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Residents of socioeconomically deprived areas perceive their neighbourhood as less conducive to healthy behaviours than residents of more affluent areas. Whether these unfavourable perceptions are based on objective neighbourhood features or other factors is poorly understood. We examined individual and contextual correlates of socioeconomic inequalities in neighbourhood perceptions across five urban regions in Europe. Data were analysed from 5205 participants of the SPOTLIGHT survey. Participants reported perceptions of their neighbourhood environment with regard to aesthetics, safety, the presence of destinations and functionality of the neighbourhood, which were summed into an overall neighbourhood perceptions score. Multivariable multilevel regression analyses were conducted to investigate whether the following factors were associated with socioeconomic inequalities in neighbourhood perceptions: objectively observed neighbourhood features, neighbourhood social capital, exposure to the neighbourhood, self-rated health and lifestyle behaviours. Objectively observed traffic safety, aesthetics and the presence of destinations in the neighbourhood explained around 15% of differences in neighbourhood perceptions between residents of high and low neighbourhoods; levels of neighbourhood social cohesion explained around 52%. Exposure to the neighbourhood, self-rated health and lifestyle behaviours were significant correlates of neighbourhood perceptions but did not contribute to socioeconomic differences. This cross-European study provided evidence that socioeconomic differences in neighbourhood perceptions are not only associated with objective neighbourhood features but also with social cohesion. Levels of physical activity, sleep duration, self-rated health, happiness and neighbourhood preference were also associated with neighbourhood perceptions., (© 2016 World Obesity.)

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., (Copyright © 2015 Newton et al. Open Access article distributed under the terms of CC BY. Published by Elsevier Ltd.. All rights reserved.)

Objective: The prevalence of childhood and adult obesity in Malta is among the highest in the world. Although increasingly recognised as a public health problem with substantial future economic implications for the national health and social care systems, understanding the context underlying the burden of obesity is necessary for the development of appropriate counter-strategies., Design: We conducted a contextual analysis to explore factors that may have potentially contributed to the establishment of an obesogenic environment in Malta. A search of the literature published between 1990 and 2013 was conducted in MEDLINE and EMBASE. Twenty-two full-text articles were retrieved. Additional publications were identified following recommendations by Maltese public health experts; a review of relevant websites; and thorough hand searching of back issues of the Malta Medical Journal since 1990., Setting: Malta., Subjects: Whole population, with a focus on children., Results: Results are organised and presented using the ANalysis Grid for Elements Linked to Obesity (ANGELO) framework. Physical, economic, policy and socio-cultural dimensions of the Maltese obesogenic environment are explored., Conclusions: Malta's obesity rates may be the result of an obesogenic environment characterised by limited infrastructure for active living combined with an energy-dense food supply. Further research is required to identify and quantify the strength of interactions between these potential environmental drivers of obesity in order to enable appropriate countermeasures to be developed.

Objectives: To describe the design, methods and first results of a survey on obesity-related behaviours and body mass index (BMI) in adults living in neighbourhoods from five urban regions across Europe., Design: A cross-sectional observational study in the framework of an European Union-funded project on obesogenic environments (SPOTLIGHT)., Setting: 60 urban neighbourhoods (12 per country) were randomly selected in large urban zones in Belgium, France, Hungary, the Netherlands and the UK, based on high or low values for median household income (socioeconomic status, SES) and residential area density., Participants: A total of 6037 adults (mean age 52 years, 56% female) participated in the online survey., Outcome Measures: Self-reported physical activity, sedentary behaviours, dietary habits and BMI. Other measures included general health; barriers and motivations for a healthy lifestyle, perceived social and physical environmental characteristics; the availability of transport modes and their use to specific destinations; self-defined neighbourhood boundaries and items related to residential selection., Results: Across five countries, residents from low-SES neighbourhoods ate less fruit and vegetables, drank more sugary drinks and had a consistently higher BMI. SES differences in sedentary behaviours were observed in France, with residents from higher SES neighbourhoods reporting to sit more. Residents from low-density neighbourhoods were less physically active than those from high-density neighbourhoods; during leisure time and (most pronounced) for transport (except for Belgium). BMI differences by residential density were inconsistent across all countries., Conclusions: The SPOTLIGHT survey provides an original approach for investigating relations between environmental characteristics, obesity-related behaviours and obesity in Europe. First descriptive results indicate considerable differences in health behaviours and BMI between countries and neighbourhood types., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Variations in data collection between collecting regions can affect the outcome measures. This study examines the impact of improvements in data collection on outcome measures in a national monitoring programme between 2007/2008 and 2010/2011. Multilevel analysis of 2007/2008 and 2010/2011 National Child Measurement Programme (NCMP) data estimated the relationship between body mass index (BMI) z-score and data collection variations within coordinating regions, while adjusting for individual-level and school-level factors. The total sample was 2,013,285 students from 17,279 primary schools in 152 coordinating regions in England. Data collection differences accounted for 31.2% of the regional variation in BMI z-score for Reception (aged 4-5 years) students in 2007/2008; this reduced to 12.6% in 2010/2011. For Year 6 (aged 10-11 years) students, it reduced from 5.3% in 2007/2008 to 2.4% in 2010/2011. Digit preference in the rounding of weight measurements showed the largest decreases, from 27.3 to 4.5% for Reception year pupils and from 4.2 to 1.0% for Year 6 pupils. This demonstrates that improvements in data collection variation between regions in the NCMP have led to improvements in data quality.

Background: International evidence shows that severe paediatric obesity results in an increased risk of ill health and may require specialised weight management strategies, yet there remains a lack of data on the extent of the problem., Objective: To examine the prevalence of severe obesity in children aged 4-5 and 10-11 years, attending English schools between 2006/2007 and 2012/2013., Design: A retrospective analysis of National Child Measurement Programme (NCMP) data., Setting: Maintained schools in England., Participants: All children aged 4-5 and 10-11 years included in the NCMP dataset., Main Outcome Measures: Prevalence of severe childhood obesity, defined using the 99.6th centile of the British 1990 (UK90) growth reference for body mass index (BMI), analysed by sex, geography, ethnic group and deprivation., Results: The key findings show that in 2012/2013, severe obesity (BMI ≥UK90 99.6th centile) was found in 1.9% of girls and 2.3% of boys aged 4-5 years, and 2.9% of girls and 3.9% of boys aged 10-11 years. Severe obesity prevalence varies geographically and is more prevalent in children from deprived areas, and among those from black ethnic groups., Conclusions: The findings from this study should help to raise awareness of the prevalence of severe obesity and support the provision of adequate treatment and prevention services both to support children who are already severely obese and reduce the prevalence of extreme weight in the future., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

To achieve WHO's target to halt the rise in obesity and diabetes, dramatic actions are needed to improve the healthiness of food environments. Substantial debate surrounds who is responsible for delivering effective actions and what, specifically, these actions should entail. Arguments are often reduced to a debate between individual and collective responsibilities, and between hard regulatory or fiscal interventions and soft voluntary, education-based approaches. Genuine progress lies beyond the impasse of these entrenched dichotomies. We argue for a strengthening of accountability systems across all actors to substantially improve performance on obesity reduction. In view of the industry opposition and government reluctance to regulate for healthier food environments, quasiregulatory approaches might achieve progress. A four step accountability framework (take the account, share the account, hold to account, and respond to the account) is proposed. The framework identifies multiple levers for change, including quasiregulatory and other approaches that involve government-specified and government-monitored progress of private sector performance, government procurement mechanisms, improved transparency, monitoring of actions, and management of conflicts of interest. Strengthened accountability systems would support government leadership and stewardship, constrain the influence of private sector actors with major conflicts of interest on public policy development, and reinforce the engagement of civil society in creating demand for healthy food environments and in monitoring progress towards obesity action objectives., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: Self-management strategies have the potential to support patients with chronic obstructive pulmonary disease (COPD). Telehealth interventions may have a role in delivering this support along with the opportunity to monitor symptoms and physiological variables. This paper reports findings from a six-month, clinical, cohort study of COPD patients' use of a mobile telehealth based (mHealth) application and how individually determined alerts in oxygen saturation levels, pulse rate and symptoms scores related to patient self-initiated treatment for exacerbations., Methods: The development of the mHealth intervention involved a patient focus group and multidisciplinary team of researchers, engineers and clinicians. Individual data thresholds to set alerts were determined, and the relationship to exacerbations, defined by the initiation of stand-by medications, was measured. The sample comprised 18 patients (age range of 50-85 years) with varied levels of computer skills., Results: Patients identified no difficulties in using the mHealth application and used all functions available. 40% of exacerbations had an alert signal during the three days prior to a patient starting medication. Patients were able to use the mHealth application to support self- management, including monitoring of clinical data. Within three months, 95% of symptom reporting sessions were completed in less than 100 s., Conclusions: Home based, unassisted, daily use of the mHealth platform is feasible and acceptable to people with COPD for reporting daily symptoms and medicine use, and to measure physiological variables such as pulse rate and oxygen saturation. These findings provide evidence for integrating telehealth interventions with clinical care pathways to support self-management in COPD.

Background: Relapse is high in lifestyle obesity interventions involving behavior and weight change. Identifying mediators of successful outcomes in these interventions is critical to improve effectiveness and to guide approaches to obesity treatment, including resource allocation. This article reviews the most consistent self-regulation mediators of medium- and long-term weight control, physical activity, and dietary intake in clinical and community behavior change interventions targeting overweight/obese adults., Methods: A comprehensive search of peer-reviewed articles, published since 2000, was conducted on electronic databases (for example, MEDLINE) and journal reference lists. Experimental studies were eligible if they reported intervention effects on hypothesized mediators (self-regulatory and psychological mechanisms) and the association between these and the outcomes of interest (weight change, physical activity, and dietary intake). Quality and content of selected studies were analyzed and findings summarized. Studies with formal mediation analyses were reported separately., Results: Thirty-five studies were included testing 42 putative mediators. Ten studies used formal mediation analyses. Twenty-eight studies were randomized controlled trials, mainly aiming at weight loss or maintenance (n = 21). Targeted participants were obese (n = 26) or overweight individuals, aged between 25 to 44 years (n = 23), and 13 studies targeted women only. In terms of study quality, 13 trials were rated as "strong", 15 as "moderate", and 7 studies as "weak". In addition, methodological quality of formal mediation analyses was "medium". Identified mediators for medium-/long-term weight control were higher levels of autonomous motivation, self-efficacy/barriers, self-regulation skills (such as self-monitoring), flexible eating restraint, and positive body image. For physical activity, significant putative mediators were high autonomous motivation, self-efficacy, and use of self-regulation skills. For dietary intake, the evidence was much less clear, and no consistent mediators were identified., Conclusions: This is the first systematic review of mediational psychological mechanisms of successful outcomes in obesity-related lifestyle change interventions. Despite limited evidence, higher autonomous motivation, self-efficacy, and self-regulation skills emerged as the best predictors of beneficial weight and physical activity outcomes; for weight control, positive body image and flexible eating restraint may additionally improve outcomes. These variables represent possible targets for future lifestyle interventions in overweight/obese populations.

Background: Public health decision-making is hampered by inappropriate adherence to underpowered randomized controlled trials (RCTs) which give inconclusive results and lead to decision-makers being loath to recommend interventions with strong theoretical and observational support., Methods: We outline situations in which robust decisions about health interventions can be made without trial evidence. We present a new approach in which theory, causal models and past observations are given proper regard in the decision-making process., Results: Using our approach, we provide examples where the use of causal theories and observations in areas, such as salt reduction, smoking cessation and gardening to improve mental health, is sufficient for deciding that such interventions are effective for improving health without needing the support of underpowered RCTs. Particularly where RCT evidence is inconclusive, our approach may provide similar aggregate health outcomes for society for vastly lower cost., Conclusions: When knowledge and theoretical understanding are unable sufficiently to reduce doubt about the direction of effect from an intervention, decisions should be made using evidence-based medicine approaches. There are, however, many cases where the combination of robust theory, causal understanding and observation are able to provide sufficient evidence of the direction of effect from an intervention that current practice should be altered., (© The Author 2014. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: This systematic literature review describes the potential public health impact of evidence-based multi-level interventions to improve obesity-related behaviours in adults, using the Reach, Efficacy, Adoption, Implementation and Maintenance (RE-AIM) framework., Methods: Electronic databases (PubMed, Embase, and The Cochrane Library) were searched to identify intervention studies published between January 2000 and October 2013. The following inclusion criteria were used: (1) the study included at least one outcome measure assessing obesity-related behaviours (i.e. diet, physical activity or sedentary behaviour), (2) the study collected data over at least one year and (3) the study's intervention targeted adults, was conducted in a specified geographical area or worksite, and was multi-level (i.e. targeting both individual and environmental level). Evidence of RE-AIM of the selected interventions was assessed. Potential public health impact of an intervention was evaluated if information was provided on at least four of the five RE-AIM dimensions., Results: Thirty-five multi-level interventions met the inclusion criteria. RE-AIM evaluation revealed that the included interventions generally had the potential to: reach a large number of people (on average 58% of the target population was aware of the intervention); achieve the assumed goals (89% found positive outcomes); be broadly adopted (the proportion of intervention deliverers varied from 9% to 92%) and be sustained (sixteen interventions were maintained). The highest potential public health impact was found in multi-level interventions that: 1) focused on all levels at the beginning of the planning process, 2) guided the implementation process using diffusion theory, and 3) used a website to disseminate the intervention., Conclusions: Although most studies underreported results within the RE-AIM dimensions, the reported Reach, Effectiveness, Adoption, Implementation and Maintenance were positively evaluated. However, more information on external validity and sustainability is needed in order to take informed decisions on the choice of interventions that should be implemented in real-world settings to accomplish long-term changes in obesity-related behaviours.

Background: The World Health Organization (WHO) Regional Office for Europe has established the Childhood Obesity Surveillance Initiative (COSI) to monitor changes in overweight in primary-school children. The aims of this paper are to present the anthropometric results of COSI Round 2 (2009/2010) and to explore changes in body mass index (BMI) and overweight among children within and across nine countries from school years 2007/2008 to 2009/2010., Methods: Using cross-sectional nationally representative samples of 6-9-year-olds, BMI, anthropometric Z-scores and overweight prevalence were derived from measured weight and height. Significant changes between rounds were assessed using variance and t-tests analyses., Results: At Round 2, the prevalence of overweight (including obesity; WHO definitions) ranged from 18% to 57% among boys and from 18% to 50% among girls; 6 - 31% of boys and 5 - 21% of girls were obese. Southern European countries had the highest overweight prevalence. Between rounds, the absolute change in mean BMI (range: from -0.4 to +0.3) and BMI-for-age Z-scores (range: from -0.21 to +0.14) varied statistically significantly across countries. The highest significant decrease in BMI-for-age Z-scores was found in countries with higher absolute BMI values and the highest significant increase in countries with lower BMI values. The highest significant decrease in overweight prevalence was observed in Italy, Portugal and Slovenia and the highest significant increase in Latvia and Norway., Conclusions: Changes in BMI and prevalence of overweight over a two-year period varied significantly among European countries. It may be that countries with higher prevalence of overweight in COSI Round 1 have implemented interventions to try to remedy this situation.

Background: Understanding which physical environmental factors affect adult obesity, and how best to influence them, is important for public health and urban planning. Previous attempts to summarise the literature have not systematically assessed the methodological quality of included studies, or accounted for environmental differences between continents or the ways in which environmental characteristics were measured., Methods: We have conducted an updated review of the scientific literature on associations of physical environmental factors with adult weight status, stratified by continent and mode of measurement, accompanied by a detailed risk-of-bias assessment. Five databases were systematically searched for studies published between 1995 and 2013., Results: Two factors, urban sprawl and land use mix, were found consistently associated with weight status, although only in North America., Conclusions: With the exception of urban sprawl and land use mix in the US the results of the current review confirm that the available research does not allow robust identification of ways in which that physical environment influences adult weight status, even after taking into account methodological quality.

Introduction: The potential for telehealth-based interventions to provide remote support, education and improve self-management for long-term conditions is increasingly recognised. This trial aims to determine whether an intervention delivered through an easy-to-use tablet computer can improve the quality of life of patients with chronic obstructive pulmonary disease (COPD) by providing personalised self-management information and education., Methods and Analysis: The EDGE (sElf management anD support proGrammE) for COPD is a multicentre, randomised controlled trial designed to assess the efficacy of an Internet-linked tablet computer-based intervention (the EDGE platform) in improving quality of life in patients with moderate to very severe COPD compared with usual care. Eligible patients are randomly allocated to receive the tablet computer-based intervention or usual care in a 2:1 ratio using a web-based randomisation system. Participants are recruited from respiratory outpatient clinics and pulmonary rehabilitation courses as well as from those recently discharged from hospital with a COPD-related admission and from primary care clinics. Participants allocated to the tablet computer-based intervention complete a daily symptom diary and record clinical symptoms using a Bluetooth-linked pulse oximeter. Participants allocated to receive usual care are provided with all the information given to those allocated to the intervention but without the use of the tablet computer or the facility to monitor their symptoms or physiological variables. The primary outcome of quality of life is measured using the St George's Respiratory Questionnaire for COPD patients (SGRQ-C) baseline, 6 and 12 months. Secondary outcome measures are recorded at these intervals in addition to 3 months., Ethics and Dissemination: The Research Ethics Committee for Berkshire-South Central has provided ethical approval for the conduct of the study in the recruiting regions. The results of the study will be disseminated through peer review publications and conference presentations., Trial Registration: Current controlled trials ISRCTN40367841.

Chronic Obstructive Pulmonary Disease (COPD) is a progressive chronic disease, predicted to become the third leading cause of death by 2030. COPD patients are at risk of sudden and acute worsening of symptoms, reducing the patient's quality of life and leading to hospitalization. We present the results of a pilot study with 18 COPD patients using an m-Health system, based on a tablet computer and pulse oximeter, for a period of six months. For prioritizing patients for clinical review, a data-driven approach has been developed which generates personalized alerts using the electronic symptom diary, pulse rate, blood oxygen saturation, and respiratory rate derived from oximetry data. This work examines the advantages of multivariate novelty detection over univariate approaches and shows the benefit of including respiratory rate as a predictor.

We performed a systematic literature review on the use of free geospatial services as potential tools to assess built environmental characteristics related to dietary behaviour and physical activity. We included 13 studies, all published since 2010 and conducted in urban contexts, with Google Earth and Google Street View as the two main free geospatial services used. The agreement between virtual and field audit was higher for items related to objectively verifiable measures (e.g. presence of infrastructure and equipment) and lower for subjectively assessed items (e.g. aesthetics, street atmosphere, etc.). Free geospatial services appear as promising alternatives to field audit for assessment of objective dimensions of the built environment., (© 2013 Elsevier Ltd. All rights reserved.)

Background: The approach currently used to appraise public health interventions is close to that of health technology appraisal for drugs. This approach is not appropriate for many public health interventions, however, when extremely small individual level benefits are delivered to extremely large populations. In many such situations, randomized controlled trials with sufficient size and power to determine individual level effects are impractical. Such interventions may be cost-effective, even in the absence of traditional evidence to demonstrate this., Methods: We outline an alternative approach based on decision theory. We apply it to cases where prior beliefs are sufficiently strong and well grounded to allow decision-makers to assume the direction of change of the intervention's outcome, within the context of a transparent and deliberative decision-making process. Decision theory also assumes that decision-makers are risk neutral, implying that they should make decisions based on an intervention's mean cost-effectiveness, and should therefore disregard variance except when deciding to wait for more information. However, they must allow for biases., Results: A framework is presented which has the potential to achieve large health gains at no additional cost., Conclusions: This analysis provides a rigorous theoretical framework for decision-makers in public health. The implied paradigm shift also applies to some clinically based areas.

Unlabelled: What is already known about this subject Overweight and obesity prevalence estimates among children based on International Obesity Task Force definitions are substantially lower than estimates based on World Health Organization definitions. Presence of a north-south gradient with the highest level of overweight found in southern European countries. Intercountry comparisons of overweight and obesity in primary-school children in Europe based on measured data lack a similar data collection protocol. What this study adds Unique dataset on overweight and obesity based on measured weights and heights in 6-9-year-old children from 12 European countries using a harmonized surveillance methodology. Because of the use of a consistent data collection protocol, it is possible to perform valid multiple comparisons between countries. It demonstrates wide variations in overweight and obesity prevalence estimates among primary-school children between European countries and regions., Background: Nutritional surveillance in school-age children, using measured weight and height, is not common in the European Region of the World Health Organization (WHO). The WHO Regional Office for Europe has therefore initiated the WHO European Childhood Obesity Surveillance Initiative., Objective: To present the anthropometric results of data collected in 2007/2008 and to investigate whether there exist differences across countries and between the sexes., Methods: Weight and height were measured in 6-9-year-old children in 12 countries. Prevalence of overweight, obesity, stunting, thinness and underweight as well as mean Z-scores of anthropometric indices of height, weight and body mass index were calculated., Results: A total of 168 832 children were included in the analyses and a school participation rate of more than 95% was obtained in 8 out of 12 countries. Stunting, underweight and thinness were rarely prevalent. However, 19.3-49.0% of boys and 18.4-42.5% of girls were overweight (including obesity and based on the 2007 WHO growth reference).The prevalence of obesity ranged from 6.0 to 26.6% among boys and from 4.6 to 17.3% among girls. Multi-country comparisons suggest the presence of a north-south gradient with the highest level of overweight found in southern European countries., Conclusions: Overweight among 6-9-year-old children is a serious public health concern and its variation across the European Region highly depends on the country. Comparable monitoring of child growth is possible across Europe and should be emphasized in national policies and implemented as part of action plans., (© 2012 World Health Organization. Pediatric Obesity © 2012 International Association for the Study of Obesity.)

Carbon dioxide (CO 2 ) emissions from motorised travel are hypothesised to be associated with individual, household, spatial and other environmental factors. Little robust evidence exists on who contributes most (and least) to travel CO 2 and, in particular, the factors influencing commuting, business, shopping and social travel CO 2 . This paper examines whether and how demographic, socio-economic and other personal and environmental characteristics are associated with land-based passenger transport and associated CO 2 emissions. Primary data were collected from 3474 adults using a newly developed survey instrument in the iConnect study in the UK. The participants reported their past-week travel activity and vehicle characteristics from which CO 2 emissions were derived using an adapted travel emissions profiling method. Multivariable linear and logistic regression analyses were used to examine what characteristics predicted higher CO 2 emissions. CO 2 emissions from motorised travel were distributed highly unequally, with the top fifth of participants producing more than two fifth of emissions. Car travel dominated overall CO 2 emissions, making up 90% of the total. The strongest independent predictors of CO 2 emissions were owning at least one car, being in full-time employment and having a home-work distance of more than 10 km. Income, education and tenure were also strong univariable predictors of CO 2 emissions, but seemed to be further back on the causal pathway than having a car. Male gender, late-middle age, living in a rural area and having access to a bicycle also showed significant but weaker associations with emissions production. The findings may help inform the development of climate change mitigation policies for the transport sector. Targeting individuals and households with high car ownership, focussing on providing viable alternatives to commuting by car, and supporting planning and other policies that reduce commuting distances may provide an equitable and efficient approach to meeting carbon mitigation targets.

Objectives: The authors designed an instrument to measure objectively aspects of the built and food environments in urban areas, the EURO-PREVOB Community Questionnaire, within the EU-funded project 'Tackling the social and economic determinants of nutrition and physical activity for the prevention of obesity across Europe' (EURO-PREVOB). This paper describes its development, reliability, validity, feasibility and relevance to public health and obesity research., Study Design: The Community Questionnaire is designed to measure key aspects of the food and built environments in urban areas of varying levels of affluence or deprivation, within different countries. The questionnaire assesses (1) the food environment and (2) the built environment., Methods: Pilot tests of the EURO-PREVOB Community Questionnaire were conducted in five to 10 purposively sampled urban areas of different socio-economic status in each of Ankara, Brno, Marseille, Riga, and Sarajevo. Inter-rater reliability was compared between two pairs of fieldworkers in each city centre using three methods: inter-observer agreement (IOA), kappa statistics, and intraclass correlation coefficients (ICCs)., Results: Data were collected successfully in all five cities. Overall reliability of the EURO-PREVOB Community Questionnaire was excellent (inter-observer agreement (IOA) > 0.87; intraclass correlation coefficients (ICC)s > 0.91 and kappa statistics > 0.7. However, assessment of certain aspects of the quality of the built environment yielded slightly lower IOA coefficients than the quantitative aspects., Conclusions: The EURO-PREVOB Community Questionnaire was found to be a reliable and practical observational tool for measuring differences in community-level data on environmental factors that can impact on dietary intake and physical activity. The next step is to evaluate its predictive power by collecting behavioural and anthropometric data relevant to obesity and its determinants., (Copyright © 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Increasing regular physical activity is a key public health goal. One strategy is to change the physical environment to encourage walking and cycling, requiring partnerships with the transport and urban planning sectors. Economic evaluation is an important factor in the decision to fund any new transport scheme, but techniques for assessing the economic value of the health benefits of cycling and walking have tended to be less sophisticated than the approaches used for assessing other benefits. This study aimed to produce a practical tool for estimating the economic impact of reduced mortality due to increased cycling. The tool was intended to be transparent, easy to use, reliable, and based on conservative assumptions and default values, which can be used in the absence of local data. It addressed the question: For a given volume of cycling within a defined population, what is the economic value of the health benefits? The authors used published estimates of relative risk of all-cause mortality among regular cyclists and applied these to levels of cycling defined by the user to produce an estimate of the number of deaths potentially averted because of regular cycling. The tool then calculates the economic value of the deaths averted using the "value of a statistical life." The outputs of the tool support decision making on cycle infrastructure or policies, or can be used as part of an integrated economic appraisal. The tool's unique contribution is that it takes a public health approach to a transport problem, addresses it in epidemiologic terms, and places the results back into the transport context. Examples of its use include its adoption by the English and Swedish departments of transport as the recommended methodologic approach for estimating the health impact of walking and cycling., (Copyright © 2013 World Health Organization. Published by Elsevier Inc. All rights reserved.)

Introduction: Previous studies place Portugal among the five countries with the highest prevalence of childhood obesity in Europe. This paper describes the prevalence of thinness, overweight and obesity in Portuguese children of 6-8 years of age, based on the first data collection from Childhood Obesity Surveillance Initiative Portugal, which took place during the 2007/2008 school year., Methods: This study uses a semi-longitudinal design with repeated cross-sectional national representative samples. Specific prevalence of overweight (including obesity) and obesity was determined using three different diagnostic criteria. Across the seven geographic regions, 3765 children were enrolled from 181 schools; 50.3% of participants were males., Results: Using the International Obesity Task Force reference, the prevalence of thinness, overweight and obesity were 4.8%, 28.1% and 8.9%, respectively; using the Center for Disease Control and Prevention reference they were 2.1%, 32.2% and 14.6%, respectively; and according to the World Health Organization reference, they were 1.0%, 37.9% and 15.3%, respectively. Univariate analysis showed a higher risk of obesity in older children, in boys and in the Azores region. The islands of Madeira and the Azores were the regions with the highest prevalence of overweight at 39.4% and 46.6%, respectively, and Algarve was the one with the lowest (21.4%)., Conclusion: These findings demonstrate the need for urgent action in Portugal and provide policy-makers with comprehensive and detailed information to assist with this., (© 2012 The Authors. Pediatric Obesity © 2012 International Association for the Study of Obesity.)

Past studies have suggested that a link between health outcomes and green space is due to increased levels of physical activity of individuals living in areas with more green space. We found a positive association between green space and physical activity levels. The odds of achieving the recommended amount of physical activity was 1.27 (95% CI: 1.13-1.44) for people living in the greenest quintile in England compared to those living in the least green quintile, after controlling for individual and environmental factors. However, no association was found between green space and types of physical activity normally associated with green space. An association was found with other types of physical activity (gardening and do-it-yourself, and occupational physical activity). These findings suggest that although there is a positive association between physical activity and green space it may not be explained by individuals using green space for recreation., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

There is growing evidence of social disparities in overweight among European children. This paper examines whether there is an association between socioeconomic inequality and prevalence of child overweight in European countries, and if socioeconomic disparities in child overweight are increasing. We analyse cross-country comparisons of household inequality and child overweight prevalence in Europe and review within-country variations over time of childhood overweight by social grouping, drawn from a review of the literature. Data from 22 European countries suggest that greater inequality in household income is positively associated with both self-reported and measured child overweight prevalence. Moreover, seven studies from four countries reported on the influence of socioeconomic factors on the distribution of child overweight over time. Four out of seven reported widening social disparities in childhood overweight, a fifth found statistically significant disparities only in a small sub-group, one found non-statistically significant disparities, and a lack of social gradient was reported in the last study. Where there is evidence of a widening social gradient in child overweight, it is likely that the changes in lifestyles and dietary habits involved in the increase in the prevalence of overweight have had a less favourable impact in low socio-economic status groups than in the rest of the population. More profound structural changes, based on population-wide social and environmental interventions are needed to halt the increasing social gradient in child overweight in current and future generations.

Introduction: Improving infrastructure to support walking and cycling is often regarded as fundamental to encouraging their widespread uptake. However, there is little evidence that specific provision of this kind has led to a significant increase in walking or cycling in practice, let alone wider impacts such as changes in overall physical activity or carbon emissions. Connect2 is a major new project that aims to promote walking and cycling in the UK by improving local pedestrian and cycle routes. It therefore provides a useful opportunity to contribute new evidence in this field by means of a natural experimental study., Methods and Analysis: iConnect is an independent study that aims to integrate the perspectives of public health and transport research on the measurement and evaluation of the travel, physical activity and carbon impacts of the Connect2 programme. In this paper, the authors report the study design and methods for the iConnect core module. This comprised a cohort study of residents living within 5 km of three case study Connect2 projects in Cardiff, Kenilworth and Southampton, supported by a programme of qualitative interviews with key informants about the projects. Participants were asked to complete postal questionnaires, repeated before and after the opening of the new infrastructure, which collected data on demographic and socioeconomic characteristics, travel, car fuel purchasing and physical activity, and potential psychosocial and environmental correlates and mediators of those behaviours. In the absence of suitable no-intervention control groups, the study design drew on heterogeneity in exposure both within and between case study samples to provide for a counterfactual., Ethics and Dissemination: The study was approved by the University of Southampton Research Ethics Committee. The findings will be disseminated through academic presentations, peer-reviewed publications and the study website (http://www.iconnect.ac.uk) and by means of a national seminar at the end of the study.

Objective: Evidence suggests that area-level deprivation is associated with obesity independently of individual socioeconomic status; however, although the school may also have an impact on child health, few studies have investigated the association between school-level deprivation and the body mass index (BMI) of students. The aim of this study was to assess the relationship between the BMI for children of different ages and area-level and school-level deprivation., Subjects: BMI measurements were collected through the National Child Measurement Programme (NCMP) that samples from two school years: 396,171 reception year pupils (4-5-year olds) and 392,344 year 6 pupils (10-11-year olds) from 14,054 primary schools in England., Design: Cross-classified multilevel models with four levels: individual (n=788,525), lower super output areas corresponding to area of residence (n=29,606), schools (n=14,054) and primary care trusts (PCTs, n=143), which coordinate the collection of data within a large area, were used to study the relationship between measures of deprivation at an area and school level, and childhood BMI within England., Results: A positive association was found between the area and school measures of deprivation, and student BMI. Both the measures of deprivation explained a greater proportion of variance in BMI z-scores for year 6 students than for the reception year students, with a greater difference between the year groups found with the school-level measure of socioeconomic status than for the the area-level measure., Conclusions: Deprivation explains a greater proportion of the variance in BMI for older compared with younger children, perhaps reflecting the impact of deprivation as children age, highlighting the widening of health inequalities through childhood. The association with school-level deprivation illustrates the impact of the school on BMI status throughout the primary school years.

Background: The World Health Organization (WHO) promotes the surveillance of obesity prevalence through standardized and harmonized surveillance systems. However, variations in data collection between countries, or between coordinating regions in countries can affect outcome measures., Methods: Multilevel analysis of 2007/08 National Child Measurement Programme (NCMP) data estimating the relationship between BMI z-score and data collection variations within coordinating regions whilst adjusting for individual-level and school-level variables. The 2007/08 NCMP collected height and weight measurements for 478,381 Reception year pupils (4-5-year-olds) and 496,297 year 6 pupils (10-11-year-olds) from 17,279 primary schools in 152 data collection coordinating regions in England., Results: Data collection variables accounted for 29.7% of the regional variation in BMI z-score for Reception year pupils but only 5.3% for the older Year 6 pupils. Digit preference in the rounding of weight measurements had the greatest impact of all the data collection variables, explaining 26.4% of the regional variation in BMI z-score for Reception year pupils and 4.0% for Year 6 pupils., Conclusions: Although variations in data collection may have a small effect on individual measurements their impact can be magnified when scaled up to regional or national figures. All measurement programmes must regularly identify and minimize variations in data collection to improve accuracy of outcome measures. These factors include those identified within this study: participation and opt out rates, the time in the year the measurements are taken and the recording of measurements to the correct decimal place.

Improving infrastructure for walking and cycling is increasingly recommended as a means to promote physical activity, prevent obesity, and reduce traffic congestion and carbon emissions. However, limited evidence from intervention studies exists to support this approach. Drawing on classic epidemiological methods, psychological and ecological models of behavior change, and the principles of realistic evaluation, we have developed an applied ecological framework by which current theories about the behavioral effects of environmental change may be tested in heterogeneous and complex intervention settings. Our framework guides study design and analysis by specifying the most important data to be collected and relations to be tested to confirm or refute specific hypotheses and thereby refine the underlying theories.

Background: There is increasing recognition of the importance of obesity as a cause of death but it is uncommon for obesity to be certified on death certificates. We considered it useful to study what doctors actually do in respect of certification of obesity and to study trends, if any, in certification practice., Methods: Analysis of two datasets that include all certified causes of death ('mentions'), not just the underlying cause-the Oxford record linkage study 1979-2006 and English national mortality data 1995-2006., Results: Underlying-cause mortality identified only a quarter (26% in Oxford, 25% in England) of all deaths with obesity as a certified cause. The longstanding Oxford dataset showed that there were significant changes over time in the percentage of certificates, with mention of obesity, that were coded with obesity as the underlying cause. Changes coincided with times of national change in selection and coding rules for underlying cause mortality. In the recent English dataset from 1995-2006, mention-based death rates rose by an average annual rate of 7.5% [95% confidence intervals (CI) 6.1-8.8] for men and by 4.0% (2.3-5.7) for women. Analysis of mortality based on underlying cause alone would have missed this rise. We report on diseases commonly certified alongside obesity on death certificates in England., Conclusion: There is an emerging trend of increased certification of obesity as a cause of death in England. The use of underlying-cause mortality statistics alone fails to capture the majority of obesity deaths.

Background: A questionnaire to assess physical activity related environmental factors in the European population (a 49-item and an 11-item version) was created as part of the framework of the EU-funded project "Instruments for Assessing Levels of PHysical Activity and fitness (ALPHA)". This paper reports on the development and assessment of the questionnaire's test-retest stability, predictive validity, and applicability to European adults., Methods: The first pilot test was conducted in Belgium, France and the UK. In total 190 adults completed both forms of the ALPHA questionnaire twice with a one-week interval. Physical activity was concurrently measured (i) by administration of the long version of the International Physical Activity Questionnaire (IPAQ) by interview and (ii) by accelerometry (Actigraph device). After adaptations, the second field test took place in Belgium, the UK and Austria; 166 adults completed the adapted questionnaire at two time points, with minimum one-week interval. In both field studies intraclass correlation coefficients (ICC) and proportion of agreement were computed to assess the stability of the two test scores. Predictive validity was examined in the first field test by correlating the results of the questionnaires with physical activity data from accelerometry and long IPAQ-last 7 days., Results: The reliability scores of the ALPHA questionnaire were moderate-to good in the first field testing (ICC range 0.66 - 0.86) and good in the second field testing (ICC range 0.71 - 0.87). The proportion of agreement for the ALPHA short increased significantly from the first (range 50 - 83%) to the second field testing (range 85 - 95%). Environmental scales from both versions of the ALPHA questionnaire were significantly associated with self-reported minutes of transport-related walking, and objectively measured low intensity physical activity levels, particularly in women. Both versions were easily administered with an average completion time of six minutes for the 49-item version and less than two minutes for the short version., Conclusion: The ALPHA questionnaire is an instrument to measure environmental perceptions in relation to physical activity. It appears to have good reliability and predictive validity. The questionnaire is now available to other researchers to investigate its usefulness and applicability across Europe.

Background: There is growing interest in "Health in All Policies" approaches, aiming at promoting health through policies which are under the control of nonhealth sectors. While economic appraisal is an established practice in transport planning, health effects are rarely taken into account. An international project was carried out to develop guidance and tools for practitioners for quantifying the health effects of cycling and walking, supporting their full appraisal., Development Process: A systematic review of existing approaches was carried out. Then, the products were developed with an international expert panel through an extensive consensus finding process., Products and Applications: Methodological guidance was developed which addresses the main challenges practitioners encounter in the quantification of health effects from cycling and walking. A "Health Economic Assessment Tool (HEAT) for cycling" was developed which is being used in several countries., Conclusions: There is a need for a more consistent approach to the quantification of health benefits from cycling and walking. This project is providing guidance and an illustrative tool for cycling for practical application. Results show that substantial savings can be expected. Such tools illustrate the importance of considering health in transport policy and infrastructure planning, putting "Health in All Policies" into practice.

Objective: To examine the impact of traffic on levels of walking and bicycling., Method: Review of the literature of medical, public health, city planning, public administration and traffic engineering., Results: The real and perceived danger and discomfort imposed by traffic discourage walking and bicycling. Accurately or not, pedestrians and bicyclists judge injury risk and respond accordingly. Although it can be difficult to measure these effects, observed behaviour provides good evidence for these effects, with the strongest association being an inverse correlation between volumes and speeds of traffic and levels of walking and cycling., Conclusion: Interventions to reduce traffic speed and volume are likely to promote walking and bicycling and thus result in public health gains.

Background: Research on the influence of the physical environment on physical activity is rapidly expanding and different measures of environmental perceptions have been developed, mostly in the US and Australia. The purpose of this paper is to (i) provide a literature review of measures of environmental perceptions recently used in European studies and (ii) develop a questionnaire for population monitoring purposes in the European countries., Methods: This study was done within the framework of the EU-funded project 'Instruments for Assessing Levels of Physical Activity and Fitness (ALPHA)', which aims to propose standardised instruments for physical activity and fitness monitoring across Europe. Quantitative studies published from 1990 up to November 2007 were systematically searched in Pubmed, Web of Science, TRIS and Geobase. In addition a survey was conducted among members of the European network for the promotion of Health-Enhancing Physical Activity (HEPA Europe) and European members of the International Physical Activity and Environment Network (IPEN) to identify published or ongoing studies. Studies were included if they were conducted among European general adult population (18+y) and used a questionnaire to assess perceptions of the physical environment. A consensus meeting with an international expert group was organised to discuss the development of a European environmental questionnaire., Results: The literature search resulted in 23 European studies, 15 published and 8 unpublished. In these studies, 13 different environmental questionnaires were used. Most of these studies used adapted versions of questionnaires that were developed outside Europe and that focused only on the walkability construct: The Neighborhood Environment Walkability Scale (NEWS), the abbreviated version of the NEWS (ANEWS) and the Neighborhood Quality of Life Study (NQLS) questionnaire have been most commonly used. Based on the results of the literature review and the output of the meeting with international experts, a European environmental questionnaire with 49 items was developed., Conclusion: There is need for a greater degree of standardization in instruments/methods used to assess environmental correlates of physical activity, taking into account the European-specific situation. A first step in this process is taken by the development of a European environmental questionnaire.

Objective: To examine the effects on nutrition, health and expenditure of extending value added tax (VAT) to a wider range of foods in the UK., Method: A model based on consumption data and elasticity values was constructed to predict the effects of extending VAT to certain categories of food. The resulting changes in demand, expenditure, nutrition and health were estimated. Three different tax regimens were examined: (1) taxing the principal sources of dietary saturated fat; (2) taxing foods defined as unhealthy by the SSCg3d nutrient scoring system; and (3) taxing foods in order to obtain the best health outcome., Data: Consumption patterns and elasticity data were taken from the National Food Survey of Great Britain. The health effects of changing salt and fat intake were from previous meta-analyses., Results: (1) Taxing only the principal sources of dietary saturated fat is unlikely to reduce the incidence of cardiovascular disease because the reduction in saturated fat is offset by a rise in salt consumption. (2) Taxing unhealthy foods, defined by SSCg3d score, might avert around 2,300 deaths per annum, primarily by reducing salt intake. (3) Taxing a wider range of foods could avert up to 3,200 cardiovascular deaths in the UK per annum (a 1.7% reduction)., Conclusions: Taxing foodstuffs can have unpredictable health effects if cross-elasticities of demand are ignored. A carefully targeted fat tax could produce modest but meaningful changes in food consumption and a reduction in cardiovascular disease.

Cells grown in three-dimensional (3D) culture take on in vivo phenotypes and organize into tissue-like structures. Understanding the pathways and mechanisms contributing to this in vitro tissuegenesis is a critical goal of tissue engineering. To identify pathways relevant to cardiac tissue engineering, we compared mRNA expression profiles from bioreactor-cultured 3D aggregates of primary neonatal rat heart cells (NRHCs), which form layered structures similar to cardiac tissue, and standard plate-cultured NRHCs, which do not. In a series of two experiments, NRHCs were grown on solid microcarrier surfaces within clinostatically rotated polytetrafluoroethylene (PTFE) vessels and compared to parallel cultures grown on standard tissue culture plates without rotation. After 1, 4, and 6 days, gene expression profiles were analyzed using Affymetrix Rat Genome U34A (RG-U34A) arrays. The results were validated using real-time PCR, and the data set was filtered to generate a list of 93 probe sets that were substantially the same in replicate samples but substantially different between the bioreactor and plate groups. Cluster analysis indicated that the bioreactor and plate samples had similar expression patterns on day 1 but that these patterns diverged thereafter. Database for Annotation, Visualization, and Integrated Discovery (DAVID) analysis revealed a number of statistically significant gene groupings, including groups associated with muscle development and morphogenesis. Further analysis of the annotated gene list indicated that 13 of the 93 filtered genes were associated with endothelial cells, blood vessels, or angiogenesis. These results suggest that 3D aggregate culture of NRHCs in bioreactors is associated with the differential expression of morphogenic and angiogenic pathways similar to those seen during cardiac development.

Background: Cycling is a form of physical activity with the potential to make a significant contribution to improving public health; however, participation levels are decreasing. Primary-care trusts (PCTs) are in a position to influence local provision for cycling but the extent of their involvement in policy and practice on cycling is unknown. A survey of Directors of Public Health in PCTs was conducted to establish the level and type of PCT involvement in policies, strategies, programmes and projects on cycling., Methods: Directors of Public Health on the Faculty of Public Health database were sent an e-mail inviting them to complete an online questionnaire that addressed key issues of PCT involvement with cycling., Results: One hundred and sixty-five responses were received (49% of all PCTs). Thirty-two per cent of respondents said there was someone in the PCT with specific responsibility for cycling. Less than half of PCTs had the basic facilities to encourage staff or visitors to cycle to their premises. Around one in 10 said that cycling was included in their travel plan or local delivery plan, and 49% of respondents said that their physical activity strategy contained reference to cycling. Joint working on the local strategic partnership and community plan was common, with 94% and 82% of PCTs, respectively, saying they had worked with other agencies on these plans. Most PCTs (60%) had worked on the Local Transport Plan. Specific knowledge of cycling policy was low, and demand for additional resources high., Conclusion: Cycling does not seem to be high on PCTs' agendas, despite its great potential to improve public health. More could be done to ensure that cycling is given a far greater emphasis within the work of PCTs, notably PCT input into local transport plan development, and production of local physical activity strategies.

Two apparently linked fatal cases of pneumococcal meningitis were investigated. Pneumolysin PCR performed on blood and cerebrospinal fluid was positive in a culture-negative case. A second case yielded Streptococcus pneumoniae from blood culture. Multilocus sequence typing performed on DNA extracted from case 1 (specimens) and case 2 (isolate) revealed identical sequence types (ST53) substantiating the link between them.

Objective: To explore the relationship between a teaching role and stress in doctors and dentists who teach., Methods: Medline, PubMed, BIDS database for social sciences literature, and the ERIC database for educational literature were searched using the key words 'stress' or 'burnout' with the terms doctor, physician, dentist, teacher, lecturer, academic staff, and university staff. Other books and journals known to the authors were also used., Results: Many studies have shown high levels of stress in doctors, dentists, teachers, and lecturers. A large number of factors are implicated, including low autonomy, work overload, and lack of congruence between power and responsibility. Doctors and dentists who take on a teaching role in addition to their clinical role may increase their levels of stress, but there is also evidence that this dual role may reduce job-related stress., Conclusions: Working as a doctor or dentist may entail higher levels of stress than are experienced by the general population. In some situations adding in the role of teacher reduces this stress, but more research is needed to explain this finding.

Context: Previous studies have drawn attention to the stresses experienced by doctors in their first year., Objectives: To gain a deeper understanding of the causes of stress in newly qualified doctors, how they cope, and what interventions might make the year less traumatic., Design: Postal questionnaire. This study focused on an open question asking about a stressful incident, the coping strategy used to deal with it, stressors in general and current levels of stress using the General Health Questionnaire., Setting: 336 hospitals throughout the United Kingdom., Subjects: A cohort of doctors followed from the time of their application to medical school, studied towards the end of their pre-registration year (n=2456)., Results: The response rate to the questionnaire was 58.4%. The incidents were categorised into the major groups Responsibility (33.6%), Interpersonal (29.7%), Overwork (17.0%), Death and disease (13.0%), and Self (6.7%). GHQ revealed psychological morbidity in 31% of respondents. Stress levels were highest in those reporting an incident about Responsibility or Self, lowest in those describing Death or disease. Stressors in general and preferred coping strategies differed between the groups., Conclusion: The incidents suggested the following interventions to reduce stress: better supervision in the first few weeks in post, at night, and for medical problems on surgical wards; more attention to avoiding sleep deprivation; more time for discussion with colleagues at work; more personal time with friends and family. The choice of incident described was influenced by the personal characteristics of the respondent.

Primary cardiac tumours have been described as great imitators. They are rare, and clinical presentations are diverse. Diagnosis is usually made by two-dimensional echocardiography. The present case report describes a case where a left atrial fibrosarcoma eluded diagnosis by echocardiography, and was eventually demonstrated by computed tomography. Management was complicated by the presence of persistent mismatch demonstrated by ventilation-perfusion lung scans. The likely mechanism underlying this phenomenon is discussed.