICE) clinical guidelines for managing LBP in primary care.

SUMMARY OF BACKGROUND DATA

Merely publishing clinical guidelines is known to be insufficient to ensure their implementation. Gaining an in-depth understanding of clinicians' perspectives on specific clinical guidelines can suggest ways to improve the relevance of guidelines for clinical practice.

METHODS

We conducted semi-structured interviews with 53 purposively sampled clinicians. Participants were 16 general practitioners (GPs), 10 chiropractors, 8 acupuncturists, 8 physiotherapists, 7 osteopaths, and 4 nurses, from the public sector (20), private sector (21), or both (12). We used thematic analysis.

RESULTS

Official guidelines comprised just 1 of many inputs to clinical decision-making. Clinicians drew on personal experience and inter-professional networks and were constrained by organizational factors when deciding which treatment to prescribe, refer for, or deliver to an individual patient with LBP. Some found the guideline terminology-"non-specific LBP"-unfamiliar and of limited relevance to practice. They were frustrated by disparities between recommendations in the guidelines and the real-world situation of short consultation times, difficult-to-access specialist services, and sparse commissioning of guideline-recommended treatments.

CONCLUSION

The NICE guidelines for managing LBP in primary care are one, relatively peripheral, influence on clinical decision-making among GPs, chiropractors, acupuncturists, physiotherapists, osteopaths, and nurses. When revised, these guidelines could be made more clinically relevant by: ensuring that guideline terminology reflects clinical practice terminology; dispelling the image of guidelines as rigid and prohibiting patient-centered care; providing opportunities for clinicians to engage in experiential learning about guideline-recommended complementary therapies; and commissioning guideline-recommended treatments for public sector patients.

LEVEL OF EVIDENCE

N/A.

Trends in the Burden of Hepatitis B in a Southern Brazilian State

BACKGROUND

Viral hepatitis is a major health problem in Brazil and worldwide. The state of Santa Catarina has high endemic areas, and the disease burden is unknown.

OBJECTIVES

To estimate and analyze the burden of hepatitis B in the state of Santa Catarina, in 2005 - 2010.

MATERIALS AND METHODS

A time-series analysis was conducted using notification data of incidence and mortality rates from hepatitis B. The Disability-Adjusted Life Years (DALY) and the components Years of Life Lost (YLL) and Years Lived with Disability (YLD) were calculated. The annual variation was estimated using segmented linear regression, identifying the points at which there were changes in the trend.

RESULTS

The state of Santa Catarina showed an increase of 11.9% (95% CI 0.9, 24.2) per year in YLL rates. A significant increase was observed for men and within the 70 - 79 age group. There was a significant decrease of -9.4% (95% CI -16.1, -2.2) in the YLD rates per year. The decline was significant for women and within the 15-34 age group. Regarding the DALY rates, the state of Santa Catarina showed a decline of -6.6% (95% CI: -11.0, -2.0) per year. Significant decreases occurred for females and within the 15 - 29 and 45 - 59 age groups. However, there was a significant increase within the 70 - 79 age range.

CONCLUSIONS

The state of Santa Catarina has reduced the disease burden rates attributed to disability from hepatitis B, but there has been an increase in the burden of premature mortality from 2005 to 2010.

Health Services for Management of Chronic Non-Cancer Pain in Kuwait: A Case Study Review

The experience of chronic pain is universal, yet pain management services delivered by health professionals vary substantially, depending on the context and patient. This review is a part of a series that has examined the issue of chronic non-cancer pain services and management in different global cities. The review is structured as a case study of the availability of management services for people living with chronic non-cancer pain within the context of the Kuwaiti health systems, and the cases are built from evidence in the published literature identified through a comprehensive review process. The evolution of the organizational structure of the public and private health systems in Kuwait is described. These are discussed in terms of their impact on the delivery of comprehensive chronic pain management service by health professionals in Kuwait. This review also includes a description of chronic pain patient personas to highlight expected barriers as well as compliance issues with services likely to be encountered in Kuwait. The case study analysis and persona descriptions illustrate a need to move beyond pain symptom management towards considering the entire person and his/her individual experience of pain such that health care success is judged by enhancement of patient well-being rather than access to services. A road map for improving integrative chronic pain management in Kuwait is discussed.

The relative importance of perceived doctor's attitude on the decision to consult for symptomatic osteoarthritis: a choice-based conjoint analysis study

OBJECTIVES

Some patients spend years with painful osteoarthritis without consulting for it, including times when they are experiencing persistent severe pain and disability. Beliefs about osteoarthritis and what primary care has to offer may influence the decision to consult but their relative importance has seldom been quantified. We sought to investigate the relative importance of perceived service-related and clinical need attributes in the decision to consult a primary care physician for painful osteoarthritis.

DESIGN

Partial-profile choice-based conjoint analysis study, using a self-complete questionnaire containing 10 choice tasks, each presenting two scenarios based on a combination of three out of six selected attributes.

SETTING

General population.

PARTICIPANTS

Adults aged 50 years and over with hip, knee or hand pain registered with four UK general practices.

OUTCOME MEASURES

Relative importance of pain characteristics, level of disruption to everyday life, extent of comorbidity, assessment, management, perceived general practitioner (GP) attitude.

RESULTS

863 (74%) people responded (55% female; mean age 70 years, range: 58-93). The most important determinants of the patient's decision to consult the GP for joint pain were the extent to which pain disrupted everyday life ('most' vs 'none': relative importance 31%) and perceived GP attitude ('legitimate problem, requires treatment' vs 'part of the normal ageing process that one just has to accept': 24%). Thoroughness of assessment (14%), management options offered (13%), comorbidity (13%) and pain characteristics (5%) were less strongly associated with the decision to consult.

CONCLUSIONS

Anticipating that the GP will regard joint pain as 'part of the normal ageing process that one just has to accept' is a strong disincentive to seeking help, potentially outweighing other aspects of quality of care. Alongside the recognition and management of disrupted function, an important goal of each primary care consultation for osteoarthritis should be to avoid imparting or reinforcing this perception.

The burden of infectious diseases in the Brazilian Southern state of Santa Catarina

Infectious diseases are still significant causes of deaths in Brazil. The objective of this study was to estimate the burden of selected infectious diseases in the Brazilian Southern state of Santa Catarina in 2011. An ecological study was conducted. The infectious diseases included were HIV/AIDS, tuberculosis, hepatitis B, hepatitis C, Chagas disease, diarrheal diseases and other infectious diseases. Data were collected from official health information systems. Disability Adjusted Life Years (DALY) were estimated by the sum of Years of Life Lost (YLL) and Years Lived with Disability (YLD). 45,237.33 DALYs were estimated, with a rate of 685.46 DALYs per 100,000 population. 92.9% was due to YLL and 7.1% to YLD. Men and the age range of 0-4 years presented higher burden. The highest burden was attributed to HIV/AIDS. There was a high concentration of burden rates in the coast regions of the state. It could be concluded that more than 90% of the burden was attributed to the early mortality component. The highest burden was observed among men, children under 5 years of age and at the coast regions of the state. The highest levels of burden were due to HIV/AIDS.

Understanding poor health behaviours as predictors of different types of hospital admission in older people: findings from the Hertfordshire Cohort Study

BACKGROUND

Rates of hospital admission are increasing, particularly among older people. Poor health behaviours cluster but their combined impact on risk of hospital admission among older people in the UK is unknown.

METHODS

2997 community-dwelling men and women (aged 59-73) participated in the Hertfordshire Cohort Study (HCS). We scored (from 0 to 4) number of poor health behaviours engaged in at baseline (1998-2004) out of: current smoking, high weekly alcohol, low customary physical activity and poor diet. We linked HCS with Hospital Episode Statistics and mortality data to 31/03/2010 and analysed associations between the score and risk of different types of hospital admission: any; elective; emergency; long stay (>7 days); 30-day readmission (any, or emergency).

RESULTS

32%, 40%, 20% and 7% of men engaged in 0, 1, 2 and 3/4 poor health behaviours; corresponding percentages for women 51%, 38%, 9%, 2%. 75% of men (69% women) experienced at least one hospital admission. Among men and women, increased number of poor health behaviours was strongly associated (p<0.01) with greater risk of long stay and emergency admissions, and 30-day emergency readmissions. Hazard ratios (HRs) for emergency admission for 3/4 poor health behaviours in comparison with none were: men, 1.37 (95% CI 1.11 to 1.69); women, 1.84 (95% CI 1.22 to 2.77). Associations were unaltered by adjustment for age, body mass index and comorbidity.

CONCLUSIONS

Clustered poor health behaviours are associated with increased risk of hospital admission among older people in the UK. Lifecourse interventions to reduce number of poor health behaviours could have substantial beneficial impact on health and use of healthcare in later life.

How can we improve teaching of ECG interpretation skills? Findings from a prospective randomised trial

BACKGROUND

There is an ongoing debate on how ECG interpretation should be taught during undergraduate medical training. This study addressed the impact of teaching format, examination consequences and student motivation on skills retention.

METHODS

A total of 493 fourth-year medical students participated in a six-group, partially randomised trial. Students received three levels of teaching intensity: self-directed learning (2 groups), lectures (2 groups) or small-group peer-teaching (2 groups). On each level of teaching intensity, end-of-course written examinations (ECG exit exam) were summative in one group and formative in the other. Learning outcome was assessed in a retention test two months later.

RESULTS

Retention test scores were predicted by summative assessments (adjusted beta 4.08; 95% CI 1.39-6.78) but not by the type of teaching. Overall performance levels and motivation did not predict performance decrease or skills retention.

CONCLUSIONS

Summative assessments increase medium-term retention of ECG interpretation skills, irrespective of instructional format.

Disability is associated with emergency room visits in the elderly: a population-based study

BACKGROUND

Emergency room (ER) visits and hospitalizations of elderly subjects with chronic comorbidities, often disabled, are increasing.

AIMS

The aim of the present study was to assess whether among older subjects functional disability is associated with increased ER visits and hospitalization rates.

METHODS

We assessed the association of functional ability with 1-year ER visits and hospitalization rates in all 342 subjects aged 75+ living in Tuscania (Italy) in 2004. Functional ability was estimated using the Katz' activities of daily living (ADLs), and the Lawton and Brody scale for the instrumental activities of daily living (IADLs). Functional disability was defined as the dependence for two or more ADLs or IADLs.

RESULTS

According to Cox regression, disability in ADLs was associated with increased risk of ER visits (RR 2.12; 95 % CI 1.11-4.08; P = .023) but not of hospital admission (RR 1.50; 95 % CI .80-2.80; P = .208). Also, in Poisson regression, ADLs disability predicted the number of ER visits (IRR 2.56; 95 % CI 1.48-4.40; P = .001).

DISCUSSION

Disability is associated with increased risk of ER visits, but not of subsequent hospitalization in community-dwelling elderly, independent of clinical conditions. Dedicated studies are needed to evaluate the impact of social interventions for disabled elderly on ER access rates.

CONCLUSIONS

Emergency Departments should implement innovative triage procedures to identify older patients with disability who gain access to ER, to recognize and classify any unmet social needs.

Determinants of hospital length of stay for people with serious mental illness in England and implications for payment systems: a regression analysis

BACKGROUND

Serious mental illness (SMI), which encompasses a set of chronic conditions such as schizophrenia, bipolar disorder and other psychoses, accounts for 3.4 m (7 %) total bed days in the English NHS. The introduction of prospective payment to reimburse hospitals makes an understanding of the key drivers of length of stay (LOS) imperative. Existing evidence, based on mainly small scale and cross-sectional studies, is mixed. Our study is the first to use large-scale national routine data to track English hospitals' LOS for patients with a main diagnosis of SMI over time to examine the patient and local area factors influencing LOS and quantify the provider level effects to draw out the implications for payment systems.

METHODS

We analysed variation in LOS for all SMI admissions to English hospitals from 2006 to 2010 using Hospital Episodes Statistics (HES). We considered patients with a LOS of up to 180 days and estimated Poisson regression models with hospital fixed effects, separately for admissions with one of three main diagnoses: schizophrenia; psychotic and schizoaffective disorder; and bipolar affective disorder. We analysed the independent contribution of potential determinants of LOS including clinical and socioeconomic characteristics of the patient, access to and quality of primary care, and local area characteristics. We examined the degree of unexplained variation in provider LOS.

RESULTS

Most risk factors did not have a differential effect on LOS for different diagnostic sub-groups, however we did find some heterogeneity in the effects. Shorter LOS in the pooled model was associated with co-morbid substance or alcohol misuse (4 days), and personality disorder (8 days). Longer LOS was associated with older age (up to 19 days), black ethnicity (4 days), and formal detention (16 days). Gender was not a significant predictor. Patients who self-discharged had shorter LOS (20 days). No association was found between higher primary care quality and LOS. We found large differences between providers in unexplained variation in LOS.

CONCLUSIONS

By identifying key determinants of LOS our results contribute to a better understanding of the implications of case-mix to ensure prospective payment systems reflect accurately the resource use within sub-groups of patients with SMI.

Modelling Future Coronary Heart Disease Mortality to 2030 in the British Isles

Objective

Despite rapid declines over the last two decades, coronary heart disease (CHD) mortality rates in the British Isles are still amongst the highest in Europe. This study uses a modelling approach to compare the potential impact of future risk factor scenarios relating to smoking and physical activity levels, dietary salt and saturated fat intakes on future CHD mortality in three countries: Northern Ireland (NI), Republic of Ireland (RoI) and Scotland.

Methods

CHD mortality models previously developed and validated in each country were extended to predict potential reductions in CHD mortality from 2010 (baseline year) to 2030. Risk factor trends data from recent surveys at baseline were used to model alternative future risk factor scenarios: Absolute decreases in (i) smoking prevalence and (ii) physical inactivity rates of up to 15% by 2030; relative decreases in (iii) dietary salt intake of up to 30% by 2030 and (iv) dietary saturated fat of up to 6% by 2030. Probabilistic sensitivity analyses were then conducted.

Results

Projected populations in 2030 were 1.3, 3.4 and 3.9 million in NI, RoI and Scotland respectively (adults aged 25–84). In 2030: assuming recent declining mortality trends continue: 15% absolute reductions in smoking could decrease CHD deaths by 5.8–7.2%. 15% absolute reductions in physical inactivity levels could decrease CHD deaths by 3.1–3.6%. Relative reductions in salt intake of 30% could decrease CHD deaths by 5.2–5.6% and a 6% reduction in saturated fat intake might decrease CHD deaths by some 7.8–9.0%. These projections remained stable under a wide range of sensitivity analyses.

Conclusions

Feasible reductions in four cardiovascular risk factors (already achieved elsewhere) could substantially reduce future coronary deaths. More aggressive polices are therefore needed in the British Isles to control tobacco, promote healthy food and increase physical activity.

Improving cardiovascular disease using managed networks in general practice: an observational study in inner London

BACKGROUND

System redesign is described in one primary care trust (PCT)/clinical commissioning group (CCG) resulting in improved cardiovascular disease (CVD) management.

AIM

To evaluate CVD managed practice networks in one entire local health economy using practice networks, compared with PCTs in London, England, and local PCTs.

DESIGN AND SETTING

Observational study of 34 general practices in Tower Hamlets, a socially disadvantaged inner-London borough.

METHOD

In 2009, all 34 practices were allocated to eight geographical networks of four to five practices, each serving 30 000-50 000 patients. Each network had a network manager, administrative support, and an educational budget to deliver financially-incentivised attainment targets in four care packages of which CVD comprised one.

RESULTS

In 2009/11, Tower Hamlets increased total statin prescribing (ADQ-STAR PU) by 17.9% compared with 5.5% in England (P<0.001). Key CVD indicators improved faster in Tower Hamlets than in England, London, or local PCTs, and in 2012/13, Tower Hamlets ranked top in the national Quality and Outcomes Framework for blood pressure and cholesterol control in coronary heart disease (CHD) and diabetes, top five for stroke and top in London for all these measures. Male mortality from CHD was fourth highest in England in 2008 and reduced more than any other PCT in the next 3 years; reducing by 43% compared with an average fall of 25% for the top 10 PCTs in 2008 ranked by mortality.

CONCLUSION

Managed geographical practice networks delivered a step-change in key CVD performance indicators in comparison with England, London, or similar PCT/CCGs.

Alcohol use, socioeconomic deprivation and ethnicity in older people

OBJECTIVES

This study explores the relationship between alcohol consumption, health, ethnicity and socioeconomic deprivation.

PARTICIPANTS

27,991 people aged 65 and over from an inner-city population, using a primary care database.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures were alcohol use and misuse (>21 units per week for men and >14 for units per week women).

RESULTS

Older people of black and minority ethnic (BME) origin from four distinct ethnic groups comprised 29% of the sample. A total of 9248 older drinkers were identified, of whom 1980 (21.4%) drank above safe limits. Compared with older drinkers, older unsafe drinkers contained a higher proportion of males, white and Irish ethnic groups and a lower proportion of Caribbean, African and Asian groups. For older drinkers, the strongest independent predictors of higher alcohol consumption were younger age, male gender and Irish ethnicity. Independent predictors of lower alcohol consumption were Asian, black Caribbean and black African ethnicity. Socioeconomic deprivation and comorbidity were not significant predictors of alcohol consumption in older drinkers. For older unsafe drinkers, the strongest predictor variables were younger age, male gender and Irish ethnicity; comorbidity was not a significant predictor. Lower socioeconomic deprivation was a significant predictor of unsafe consumption whereas African, Caribbean and Asian ethnicity were not.

CONCLUSIONS

Although under-reporting in high-alcohol consumption groups and poor health in older people who have stopped or controlled their drinking may have limited the interpretation of our results, we suggest that closer attention is paid to 'young older' male drinkers, as well as to older drinkers born outside the UK and those with lower levels of socioeconomic deprivation who are drinking above safe limits.

Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

Up-to-date evidence about levels and trends in disease and injury incidence, prevalence, and years lived with disability (YLDs) is an essential input into global, regional, and national health policies. In the Global Burden of Disease Study 2013 (GBD 2013), we estimated these quantities for acute and chronic diseases and injuries for 188 countries between 1990 and 2013.

METHODS

Estimates were calculated for disease and injury incidence, prevalence, and YLDs using GBD 2010 methods with some important refinements. Results for incidence of acute disorders and prevalence of chronic disorders are new additions to the analysis. Key improvements include expansion to the cause and sequelae list, updated systematic reviews, use of detailed injury codes, improvements to the Bayesian meta-regression method (DisMod-MR), and use of severity splits for various causes. An index of data representativeness, showing data availability, was calculated for each cause and impairment during three periods globally and at the country level for 2013. In total, 35 620 distinct sources of data were used and documented to calculated estimates for 301 diseases and injuries and 2337 sequelae. The comorbidity simulation provides estimates for the number of sequelae, concurrently, by individuals by country, year, age, and sex. Disability weights were updated with the addition of new population-based survey data from four countries.

FINDINGS

Disease and injury were highly prevalent; only a small fraction of individuals had no sequelae. Comorbidity rose substantially with age and in absolute terms from 1990 to 2013. Incidence of acute sequelae were predominantly infectious diseases and short-term injuries, with over 2 billion cases of upper respiratory infections and diarrhoeal disease episodes in 2013, with the notable exception of tooth pain due to permanent caries with more than 200 million incident cases in 2013. Conversely, leading chronic sequelae were largely attributable to non-communicable diseases, with prevalence estimates for asymptomatic permanent caries and tension-type headache of 2·4 billion and 1·6 billion, respectively. The distribution of the number of sequelae in populations varied widely across regions, with an expected relation between age and disease prevalence. YLDs for both sexes increased from 537·6 million in 1990 to 764·8 million in 2013 due to population growth and ageing, whereas the age-standardised rate decreased little from 114·87 per 1000 people to 110·31 per 1000 people between 1990 and 2013. Leading causes of YLDs included low back pain and major depressive disorder among the top ten causes of YLDs in every country. YLD rates per person, by major cause groups, indicated the main drivers of increases were due to musculoskeletal, mental, and substance use disorders, neurological disorders, and chronic respiratory diseases; however HIV/AIDS was a notable driver of increasing YLDs in sub-Saharan Africa. Also, the proportion of disability-adjusted life years due to YLDs increased globally from 21·1% in 1990 to 31·2% in 2013.

INTERPRETATION

Ageing of the world's population is leading to a substantial increase in the numbers of individuals with sequelae of diseases and injuries. Rates of YLDs are declining much more slowly than mortality rates. The non-fatal dimensions of disease and injury will require more and more attention from health systems. The transition to non-fatal outcomes as the dominant source of burden of disease is occurring rapidly outside of sub-Saharan Africa. Our results can guide future health initiatives through examination of epidemiological trends and a better understanding of variation across countries.

FUNDING

Bill & Melinda Gates Foundation.

Quantifying the Socio-Economic Benefits of Reducing Industrial Dietary Trans Fats: Modelling Study

BACKGROUND

Coronary Heart Disease (CHD) remains a leading cause of UK mortality, generating a large and unequal burden of disease. Dietary trans fatty acids (TFA) represent a powerful CHD risk factor, yet to be addressed in the UK (approximately 1% daily energy) as successfully as in other nations. Potential outcomes of such measures, including effects upon health inequalities, have not been well quantified. We modelled the potential effects of specific reductions in TFA intake on CHD mortality, CHD related admissions, and effects upon socioeconomic inequalities.

METHODS & RESULTS

We extended the previously validated IMPACTsec model, to estimate the potential effects of reductions (0.5% & 1% reductions in daily energy) in TFA intake in England and Wales, stratified by age, sex and socioeconomic circumstances. We estimated reductions in expected CHD deaths in 2030 attributable to these two specific reductions. Output measures were deaths prevented or postponed, life years gained and hospital admissions. A 1% reduction in TFA intake energy intake would generate approximately 3,900 (95% confidence interval (CI) 3,300-4,500) fewer deaths, 10,000 (8,800-10,300) (7% total) fewer hospital admissions and 37,000 (30,100-44,700) life years gained. This would also reduce health inequalities, preventing five times as many deaths and gaining six times as many life years in the most deprived quintile compared with the most affluent. A more modest reduction (0.5%) would still yield substantial health gains.

CONCLUSIONS

Reducing intake of industrial TFA could substantially decrease CHD mortality and hospital admissions, and gain tens of thousands of life years. Crucially, this policy could also reduce health inequalities. UK strategies should therefore aim to minimise industrial TFA intake.

Exploring the attitudes towards and experiences of geocaching amongst families in the community

There is a need for physical activity interventions to focus on autonomous forms of motivation to increase uptake and maintenance. Geocaching is a GPS-based treasure-hunt game with potential to increase levels of walking. The study aim was to explore the experiences of a geocaching intervention for people introduced to geocaching. A five-week geocaching intervention took place. Participants (n = 30) were recruited via school assemblies and village posters. Semi-structured telephone interviews (n = 21) were conducted post intervention to determine the participants' motives, barriers and experiences of geocaching. Geocaching motivators (social activity, challenge/discovery) and barriers (lack of time, problems with mobile technology and unsuccessful trips) were identified. Findings suggest that geocaching is a feasible activity to promote physical activity, particularly among families. Further robust and larger scale trials are required that target sedentary individuals, adopting strategies to reduce perceived barriers to geocaching.

How many foods in the UK carry health and nutrition claims, and are they healthier than those that do not?

Objective

The present study aimed to measure the prevalence of different types of health and nutrition claims on foods and non-alcoholic beverages in a UK sample and to assess the nutritional quality of such products carrying health or nutrition claims.

Design

A survey of health and nutrition claims on food packaging using a newly defined taxonomy of claims and internationally agreed definitions of claim types.

Setting

A national UK food retailer: Tesco.

Subjects

Three hundred and eighty-two products randomly sampled from those available through the retailer’s website.

Results

Of the products, 32 % (95 % CI 28, 37 %) carried either a health or nutrition claim; 15 % (95 % CI 11, 18 %) of products carried at least one health claim and 29 % (95 % CI 25, 34 %) carried at least one nutrition claim. When adjusted for product category, products carrying health claims tended to be lower in total fat and saturated fat than those that did not, but there was no significant difference in sugar or sodium levels. Products carrying health claims had slightly higher fibre levels than products without. Results were similar for comparisons between products that carry nutrition claims and those that do not.

Conclusions

Health and nutrition claims appear frequently on food and beverage products in the UK. The nutrient profile of products carrying claims is marginally healthier than for similar products without claims, suggesting that claims may have some but limited informational value. The implication of these findings for guiding policy is unclear; future research should investigate the ‘clinical relevance’ of these differences in nutritional quality.

Trends in disease burden in Germany: results, implications and limitations of the Global Burden of Disease study

BACKGROUND

The Global Burden of Disease (GBD) study is designed to give a comprehensive and standardized assessment of the health of populations around the world. It measures the burden of disease by considering years of life lost due to premature death as well as years lived with disability. The findings enable the identification of secular trends and disparities between countries and can serve as a basis for decision-making in health policy.

METHOD

In cooperation with the authors of the GBD study, we summarize the key methods used to assess the burden of disease in terms of disability-adjusted life years (DALYs). We present findings that specifically pertain to Germany, drawn from freely available data of the most recent round of analysis for the years 1990 and 2010.

RESULTS

According to the GBD study, life expectancy in Germany rose from 75.4 years in 1990 to 80.2 years in 2010. Ischemic heart disease and back pain caused the largest number of DALYs lost (2.5 million and 2.1 million, respectively). Over the period of the study, the absolute number of DALYs due to ischemic heart disease dropped by 33%, while the number of DALYs due to low back pain rose by 11%. Nutrition-related risks ranked first among all risk factors considered, accounting for 13.8% of total DALYs, followed by high blood pressure and high body-mass index, accounting for 10.9% each.

CONCLUSION

In Germany, important changes have been seen over time in the burden of disease attributable to different chronic diseases. Some of these changes reflect the successful interventions of the past, while others indicate a need for new action. The data from Germany that went into the GBD study must be systematically assessed and supplemented by further data relating to questions of specific relevance in this country.

Mortality from heart failure, acute myocardial infarction and other ischaemic heart disease in England and Oxford: a trend study of multiple-cause-coded death certification

Background

Age-standardised death rates from acute myocardial infarction (AMI) and ischaemic heart disease (IHD) have been declining in most developed countries. However, the magnitude of such reductions and how they impact on death from heart failure are less certain. We sought to assess and compare temporal trends in mortality from heart failure, AMI and non-AMI IHD over a 30-year period in England.

Methods

We analysed death registration data for multiple-cause-coded mortality for all deaths in people aged 35 years and over in England from 1995 to 2010, population 52 million, and in a regional population (Oxford region) from 1981 to 2010, population 2.5 million, for which data on all causes of death were available.

Results

Considering all ages and both sexes combined, during the 30-year observation period, age-standardised and sex-standardised mortality rates based on all certified causes of death declined by 60% for heart failure, 80% for AMI and 46% for non-AMI IHD. These longer term trends observed in the Oxford region were consistent with those for the whole of England from 1995 to 2010, with no evidence of a plateau in recent years. Although proportional reductions in rates differed by age and sex, even in those aged 85 years or more, there were substantial reductions in mortality rates in the all-England data set (50%, 66% and 20% for heart failure, AMI and non-AMI IHD, respectively).

Conclusions

This study shows large and sustained reductions in age-specific and sex-specific and standardised death rates from heart failure, as well as from AMI and non-AMI IHD, over a 30-year period in England.

Heme Oxygenase Improves Renal Function by Potentiating Podocyte-Associated Proteins in Nω-Nitro-l-Arginine-Methyl Ester (l-NAME)-Induced Hypertension

BACKGROUND

Although heme-oxygenase (HO) is cytoprotective, its effects on podocyte regulators like podocalyxin, podocin, CD2-associated protein (CD2AP) in renal dysfunction in N (ω)-nitro-l-arginine-methyl ester (l-NAME) hypertension are largely unclear.

METHODS

Hypertension was induced in normotensive Sprague Dawley rats by administering l-NAME for 4 weeks. Enzyme immunoassay, enzyme-linked immunosorbent, histology/morphology, spectrophotometry, and western immunoblotting were used. HO was enhanced with heme-arginate (HA) or inhibited with chromium mesoporphyrin (CrMP).

RESULTS

Treatment with heme-arginate reduced several renal histo-pathological lesions including renal arteriolar thickening, glomerular abnormalities, tubular cast, tubular atrophy/fibrosis, and mononuclear cell infiltration in l-NAME-hypertensive rats. Similarly, HA abated the elevated levels of renal extracellular matrix/profibrotic proteins like collagen and fibronectin that deplete nephrin, a fundamental transmembrane protein that forms the scaffoldings of the podocyte slit diaphragm permitting small ions to filter, but not massive excretion of proteins, hence proteinuria. Correspondingly, HA enhanced the aberrant expression of nephrin alongside other important regulators of podocyte like podocalyxin, podocin, and CD2AP, and improved renal function by reducing albuminuria/proteinuria, while increasing creatinine clearance. The renoprotection by HA were accompanied by significant reduction of inflammatory/oxidative mediators including nuclear factor-kappaB, macrophage inflammatory protein-1-alpha, macrophage chemoattractant protein-1, tumor necrosis factor-alpha, interleukin (IL)-6, IL1β, 8-isoprostane, endothelin-1, and aldosterone. These were associated with increased levels of adiponectin, HO-1, HO activity, cyclic guanosine monophosphate, and atrial natriuretic peptide (ANP), whereas the HO inhibitor, CrMP annulled the renoprotection and exacerbated renal dysfunction.

CONCLUSIONS

HA improves renal function by attenuating histopathological lesions, suppressing inflammatory/oxidative mediators, abating profibrotic/extracellular matrix proteins, and reducing albuminuria/proteinuria, while concomitantly potentiating the HO-adiponectin-ANP axis, enhancing nephrin, podocin, podocalyxin, CD2AP and increasing creatinine clearance. Our study underscores the benefit of potentiating the HO-adiponectin-ANP against nephropathy.

Mesenchymal stem cell response to topographically modified CoCrMo

Surface roughness on implant materials has been shown to be highly influential on the behavior of osteogenic cells. Four surface topographies were engineered on cobalt chromium molybdenum (CoCrMo) in order to examine this influence on human mesenchymal stem cells (MSC). These treatments were smooth polished (SMO), acid etched (AE) using HCl 7.4% and H₂SO₄ 76% followed by HNO₃ 30%, sand blasted, and acid etched using either 50 μm Al₂O₃ (SLA50) or 250 μm Al₂O₃ grit (SLA250). Characterization of the surfaces included energy dispersive X‐ray analysis (EDX), contact angle, and surface roughness analysis. Human MSCs were cultured onto the four CoCrMo substrates and markers of cell attachment, retention, proliferation, cytotoxicity, and osteogenic differentiation were studied. Residual aluminum was observed on both SLA surfaces although this appeared to be more widely spread on SLA50, whilst SLA250 was shown to have the roughest topography with an R_a value greater than 1 μm. All substrates were shown to be largely non‐cytotoxic although both SLA surfaces were shown to reduce cell attachment, whilst SLA50 also delayed cell proliferation. In contrast, SLA250 stimulated a good rate of proliferation resulting in the largest cell population by day 21. In addition, SLA250 stimulated enhanced cell retention, calcium deposition, and hydroxyapatite formation compared to SMO (p < 0.05). The enhanced response stimulated by SLA250 surface modification may prove advantageous for increasing the bioactivity of implants formed of CoCrMo. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 103A: 3747–3756, 2015.

Developing a framework for estimating the potential impact of obesity interventions in a European city

Obesity is a global challenge for healthy populations. It has given rise to a wide range of public health interventions, focusing on supportive environments and lifestyle change, including diet, physical activity and behavioural change initiatives. Impact is variable. However, more evidence is slowly becoming available and is being used to develop new interventions. In a period of austerity, momentum is building to review these initiatives and understand what they do, how they do it and how they fit together. Our project seeks to develop a relatively straight forward systematic framework using readily accessible data to map the complex web of initiatives at a policy, population, group and individual level aiming to promote healthy lifestyles, diet and physical activity levels or to reduce obesity through medical treatments in a city or municipality population. It produces a system for classifying different types of interventions into groupings which will enable commissioners to assess the scope and distribution of interventions and make a judgement about gaps in provision and the likely impact on mean body mass index (BMI) as a proxy measure for health. Estimated impact in each level or type of intervention is based upon a summary of the scientific evidence of clinical and/or cost effectiveness. Finally it seeks, where possible, to quantify the potential effects of different types of interventions on BMI and produce a cost per unit of BMI reduced. This approach is less sophisticated but identifies the areas where more sophisticated evaluation would add value.

Nationwide Birth Weight and Gestational Age-specific Neonatal Mortality Rate in Taiwan

BACKGROUND

There are limited nationwide data relating to neonatal mortality rate in Taiwan. This study aims to provide updated national birth weight/gestational age-specific neonatal mortality reference rates.

METHODS

We abstracted the birth registration database from the Ministry of Interior in Taiwan from 1998 to 2002 and linked the data to the death registration database from the Ministry of Health and Welfare in Taiwan between 1998 and 2003. We included 1,331,785 infants born between 20 weeks and 44 weeks of gestation and weighing within the median ± 2 interquartile ranges in their age group in this study. We calculated the birth weight/gestational age-specific neonatal mortality rates of different genders by birth weight increments of 250 g and at gestational age intervals of 1 week. A Poisson regression model was used in modeling the mortality data.

RESULTS

A total of 4,169 deaths occurred within 28 days of life out of a total of 1,331,785 live births between 20 weeks and 44 weeks of gestation, giving a neonatal mortality rate (0-27 days) of 3.39 per 1000 live births for males and 2.80 per 1000 for females. The infant mortality rate remained higher in the male (5.91 per 1000) than the female (5.10 per 1000) population within the 1(st) year of life. Birth weight/gestational age-specific neonatal mortality rates were plotted with curves representing the 10(th) and 90(th) birth weight percentiles. The risk of an early neonatal death (0-6 days) does not exceed 50% except for female neonates < 500 g and ≤ 23 weeks, which implies that the limit of viability is now at 23 weeks for females.

CONCLUSION

We have provided an easy-to-use birth weight/gestational age-specific neonatal mortality rate chart as a reference document that physicians and parents can use to make decisions based on ethical considerations relating to whether to give palliative care or further invasive management. The normative data are crucial for public health policies on neonatal care in Taiwan.

Association between male sex and increased mortality after falls

OBJECTIVES

Whether sex affects the mortality of trauma patients remains unknown. The hypothesis of this study was that sex was associated with altered mortality rates in trauma.

METHODS

A retrospective review of trauma patients' records in the Japan Trauma Data Bank was conducted (n = 80,813) from 185 major emergency hospitals across Japan. The primary outcome variable was in-hospital mortality within 28 days. Secondary outcome variables included serious injuries to different body regions with an Abbreviated Injury Scale of ≥3.

RESULTS

In the analysis of 80,813 trauma patients, males had significantly greater 28-day mortality compared to females (adjusted p = 0.0072, odds ratio [OR] = 1.14, 95% confidence interval [CI] = 1.06 to 1.23) via logistic regression analysis adjusted for age, mechanism, Injury Severity Score, Revised Trauma Score, and potential preexisting risk factors. Of 10 injury categories examined, sex significantly affected in-hospital 28-day mortality rate in falls (adjusted p < 0.0001, OR = 1.34, 95% CI = 1.19 to 1.52). Further analysis of three fall subcategories by falling distance revealed that male patients who fell from ground level had significantly higher 28-day mortality (adjusted p < 0.0001, OR = 1.75, 95% CI = 1.43 to 2.14) and a significantly greater frequency of serious injury to the head, thorax, abdomen, and spine, but a lower frequency of serious injury to the extremities, compared to female patients.

CONCLUSIONS

Compared to female trauma patients, male trauma patients had greater 28-day mortality. In particular, ground-level falls had a significant sex difference in mortality, with serious injury to different body regions. Sex differences appeared to be important for fatalities from ground-level falls.

Applying the behaviour change technique (BCT) taxonomy v1: a study of coder training

Behaviour Change Technique Taxonomy v1 (BCTTv1) has been used to detect active ingredients of interventions. The purpose of this study was to evaluate effectiveness of user training in improving reliable, valid and confident application of BCTTv1 to code BCTs in intervention descriptions. One hundred sixty-one trainees (109 in workshops and 52 in group tutorials) were trained to code frequent BCTs. The following measures were taken before and after training: (i) inter-coder agreement, (ii) trainee agreement with expert consensus, (iii) confidence ratings and (iv) coding competence. Coding was assessed for 12 BCTs (workshops) and for 17 BCTs (tutorials). Trainees completed a course evaluation. Methods improved agreement with expert consensus (p < .05) but not inter-coder agreement (p = .08, p = .57, respectively) and increased confidence for BCTs assessed (both p < .05). Methods were as effective as one another at improving coding competence (p = .55). Training was evaluated positively. The training improved agreement with expert consensus, confidence for BCTs assessed, coding competence but not inter-coder agreement. This varied according to BCT.