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Background: The requirement to meet the palliative needs of acute hospital populations has grown in recent years. With increasing numbers of frail older people needing hospital care as a result of both malignant and nonmalignant conditions, emphasis is being placed upon understanding the physical, psychological and social burdens experienced by patients. This study explores the extent of burden in two large UK hospitals, focusing upon those patients who meet palliative care criteria. Furthermore, the paper explores the use of palliative services and identifies the most significant clinical diagnostic and demographic factors which determine physical and psychological burden. Methods: Two hospital surveys were undertaken to identify burden using the Sheffield Profile for Assessment and Referral to Care (SPARC). The Gold Standards Framework (GSF) is used to identify those patients meeting palliative care criteria. Participants were identified as being in-patients during a two-week data collection phase for each site. Data was gathered using face-to-face interviews or self-completion by patients or a proxy. Descriptive analyses highlight prevalence and use of palliative care provision. Binary logistic regression assesses clinical diagnostic predictor variables of physical and psychological burden. Results: The sample consisted of 514 patients and elevated physical, psychological and social burden is identified amongst those meeting palliative care criteria (n = 185). Tiredness (34.6%), pain (31.1%), weakness (28.8%) and psychological discomfort (low mood 19.9%; anxiety 16.1%) are noted as being prevalent. A small number of these participants accessed Specialist Palliative Care (8.2%). Dementia was identified as a predictor of physical (OR 3.94; p < .05) and psychological burden (OR 2.88; p < .05), being female was a predictor of psychological burden (OR 2.00; p < .05). Conclusion: The paper highlights elevated levels of burden experienced by patients with palliative care requirements. Moreover, the paper also indicates that a large proportion of such patients are not in receipt of palliative approaches to their care. Furthermore, the paper identifies that those with non-malignant illnesses, especially dementia, may experience high levels of physical and psychological burden. [ABSTRACT FROM AUTHOR]

Background: Although free eye testing is available in the UK from a nation-wide network of optometrists, there is evidence of unrecognised, tractable vision loss amongst older people. A recent review identified this unmet need as a priority for further investigation, highlighting the need to understand public perceptions of eye services and barriers to service access and utilisation. This paper aims to identify risk factors for (1) having poor vision and (2) not having had an eyesight check among community-dwelling older people without an established ophthalmological diagnosis. Methods: Secondary analysis of self-reported data from the ProAge trial. 1792 people without a known ophthalmological diagnosis were recruited from three group practices in London. Results: Almost two in ten people in this population of older individuals without known ophthalmological diagnoses had self-reported vision loss, and more than a third of them had not had an eye test in the previous twelve months. In this sample, those with limited education, depressed mood, need for help with instrumental and basic activities of daily living (IADLs and BADLs), and subjective memory complaints were at increased risk of fair or poor self-reported vision. Individuals with basic education only were at increased risk for not having had an eye test in the previous 12 months (OR 1.52, 95% CI 1.17-1.98 p=0.002), as were those with no, or only one chronic condition (OR 1.850, 95% CI 1.382-2.477, p<0.001). Conclusions: Self-reported poor vision in older people without ophthalmological diagnoses is associated with other functional losses, with no or only one chronic condition, and with depression. This pattern of disorders may be the basis for case finding in general practice. Low educational attainment is an independent determinant of not having had eye tests, as well as a factor associated with undiagnosed vision loss. There are other factors, not identified in this study, which determine uptake of eye testing in those with self-reported vision loss. Further exploration is needed to identify these factors and lead towards effective case finding. [ABSTRACT FROM AUTHOR]

Background Whether the quality of life (QOL) impacts longevity is an interesting research question that has been investigated only in the context of disease and health-related QOL. This paper aims to examine prospectively whether Control, Autonomy, Selfrealisation, and Pleasure (CASP) scores, a measure of generic QOL, can predict mortality in the British Household Panel Survey sample during 2001-2006. Methods The authors used data from the British Household Panel Survey wave 11 (2001-2002) when CASP was first presented to the participants in the survey. The authors selected all those who were interviewed directly and face to face and who were 40 years or older (N=10 291). The authors followed them for the next five waves (waves 12-16) and in this study primary outcome was all-cause mortality. Other covariates used were age, sex, socioeconomic position, household income, self-rated health, limiting longstanding illness and medical conditions. Results Compared with a mortality of 12/1000 personyears in those having average QOL (CASP score 29.4-45.8), those with below-average QOL had more than twice (27/1000 person-years) and those above average had a third less (8/1000 person-years) mortality. This gradient was retained for the most part when age and sex strata were examined separately. Regression models adjusted for covariates confirmed the protective effect of QOL on mortality. Domain-specific analysis showed that only control and self-realisation had this effect. Conclusion CASP predicted 5-year all-cause mortality significantly. Improvement in the QOL reduced the probability of death. [ABSTRACT FROM AUTHOR]

Objective This paper examines how negative experiences with the health-care system create a lack of confidence in receiving medical care in seven countries: Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. Methods The empirical analysis is based on data from the Commonwealth Fund International Health Policy Survey 2007, with nationally representative samples of adults aged 18 and over. For the analysis of the experience of cost barriers and confidence in receiving medical care, we conducted pairwise comparisons of group percentages as well as country-wise multivariate logistic regression models. Results Individuals who have experienced cost barriers show a significantly lower level of confidence in receiving safe and quality medical care than those who have not. This effect is most pronounced in the United States, where people who have foregone necessary treatment because of costs are four times as likely to lack confidence as individuals without the experience of cost barriers (adjusted odds ratio 4.00). In New Zealand, Germany, and Canada, individuals with the experience of cost barriers are twice as likely to report low confidence compared with those without this experience (adjusted odds ratios of 1.95, 2.19 and 2.24, respectively). In the Netherlands and UK, cost barriers are only a marginal phenomenon. Conclusions The fact that the experience of financial barriers considerably lowers confidence indicates that financial incentives, such as private co-payments, have a negative effect on overall public support and therefore on the legitimacy of health-care systems. [ABSTRACT FROM AUTHOR]

BACKGROUND: Evidence for a potential link between air pollution and rheumatoid arthritis (RA) is inconsistent, and the modified effect of genetic susceptibility on the relationship between air pollution and RA has not been well studied. OBJECTIVE: Using a general population cohort from the UK Biobank, this study aimed to investigate the associations between various air pollutants and the risk of incident RA and to further estimate the impact of combined exposure to ambient air pollutants on the risk of developing RA under the modification effect of genetic predisposition. METHODS: A total of 342,973 participants with completed genotyping data and who were free of RA at baseline were included in the study. An air pollution score was constructed by summing the concentrations of each pollutant weighted by the regression coefficients with RA from single-pollutant models to assess the combined effect of air pollutants, including particulate matter (PM) with diameters ≤ 2.5 µm (PM2.5), between 2.5 and 10 µm (PM2.5–10), and ≤ 10 µm (PM10), as well as nitrogen dioxide (NO2) and nitrogen oxides (NOx). In addition, the polygenic risk score (PRS) of RA was calculated to characterize individual genetic risk. The Cox proportional hazard model was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) of associations of single air pollutant, air pollution score, or PRS with incident RA. RESULTS: During a median follow-up time of 8.1 y, 2,034 incident events of RA were recorded. The HRs (95% CIs) of incident RA per interquartile range increment in PM2.5, PM2.5-10, PM10, NO2, and NOx were 1.07 (1.01, 1.13), 1.00 (0.96, 1.04), 1.01 (0.96, 1.07), 1.03 (0.98, 1.09), and 1.07 (1.02, 1.12), respectively. We also found a positive exposure-response relationship between air pollution score and RA risk (푝Trend = 0.000053). The HR(95% CI) of incident RA was 1.14 (1.00, 1.29) in the highest quartile group compared with the lowest quartile group of the air pollution score. Furthermore, the results of the combined effect of air pollution score and PRS on the RA risk showed that the risk of RA incidence in the highest genetic risk and air pollution score group was almost twice that of the lowest genetic risk and air pollution score group [incidence rate (IR) per 100,000 person-years: 98.46 vs. 51.19, and HR= 1.73 (95% CI: 1.39, 2.17) vs. 1 (reference)], although no statistically significant interaction between the air pollution and genetic risk for incident RA was found (푝Interaction >0.05). DISCUSSION: The results revealed that long-term combined exposure to ambient air pollutants might increase the risk of RA, particularly in those with high genetic risk. [ABSTRACT FROM AUTHOR]

Background The contemporary environment is a complex of interactions between physical, biological, socio-economic systems with major impacts on public health. However, gaps in our understanding of the causes, extent and distribution of these effects remain. The public health community in Sandwell West Midlands has collaborated to successfully develop, pilot and establish the first Environmental Public Health Tracking (EPHT) programme in Europe to address this 'environmental health gap' through systematically linking data on environmental hazards, exposures and diseases. Methods Existing networks of environmental, health and regulatory agencies developed a suite of innovative methods to routinely share, integrate and analyse data on hazards, exposures and health outcomes to inform interventions. Results Effective data sharing and horizon scanning systems have been established, novel statistical methods piloted, plausible associations framed and tested, and targeted interventions informed by local concerns applied. These have influenced changes in public health practice. Conclusion EPHT is a powerful tool for identifying and addressing the key environmental public health impacts at a local level. Sandwell's experience demonstrates that it can be established and operated at virtually no cost. The transfer of National Health Service epidemiological skills to local authorities in 2013 provides an opportunity to expand the programme to fully exploit its potential. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether the introduction of non‐invasive pre‐natal testing for Down's syndrome (DS) has the potential to undermine informed choice. Participants: Three hundred and ninety‐three health professionals; 523 pregnant women. Methods: A cross‐sectional questionnaire study across nine maternity units and three conferences in the UK designed to assess opinions regarding test delivery and how information should be communicated to women when offered Down's syndrome screening (DSS) or diagnosis using invasive (IDT) or non‐invasive testing (NIPT). Results: Both pregnant women and health professionals in the NIPT and DSS groups were less likely than the IDT group to consider that testing should take place at a return visit or that obtaining written consent was necessary, and more likely to think testing should be carried out routinely. Compared to health professionals, pregnant women expressed a stronger preference for testing to occur on the same day as pre‐test counselling (P = 0.000) and for invasive testing to be offered routinely (P = 0.000). They were also more likely to indicate written consent as necessary for DSS (P = 0.000) and NIPT (P < 0.05). Conclusions: Health professionals and pregnant women view the consenting process differently across antenatal test types. These differences suggest that informed choice may be undermined with the introduction of NIPT for DS into clinical practice. To maintain high standards of care, effective professional training programmes and practice guidelines are needed which prioritize informed consent and take into account the views and needs of service users. [ABSTRACT FROM AUTHOR]

Background: The BeWEL (BodyWEight and physicaL activity) randomised controlled trial demonstrated that a weight management programme offered in the colorectal cancer screening setting was effective. However, the differential responses of participants to the programme were notable. This study aimed to explore the factors associated with success and to identify implications for future programme design. Methods: Analyses were conducted of quantitative data (n= 148) from the BeWEL intervention group to compare demographic and psychosocial characteristics and lifestyle changes in those who met and exceeded the target 7 % weight loss ('super-achievers') with those who achieved only 'moderate' or low' amounts of weight loss (2-7 % loss, or <2 % loss, respectively). In-depth qualitative interviews (n = 24) explored in detail the motivations, actions, pathways to weight loss and circumstances of study participants. Results: Over the 12 month intervention period, mean percentage weight loss of super-achievers (n = 33) was 11.5 %, compared with moderate-achievers (n = 58) who lost 4.2 %, and low-achievers (n = 57) who gained 0.8 %. Compared to other groups, super- achievers increased their fruit and vegetable intake (p < 0.01) and physical activity (step count, p < 0.01). 'Super-achievers' did not differ in baseline demographic characteristics from other participants. However, significantly fewer reported that their activities were limited by physical and emotional health and they were more likely to perceive their current diet as harmful. Qualitative analyses found no consistent patterns among super-achievers in relation to some factors identified as important in previous studies, such as social support. However, super-achievers shared several characteristics such as determination and consistency in their engagement with the intervention, receptivity to new information and prompts, previous positive experience of changing health behaviours, being motivated by early success, making changes routine, and an ability to devise and apply strategies for dealing with setback and 'relapse' triggers. Conclusions: Successful lifestyle change depends on active engagement as well as effective intervention ingredients. Weight loss interventions are likely to be more effective where they can adapt to participants' differing characteristics and needs, while also providing core elements likely to build success. [ABSTRACT FROM AUTHOR]

Different front-of-pack (FOP) labelling systems have been developed in Europe by industry and organisations concerned with health promotion. A study (n 2068) was performed to establish the extent to which inclusion of the most prevalent FOP systems – guideline daily amounts (GDA), traffic lights (TL), GDA+TL hybrid (HYB) and health logos (HL) – impact consumer perceptions of healthiness over and above the provision of a FOP basic label (BL) containing numerical nutritional information alone. The design included within- and between-subjects factors. The within-subjects factors were: food (pizzas, yogurts and biscuits), healthiness of the food (high health, medium health and low health) and the repeated measurements under BL and test FOP label conditions. The between-subjects factors were: the system (GDA, TL, GDA+TL hybrid, HL), portion size (typical portion size and a 50 % reduction of a typical portion) and country (the UK, Germany, Poland and Turkey). Although the FOP systems tested did result in small improvements for objective understanding under some conditions, there was little difference between the provision of an FOP label containing basic numerical nutritional information alone or between the various systems. Thus, any structured and legible presentation of key nutrient and energy information on the FOP label is sufficient to enable consumers to detect a healthier alternative within a food category when provided with foods that have distinctly different levels of healthiness. Future research should focus on developing greater understanding of the psychological and contextual factors that impact motivation and the opportunity to use the various FOP systems in real-world shopping settings. [ABSTRACT FROM PUBLISHER]

Dietary intake/status of the trace mineral Se may affect the risk of developing hypertensive conditions of pregnancy, i.e. pre-eclampsia and pregnancy-induced hypertension (PE/PIH). In the present study, we evaluated Se status in UK pregnant women to establish whether pre-pregnant Se status or Se supplementation affected the risk of developing PE/PIH. The samples originated from the SPRINT (Selenium in PRegnancy INTervention) study that randomised 230 UK primiparous women to treatment with Se (60 μg/d) or placebo from 12 weeks of gestation. Whole-blood Se concentration was measured at 12 and 35 weeks, toenail Se concentration at 16 weeks, plasma selenoprotein P (SEPP1) concentration at 35 weeks and plasma glutathione peroxidase (GPx3) activity at 12, 20 and 35 weeks. Demographic data were collected at baseline. Participants completed a FFQ. UK pregnant women had whole-blood Se concentration lower than the mid-range of other populations, toenail Se concentration considerably lower than US women, GPx3 activity considerably lower than US and Australian pregnant women, and low baseline SEPP1 concentration (median 3·00, range 0·90–5·80 mg/l). Maternal age, education and social class were positively associated with Se status. After adjustment, whole-blood Se concentration was higher in women consuming Brazil nuts (P= 0·040) and in those consuming more than two seafood portions per week (P= 0·054). A stepwise logistic regression model revealed that among the Se-related risk factors, only toenail Se (OR 0·38, 95 % CI 0·17, 0·87, P= 0·021) significantly affected the OR for PE/PIH. On excluding non-compliers with Se treatment, Se supplementation also significantly reduced the OR for PE/PIH (OR 0·30, 95 % CI 0·09, 1·00, P= 0·049). In conclusion, UK women have low Se status that increases their risk of developing PE/PIH. Therefore, UK women of childbearing age need to improve their Se status. [ABSTRACT FROM PUBLISHER]

There has been a worldwide epidemic of obesity in recent decades. In animal studies, there is convincing evidence that light exposure causes weight gain, even when calorie intake and physical activity are held constant. Disruption of sleep and circadian rhythms by exposure to light at night (LAN) might be one mechanism contributing to the rise in obesity, but it has not been well-investigated in humans. Using multinomial logistic regression, we examined the association between exposure to LAN and obesity in questionnaire data from over 100,000 women in the Breakthrough Generations Study, a cohort study of women aged 16 years or older who were living in the United Kingdom and recruited during 2003–2012. The odds of obesity, measured using body mass index, waist:hip ratio, waist:height ratio, and waist circumference, increased with increasing levels of LAN exposure (P < 0.001), even after adjustment for potential confounders such as sleep duration, alcohol intake, physical activity, and current smoking. We found a significant association between LAN exposure and obesity which was not explained by potential confounders we could measure. While the possibility of residual confounding cannot be excluded, the pattern is intriguing, accords with the results of animal experiments, and warrants further investigation. [ABSTRACT FROM PUBLISHER]

Background: circulating measures of inflammatory markers, such as C-reactive protein (CRP) have been associated with an increased risk of future cognitive decline. However, the nature of the relationship among the very old (>75 years) is unclear. Cross-sectional evidence suggests that elevated CRP may even be protective in this age group. This study examines these associations longitudinally.Methods: logistic regression was used to investigate the association between CRP and drop in cognitive performance (≥3 point change on the Mini-Mental State Examination) over a 4-year period in a population of 266 people, mean age 77 years.Results: increased levels of CRP were associated with a decreased risk of a drop in cognitive performance; however, this association was only seen in those without an APOE e4 allele [odds ratio of decline per unit increase in ln(CRP) 0.57, P = 0.04]. The magnitude of the finding remained consistent after adjustment for cardiovascular confounders (smoking, drinking, MI, stroke, diabetes, education, medication and blood pressure). For those with an e4 allele, the relationship with longitudinal cognitive decline was neither statistically significant nor in a consistent direction after controlling for acute inflammation.Conclusions: this study strengthens previous cross-sectional findings and shows elevated levels of CRP to be linked to a decreased risk of longitudinal cognitive decline in the very old. However, as with prior analyses, this was only observed in those not carrying an APOE e4 allele. Future work on larger APOE e4 allele carrying samples is required to determine the nature of the association in this population. [ABSTRACT FROM AUTHOR]

Background Little is known about preschool-aged children's levels of physical activity (PA) over the course of the day. Using time-stamped data, we describe the levels and patterns of PA in a population-based sample of four-year-old British children. Methods Within the Southampton Women's Survey the PA levels of 593 4-year-old children (51% female) were measured using (Actiheart) accelerometry for up to 7 days. Three outcome measures: minutes spent sedentary (<20 cpm); in light (LPA:≥20 - 399 cpm) and in moderate-to-vigorous activity (MVPA:≥400 cpm) were derived. Average daily activity levels were calculated and then segmented across the day (morning, afternoon and evening). MVPA was log-transformed. Two-level random intercept models were used to analyse associations between activity level and temporal and demographic factors. Results Children were active for 67% (mean 568.5 SD 79.5 minutes) of their daily registered time on average, with 88% of active time spent in LPA. All children met current UK guidelines of 180 minutes of daily activity. There were no differences in children's average daily levels of sedentary activity and LPA by temporal and demographic factors: differences did emerge when activity was segmented across the day. Sex differences were largest in the morning, with girls being more sedentary, spending fewer minutes in LPA and 18% less time in MVPA than boys. Children were more sedentary and less active (LPA and MVPA) in the morning if they attended childcare full-time compared to part-time, and on weekend mornings compared to weekdays. The reverse was true for weekend afternoons and evenings. Children with more educated mothers were less active in the evenings. Children were less sedentary and did more MVPA on summer evenings compared to winter evenings. Conclusions Preschool-aged children meet current physical activity guidelines, but with the majority of their active time spent in LPA, investigation of the importance of activity intensity in younger children is needed. Activity levels over the day differed by demographic and temporal factors, highlighting the need to consider temporality in future interventions. Increasing girls' morning activity and providing opportunities for daytime activity in winter months may be worthwhile. [ABSTRACT FROM AUTHOR]

Background: unplanned hospital admissions of older patients continue to attract the attention of UK policymakers, advisors and media. Reducing the number and length of stay (LOS) of these admissions has the potential to save NHS substantial costs while reducing iatrogenic risks. Some NHS trusts have introduced geriatric admission-avoidance systems, but evidence of their effectiveness is lacking. In September 2010, The Royal Free Hospital and Haverstock Healthcare Ltd, a GP provider organisation, introduced an admission-avoidance system for patients aged 70 or over: the Triage and Rapid Elderly Assessment Team (TREAT).Objective: to measure the effect of TREAT on LOS and the rate of same-day discharges (an inverse measure of admission rate).Setting: TREAT was based in the Accident and Emergency (A&E) department of the Royal Free Hospital, London.Design: a pre- and post-retrospective cohort study comparing the 5,416 emergency geriatric admissions in the 12 months preceding the introduction of TREAT with the 5,370 emergency geriatric admissions in the 12 months following. Emergency geriatric admissions were divided into TREAT-matching and residual (non-matching) cohorts from hospital provider spell records, using the Healthcare Resource Group (HRG), treatment function and patient classification of the TREAT admissions. LOS and same-day discharge rates were measured over the pre- and post-TREAT periods: for the TREAT-matching cohort; for the residual cohort of emergency geriatric admissions; and for all emergency geriatric admissions.Intervention: TREAT is a system of care combining early Accident and Emergency (A&E)-based senior doctor review, Comprehensive Geriatric Assessment (CGA), therapist assessment and supported discharge; post-discharge supported recovery; and a rapid access geriatric ‘hot-clinic’. TREAT was supported by a post-acute care enablement (PACE) team, providing short-term nursing support immediately following discharge.Results: TREAT accepted 593 geriatric admissions over a 12-month period, of which 32.04% were discharged on the day of admission. The mean LOS was 4.41 days, and the median LOS was 1 day. After the introduction of TREAT, mean LOS reduced by 18.16% (1.78 days, P < 0.001) for TREAT-matching admissions; by 11.65% (1.13 days, P < 0.001) for all emergency geriatric admissions; and by 1.08% (0.11 days, P = 0.065) for the residual population. Over the same period, the percentage of admissions resulting in same-day discharges increased from 12.26 to 16.23% (OR: 1.386, 95% CI: 1.203–1.597, P < 0.001) for TREAT-matching admissions, but for the residual population fell from 15.01 to 9.77% (OR: 0.613, P < 0.001, 95% CI: 0.737–0.509).Conclusions: TREAT appears to have reduced avoidable emergency geriatric admissions, and to have shortened LOS for all emergency geriatric admissions. It aims to address the King's Fund's call for an ‘overall system of care rather than lots of discrete processes’ through ‘better design and co-ordination of services following the needs of older people’. The ease of set-up lends itself to replication and testing in clinical and cost-effectiveness studies. Further studies are needed to measure the impact of TREAT on re-admission rates, patient outcomes and satisfaction. [ABSTRACT FROM PUBLISHER]

Background: This study predicts the implications of under-reporting of alcohol consumption in England for alcohol consumption above Government drinking thresholds. Methods: Two nationally representative samples of private households in England were used: General LiFestyle survey (GLF) and Health Survey for England (HSE) 2008. Participants were 9608 adults with self-reported alcohol consumption on heaviest drinking day in the last week (HSE) and 12 490 adults with self-reported average weekly alcohol consumption (GLF). Alcohol consumption in both surveys was revised to account for under-reporting in three hypothetical scenarios. The prevalence of drinking more than UK Government guidelines of 21/14 (men/women) alcohol units a week, and 4/3 units per day, and the prevalence of binge drinking (>8/6 units) were investigated using logistic regression. Results: Among drinkers, mean weekly alcohol intake increases to 20.8 units and mean alcohol intake on heaviest drinking day in the last week increases to 10.6 units. Over one-third of adults are drinking above weekly guidelines and over three-quarters drank above daily limits on their heaviest drinking day in the last week. The revision changes some of the significant predictors of drinking above thresholds. In the revised scenario, women have similar odds to men of binge drinking and higher odds of drinking more than daily limits, compared with lower odds in the original survey. Conclusion: Revising alcohol consumption assuming equal under-reporting across the population does not have an equal effect on the proportion of adults drinking above weekly or daily thresholds. It is crucial that further research explores the population distribution of under-reporting. [ABSTRACT FROM AUTHOR]

In this article, the authors focus on the multicentre randomised controlled trial (ROSSINI Trial) related to the impact of a wound edge protection device (WEPD) on surgical site infection in patients after laparotomy. According to the trial, WEPDs are not useful in reducing the rate of surgical site infection and patients diagnosed with an infection experienced longer hospital stay. They also mention that they carried out secondary analyses on the basis of contamination during operation.

The article focuses on a study to investigate the role of a specialist medical and mental health unit (MMHU) in improving outcomes, experience, and satisfaction for older people with dementia or delirium admitted to an acute hospital as compared to standard care. A randomised controlled trial was compared with a specialist medical and mental health unit providing best practice care with standard hospital wards. The study took place in a single centre in Great Britain which provided sole acute hospital medical services for its population.

This study examined the impact of point-of-sale (POS) tobacco marketing restrictions in Australia and Canada, in relation to the United Kingdom and the United States where there were no such restrictions during the study period (2006-10). The data came from the International Tobacco Control Four Country Survey, a prospective multi-country cohort survey of adult smokers. In jurisdictions where POS display bans were implemented, smokers' reported exposure to tobacco marketing declined markedly. From 2006 to 2010, in Canada, the percentages noticing POS tobacco displays declined from 74.1 to 6.1% [adjusted odds ratio (OR)=0.26, P < 0.001]; and reported exposure to POS tobacco advertising decreased from 40.3 to 14.1% (adjusted OR=0.61, P<0.001). Similarly, in Australia, noticing of POS displays decreased from 73.9 to 42.9%. In contrast, exposure to POS marketing in the United States and United Kingdom remained high during this period. In parallel, there were declines in reported exposures to other forms of advertising/promotion in Canada and Australia, but again, not in the United States or United Kingdom. Impulse purchasing of cigarettes was lower in places that enacted POS display bans. These findings indicate that implementing POS tobacco display bans does result in lower exposure to tobacco marketing and less frequent impulse purchasing of cigarettes. [ABSTRACT FROM AUTHOR]

Our objective in this study was to estimate the probability that a Chlamydia trachomatis (CT) infection will cause an episode of clinical pelvic inflammatory disease (PID) and the reduction in such episodes among women with CT that could be achieved by annual screening. We reappraised evidence from randomized controlled trials of screening and controlled observational studies that followed untreated CT-infected and -uninfected women to measure the development of PID. Data from these studies were synthesized using a continuous-time Markov model which takes into account the competing risk of spontaneous clearance of CT. Using a 2-step piecewise homogenous Markov model that accounts for the distinction between prevalent and incident infections, we investigated the possibility that the rate of PID due to CT is greater during the period immediately following infection. The available data were compatible with both the homogenous and piecewise homogenous models. Given a homogenous model, the probability that a CT episode will cause clinical PID was 0.16 (95% credible interval (CrI): 0.06, 0.25), and annual screening would prevent 61% (95% CrI: 55, 67) of CT-related PID in women who became infected with CT. Assuming a piecewise homogenous model with a higher rate during the first 60 days, corresponding results were 0.16 (95% CrI: 0.07, 0.26) and 55% (95% CrI: 32, 72), respectively. [ABSTRACT FROM PUBLISHER]

Background: Approximately 18 000 personnel leave the UK Armed Forces annually. Those leaving before completing the minimum term of their contracts are called early Service leavers (ESLs). This study aims to identify characteristics associated with being an ESL, and compare the post-discharge mental health of ESLs and other Service leavers (non-ESLs). Method: A cross-sectional study used data on ex-Serving UK Armed Forces personnel. ESLs were personnel leaving before completing their 3–4.5 years minimum Service contracts and were compared with non-ESLs. Multivariable logistic regression was used to estimate odds ratios and 95% confidence intervals for the associations between Service leaving status with socio-demographics, military characteristics and mental health outcomes. Results: Of 845 Service leavers, 80 (9.5%) were ESLs. Being an ESL was associated with younger age, female sex, not being in a relationship, lower rank, serving in the Army and with a trend of reporting higher levels of childhood adversity, but not with deployment to Iraq. ESLs were at an increased risk of probable post-traumatic stress disorder (PTSD), common mental disorders, fatigue and multiple physical symptoms, but not alcohol misuse. Conclusions: The study suggests that operational Service is not a factor causing personnel to become an ESL. Current mental health problems were more commonly reported among ESLs than other Service leavers. There may be a need to target interventions to ESLs on leaving Service to smooth their transition to civilian life and prevent the negative mental health outcomes experienced by ESLs further down the line. [ABSTRACT FROM PUBLISHER]

Background: living alone in later life has been linked to psychological distress but less is known about the role of the transition into living alone and the role of social and material resources.Methods: a total of 21,535 person-years of data from 4,587 participants of the British Household Panel Survey aged 65+ are analysed. Participants provide a maximum 6 years' data (t0−t5), with trajectories of living arrangements classified as: consistently partnered/ with children/alone; transition from partnered to alone/with children to alone. General Health Questionnaire (GHQ)-12 caseness (score >3) is investigated using multi-level logistic regression, controlling for sex, age, activities of daily living, social and material resources.Results: after a transition from partnered at t0 to alone at t1, the odds for GHQ-12 caseness increased substantially, but by t3 returned to baseline levels. The odds for caseness at t0 were highest for those changing from living with a child at t0 to living alone at t1 but declined following the transition to living alone. None of the covariates explained these associations. Living consistently alone did confer increased odds for caseness.Conclusions: living alone in later life is not in itself a strong risk factor for psychological distress. The effects of transitions to living alone are dependent on the preceding living arrangement and are independent of social and material resources. This advocates a longitudinal approach, allowing identification of respondents' location along trajectories of living arrangements. [ABSTRACT FROM PUBLISHER]

An association of gestational weight gain (GWG) with offspring cognition has been postulated. We used data from the Avon Longitudinal Study of Parents and Children, a United Kingdom prospective cohort (1990 through the present) with a median of 10 maternal weight measurements in pregnancy. These were used to allocate participants to 2009 Institute of Medicine weight-gain categories and in random effect linear spline models. Outcomes were School Entry Assessment score (age, 4 years; n = 5,832), standardized intelligence quotient assessed by Wechsler Intelligence Scale for Children (age, 8 years; n = 5,191), and school final-examination results (age, 16 years; n = 7,339). Offspring of women who gained less weight than recommended had a 0.075 standard deviation lower mean School Entry Assessment score (95% confidence interval: −0.127, −0.023) and were less likely to achieve adequate final-examination results (odds ratio = 0.88, 95% confidence interval: 0.78, 0.99) compared with offspring of women who gained as recommended. GWG in early pregnancy (defined as 0–18 weeks on the basis of a knot point at 18 weeks) and midpregnancy (defined as 18–28 weeks on the basis of knot points at 18 and 28 weeks) was positively associated with School Entry Assessment score and intelligence quotient. GWG in late pregnancy (defined as 28 weeks onward on the basis of a knot point at 28 weeks) was positively associated with offspring intelligence quotient and with increased odds of offspring achieving adequate final-examination results in mothers who were overweight prepregnancy. Findings support small positive associations between GWG and offspring cognitive development, which may have lasting effects on educational attainment up to age 16 years. [ABSTRACT FROM PUBLISHER]

Background: People with larger social networks are known to have better well-being; however, little is known about (1) the association with socio-demographic factors that may predict the size and composition of social networks and (2) whether the association with well-being is independent of pre-existing psychological health or socio-demographic factors. Methods: The authors used information collected from 3169 men and 3512 women who were born in Great Britain in 1958. First, age on leaving full-time education, partnership and employment status at age 42 were used to predict the size and composition of cohort members' social networks at age 45 using ordered logistic regression. Second, using multiple linear regression, the associations between social network size by composition (relatives and friends) and psychological well-being at age 50 were assessed, adjusting for socio-demographic factors and psychological health at age 42. Results: Not having a partner and staying in full-time education after age 16 was associated with a smaller kinship network in adults. Having a smaller friendship network at age 45 was associated with poorer psychological well-being among adults at age 50, over and above socio-demographic factors and previous psychological health. Additionally, having a smaller kinship network was associated with poorer psychological well-being among men. Conclusions: Having a well-integrated friendship network is a source of psychological well-being among middle-aged adults, while kinship networks appear to be more important for men's well-being than for women's. These relationships are independent of education, material status and prior psychological health. [ABSTRACT FROM AUTHOR]

Background Emerging evidence suggests that experienced racism might help explain observed ethnic inequalities in early child health and development. There are few studies outside the US context and none that consider mothers' experiences of racism in relation to a range of early childhood health and developmental markers. Methods The authors used cross-sectional data from the UK Millennium Cohort Study on 2136 mothers and their 5-year-old children from ethnic minority groups. Measures of racism tapped two dimensions of mothers' experience: perceived frequency of racist attacks in residential area and interpersonal racism. Markers of child health and development were obesity; socioemotional difficulties; cognitive: verbal, non-verbal and spatial ability test scores. Results There was a suggestion that the mothers' experience of interpersonal racism was associated with an increased risk of obesity ('received insults' OR=1.47; 'treated unfairly' OR=1.57; 'disrespectful treatment by shop staff' OR=1.55), but all CIs crossed 1.0, and size estimates were attenuated on further statistical adjustment. Perception of racism in the residential area was associated with socioemotional difficulties (fully adjusted coefficient=1.40, SE=0.47) and spatial abilities (fully adjusted coefficient=1.99, SE=0.93) but not with verbal or non-verbal ability scores. Maternal experiences of racist insults were associated with nonverbal ability scores (fully adjusted coefficient=−1.70, SE=0.88). Conclusion The results suggest that mothers' experienced racism is linked to markers of early child health and development. Interventions that aim to improve early child development and address ethnic health inequalities need to incorporate approaches to tackling racism at all levels of society. [ABSTRACT FROM AUTHOR]

Background: Supported self-management, acupuncture and information can help reduce the symptoms of low back pain. These approaches are currently recommended by NICE guidance as treatment options for patients with persistent low back pain. However, there has been no previous evaluation of a service providing them together for this common problem. The purpose of this service evaluation was to report patient outcomes and experiences of the Beating Back Pain Service (BBPS), a pilot service based in a primary and community care setting, delivering acupuncture, self-management and information to patients with chronic low back pain. Methods: Patients completed a questionnaire at three time points: pre-BBPS, immediately post-BBPS and three months post-BBPS. Outcome measures included the Bournemouth Questionnaire (measuring musculoskeletal, MSK, problems), EuroQoL-5D (measuring quality of life), Pain and Self-efficacy Questionnaire, and additional questions on medication use, physical activity, understanding of pain and positive well-being. Additionally, the STarT Back (measuring risk of developing chronic pain) was collected at BBPS information sessions. Non-parametric tests were used to evaluate pre- and post- variables. Questionnaires also collected qualitative data (open-text responses) regarding patient views and experiences of the BBPS, which were analysed using thematic analysis. Results: 80 (out of 108) patients who attended the initial BBPS information session agreed to participate in the service evaluation (mean age 47 years, 65% female). 65 patients attended subsequent BBPS acupuncture and/or self-management sessions and were asked to complete post-treatment questionnaires; complete datasets were available for 61 patients. There were statistically significant improvements over time for pain (p <0.0001), quality of life (p = 0.006), understanding of pain (p <0.001), physical activity (p = 0.047) and relaxation (p = 0.012). Post-hoc analysis revealed that scores improved between baseline and posttreatment, these improvements were maintained at 3-month follow-up (except relaxation). Patients receiving a combination of acupuncture and self-management sessions produced the most positive results. Patient satisfaction with the BBPS was high. Conclusions: The BBPS provided a MSK pain management service that many patients found effective and valuable. Combining self-management with acupuncture was found to be particularly effective, although further consideration is required regarding how best to engage patients in self-management. [ABSTRACT FROM AUTHOR]

Introduction: In adults, multimorbidity is associated with social position. Socially disadvantaged adults typically experience more chronic illness at a younger age than comparable individuals who are more advantaged. The relation between social position and multimorbidity amongst children and adolescents has not been as widely studied and is less clear. Methods: The NHS Information Centre (NHS IC) linked participants in the Avon Longitudinal Study of Parents and Children (ALSPAC) to the General Practice Research Database (GPRD). Multimorbidity was measured in three different ways: using a count of the number of drugs prescribed, a count of chronic diseases, and a person's predicted resource use score; the latter two measures were derived using the Johns Hopkins ACG system. A number of different socio-economic position variables measured as part of ALSPAC during pregnancy and early childhood were considered. Ordered logistic and negative binomial regression models were used to investigate associations between socio-economic variables and multimorbidity. Results: After mutually adjusting for the different markers of socio-economic position, there was evidence, albeit weak, that chronic condition counts among children aged from 0 to 9 years were higher among those whose mothers were less well educated (OR = 0.44; 95% confidence interval 0.18-1.10; p = 0.08). Conversely, children whose mothers were better educated had higher rates of chronic illness between 10 and 18 years (OR = 1.94; 95% CI 1.14-3.30). However, living in a more deprived area, as indicated by the Townsend score, was associated with a higher odds of chronic illness between 10 and 18 years (OR for each increasing decile of Townsend score = 1.09; 95% CI 1.00-1.19; p = 0.06). Conclusions: We have found some evidence that, in younger children, multimorbidity may be higher amongst children whose parents are less well educated. In older children and adolescents this association is less clear. We have also demonstrated that linkage between prospective observational studies and electronic patient records can provide an effective way of obtaining objectively measured outcome variables. [ABSTRACT FROM AUTHOR]

Reserve and National Guard forces have been mobilized to an unprecedented degree in recent overseas conflicts. There is concern that rates of psychological problems may continue to rise for many years after deployment. The authors conducted a cohort study of 552 United Kingdom Reservists who deployed to Iraq in 2003 and 391 nondeployed Reservists. Measures of mental health and social functioning were collected a mean of 16 months and 4.8 years after return from possible deployment. At the first follow-up, deployment was associated with increased common mental disorder, post-traumatic stress disorder (PTSD), and poor general health. By the second follow-up, those who had deployed were no longer at increased risk for common mental disorder or poor general health and had good levels of social functioning. However, those who deployed continued to have over twice the odds of PTSD (odds ratio = 2.42, 95% confidence interval: 1.04, 5.62) and were more likely to report actual or serious consideration of separation from their partner. In conclusion, the authors found that the majority of mental health and social problems following deployment are transient. However, Reservists who deployed in the Iraq War remain at increased risk of PTSD and relationship problems 5 years after their tour of duty. [ABSTRACT FROM AUTHOR]

Background: identification of patients at risk of prolonged hospital stay allows staff to target interventions, provide informed prognosis and manage healthcare resources. Admission grip strength is associated with discharge outcomes in acute hospital settings.Objective: to explore the relationship between grip strength and length of stay in older rehabilitation in-patients.Design: single-centre prospective cohort study.Setting: community hospital rehabilitation ward.Subjects: one hundred and ten patients aged 70 years and over.Methods: data on age, height, weight, body mass index (BMI), co-morbidities, medication, residence, grip strength, physical function, cognitive function, frailty, falls, discharge destination and length of stay were recorded.Results: higher grip strength was associated with reduced length of stay, characterised by an increased likelihood of discharge to usual residence among male rehabilitation in-patients (hazard ratio 1.09 (95% confidence interval 1.01, 1.17) per kilo increase in grip strength, P = 0.02) after adjustment for age and size.Conclusions: this is the first prospective study to show that stronger grip strength, particularly among male in-patients, is associated with a shorter length of stay in a rehabilitation ward. This is important because it demonstrates that grip strength can be discriminatory among frailer people. Further research into the clinical applications of grip strength measurement in rehabilitation settings is needed. [ABSTRACT FROM AUTHOR]

Background: Despite the ban on misleading descriptors such as light or mild cigarettes in Europe, there are still widespread misperceptions of the relative harmfulness of different brands of cigarettes among smokers. This study examined the extent to which smokers in three European countries believed that some cigarette brands are less harmful and why, using data from the International Tobacco Control (ITC) Europe surveys. Methods: Cross-sectional analyses were completed among nationally representative samples of 4,956 current smokers (aged ≥ 18) from Germany (n = 1,515), France (n = 1,735) and the United Kingdom (n = 1,706) conducted between September 2006 and November 2007. Logistic regression models examined whether outcomes, including beliefs that some cigarettes could be less harmful than others, varied by socio-demographic and country of residence. Findings: Around a quarter of smokers in the UK and France, and a third in Germany believed some cigarettes are less harmful than others. Overall, of smokers who falsely believed that some cigarettes are less harmful, 86.3% thought that tar/nicotine yields, 48.7% taste, and 40.4% terms on packs such as ‘smooth’ or ‘ultra’ indicated less harmful brands. About a fifth of smokers across all countries chose their brand based on health reasons, and a similar proportion gave tar yields as a reason for choosing brands. Conclusions: Our research suggests that the current European Tobacco Products Directive is inadequate in eliminating misperceptions about the relative risk of brand descriptors on cigarettes. There is therefore an urgent need to protect smokers in Europe from these misperceptions via stronger measures such as plain packaging regulations. [ABSTRACT FROM AUTHOR]

Because few prospective studies have examined the independent influence of mothers and fathers on smoking experimentation, we tested the association between a set of parent-specific, familial and peer interactions with smoking experimentation in early adolescence. Data come from two cohorts in the British Youth Panel Survey (N = 1736; mean age at baseline, 11.26; SD = 0.65), a study of children resident with members of the British Household Panel Survey. Baseline data showed 8.2% of participants had smoked which increased to 40.3% after a 3-year follow-up. Multivariate logistic regression models showed risk factors for the onset of experimentation included frequent time spent with peers (P < 0.001), maternal smoking (P = 0.001), female gender and older participant age (P < 0.001). Parent–child quarrels, mother–child conversations, family meal frequency and household income were not significantly associated with experimentation. Frequent father–child conversations, about things which mattered to children, were the only type of parent–child contact associated with a reduced risk of experimentation (P < 0.001), and a significant interaction suggested that maternal smoking increased the likelihood of girls but not boys experimentation (P = 0.01). This study suggests that familial risk and protective factors operate independently and that more attention should be paid to the role of fathers in smoking prevention. [ABSTRACT FROM PUBLISHER]

The article offers information on a study conducted on the relationship of primary health care with persistence of insomnia. It states that pain is related to insomnia, and is a cofounder between poor sleep and the use of primary health care. It mentions that 69 percent of the participants continued to suffer from insomnia.

Background: Eating context is the immediate environment of each eating occasion (EO). There is limited knowledge on the effects of the eating context on food consumption in children, due to the difficulty in measuring the multiple eating contexts children experience throughout the day. This study applied ecological momentary assessment using food diaries to explore the relationships between eating context and fruit and vegetable consumption in UK children. Methods: Using 4 d unweighed food diaries, data were collected for 642 children aged 1.5-10y in two years of the UK National Diet and Nutrition Survey (2008-2010). Participants recorded all foods and drinks consumed at each EO, where and with whom the food was consumed, whether the TV was on and if eaten at a table. Mixed logistic regression and mixed multinomial logistic regression were used to calculate associations between eating contexts and fruit and vegetables (FV) consumed by quartiles. Results: Of 16,840 EOs, 73% took place at home and 31% with parents only. Frequency of eating alone and with friends increased with age. Compared to eating at home, children aged 1.5-3y were more likely to consume fruit at care outside home (>10-50g OR:2.39; >50-100g OR:2.12); children aged 4-6y were more likely to consume fruit (>50-100g OR:3.53; >100g OR:1.88) and vegetables at school (>30-60g OR:3.56). Compared to eating with parents only, children aged 1.5-3y were more likely to consume fruit with friends (>10-50g OR:2.69; >50-100g OR:3.49), and with carer and other children/others (>10-50g OR:2.25); children aged 4-6y were more likely to consume fruit (>50-100g OR:1.96) and vegetables with friends (>30-60g OR:3.56). Children of all ages were more likely to eat vegetables when the TV was off than on and at a table than not at table. Conclusions: The use of food diaries to capture multiple eating contexts and detailed fruit and vegetable consumption data was demonstrated at a population level. Higher odds of FV consumption were seen from structured settings such as school and care outside home than at home, as well as when eating at a table and the TV off. This study highlights eating contexts where provision of fruit and vegetables could be improved, especially at home. Future research should take eating context into consideration when planning interventions to target children's food consumption and eating behaviour. [ABSTRACT FROM AUTHOR]

Background Engagement in risk behaviours may pose a significant threat to health if involvement spans multiple behaviours. The asset model suggests that contextual aspects of young people's lives, such as factors related to family, school and community, serve as a protective function against health risk behaviours. Methods A risk-taking index was created from the English health behaviour in school-aged children study on 15 years olds, substance use and sexual activity. Using a multinomial regression, potential asset variables relating to school, family, peers, community and family affluence were tested for their association with levels of risk behaviours. Results Sense of neighbourhood belonging, strong school belonging and parental involvement in decision-making about leisure time were related to lower engagement in health risk behaviours. A weaker sense of family belonging was associated with increased risk behaviours if connectedness with teachers was also low. Factors related to school and community played a greater role in adolescent participation in health-related risk behaviours than family-related factors, including family affluence. Conclusions Feelings of safety and belonging in the out-of-home settings of adolescents were positively associated with reduced risk behaviours, and indicate the importance of the wider community alongside parents and school as protective assets for health. [ABSTRACT FROM AUTHOR]