Search

Introduction Drill sergeants work under mentally and physically challenging conditions. The current study examined self-reported rates of physical injuries in drill sergeants; rates of treatment-seeking for injuries; perceived barriers toward treatment-seeking; and associated demographic and environmental factors. Materials and Methods Drill sergeants from across all Army basic training locations completed self-report surveys from September to November of 2018. In total, 726 drill sergeants were included in analyses. Drill sergeants indicated whether they had acquired an injury during their time in the drill sergeant role and whether they had sought treatment for all such injuries. Furthermore, drill sergeants rated their agreement with a number of possible perceived barriers to treatment-seeking for physical injuries. Regression models examining each phenomenon included hours of sleep obtained per day; general- and health-specific leadership behaviors of the company command teams; unit cohesion; time as a drill sergeant; duty location; gender; military operational specialty; years in the military; previous combat deployments; and route of assignment. The study was approved by the Walter Reed Army Institute of Research Institutional Review Board. Results In total, 38% of respondents reported acquiring an injury during their time as drill sergeants. Of those who had acquired an injury, 61% reported seeking medical help for all injuries acquired. Injuries were more likely in females (49%) than in males (34%) and less likely in drill sergeants reporting at least 6 hours of sleep (27%) versus those reporting 5 hours (40%) and 4 hours or less (43%). Reported comparisons were significant after controlling for demographic and environmental variables in regression models. The most strongly endorsed perceived barriers to treatment-seeking were “Seeking help would place too much burden on the other drill sergeants” (69%) and “Seeking help would interfere with my ability to train the recruits” (60%). Both of these perceived barriers were significantly associated with reduced treatment-seeking in injured drill sergeants, after controlling for demographic and environmental variables. Conclusions This study is the first to examine injury occurrence, treatment-seeking, and perceived barriers to treatment-seeking in U.S. Army drill sergeants. Building on previous studies that showed the negative effects of sleep deprivation on the safety and behavioral health of drill sergeants, the current study gives further evidence of the negative effects of such sleep deprivation, this time in the domain of physical injuries. The results suggest that pursuing strategies that allow for healthier sleep duration may contribute to injury reduction.

Insomnia is a threat to the well-being and combat readiness of military service members. Brief Behavioral Treatment for Insomnia (BBTI) is effective in treating insomnia, but the treatment schedule is difficult to implement in the Military Health System due to shorter appointment windows than what is offered in civilian settings. In the present study, 23 behavioral health providers were trained in a version of BBTI adapted for use within the Military Health System. Training was conducted remotely via a 2-day webinar, followed by 12 weekly telephone consultations with a trainer. Surveys were conducted before and after the 2-day webinar, and after the consultation period. Training led to increases in target knowledge scores and self-rated confidence in administering BBTI. All providers reported implementing the treatment with multiple patients during the 12-week period, and all providers reported that the intervention was more effective than their usual treatment method. All behavioral health providers also reported that they were likely to use BBTI in the future when treating patients with insomnia, and that they would advertise their BBTI skills to primary care providers to encourage insomnia referrals. Although conducted with a small sample size, the current study gives provisional support for (a) feasibility of implementing the adapted version of BBTI within the Military Health System and (b) feasibility of training the adapted BBTI to behavioral health providers via remote learning methodology. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

BackgroundFor decades confirmatory factor analysis (CFA) has been the preeminent method to study the underlying structure of posttraumatic stress disorder (PTSD); however, methodological limitations of CFA have led to the emergence of other analytic approaches. In particular, network analysis has become a gold standard to investigate the structure and relationships between PTSD symptoms. A key methodological limitation, however, which has significant clinical implications, is the lack of data on the potential impact of item order effects on the conclusions reached through network analyses.MethodsThe current study, involving a large sample (N = 5055) of active duty army soldiers following deployment to Iraq, assessed the vulnerability of network analyses and prevalence rate to item order effects. This was done by comparing symptom networks of the DSM-IV PTSD checklist items to these same items distributed in random order. Half of the participants rated their symptoms on traditionally ordered items and half the participants rated the same items, but in random order and interspersed between items from other validated scales. Differences in prevalence rate and network composition were examined.ResultsThe prevalence rate differed between the ordered and random item samples. Network analyses using the ordered survey closely replicated the conclusions reached in the existing network analyses literature. However, in the random item survey, network composition differed considerably.ConclusionOrder effects appear to have a significant impact on conclusions reached from PTSD network analysis. Prevalence rates were also impacted by order effects. These findings have important diagnostic and clinical treatment implications.

Introduction The role of the drill sergeant is one of the most challenging within the US Army, involving unusually long hours and little time off, for a minimum of 2 years. The current study sought to examine the behavioral health of this population and identify risk factors that might be addressed by policy changes. Materials and Methods In total, 856 drill sergeants across all Army basic training sites completed surveys from September to November of 2018. Drill sergeants identified factors that had caused stress or worry during their assignment. Rates were measured for behavioral health outcomes including depression, insomnia, anxiety, burnout, functional impairment, alcohol misuse, aggression, and low morale. Potential risk and resilience factors included time as a drill sergeant, sleep, route of assignment, general leadership, health-promoting leadership, and drill sergeant camaraderie. The study was approved by the Walter Reed Army Institute of Research Institutional Review Board. Results The most commonly experienced stressors were finding time to exercise, lack of sleep, and long work hours. Percentages of drill sergeants meeting behavioral health screening criteria were 19% for depression, 27% for moderate-to-severe insomnia, 14% for generalized anxiety disorder, 48% for high burnout, 32% for functional impairment, 35% for moderate alcohol misuse, 32% for off-duty aggression, and 25% for low morale. Rates for most outcomes were associated with time spent as a drill sergeant, with behavioral health issues peaking during 13-18 months. Poorer outcomes were also associated with fewer hours of sleep and initial unhappiness regarding involuntary assignment to the role of drill sergeant, while better outcomes were associated with higher ratings of general leadership, health-promoting leadership, and drill sergeant camaraderie. Conclusions This study is the first to examine behavioral health and morale of drill sergeants and to identify risk and resilience factors. Suggestions for policy changes include increasing the number of drill sergeants to decrease workload and allow sufficient time for recovery and sleep.

Introduction The Secretary of the U.S. Army issued two directives in late 2017 to directly combat the problem of suicide in the U.S. Army. The first was to develop an Army tool to assist commanders and first-line leaders in preventing suicide and improving behavioral health (BH) outcomes, which has been previously published as the BH Readiness and Risk Reduction Review (R4). The second was to conduct an evaluation study of the tool with Army units in the field. This study is the first to empirically examine the Army’s tool-based methods for identifying and caring for the health and welfare of soldiers at risk for suicide, and this article outlines the methodology employed to study the effectiveness of the R4 tools and accomplish the Secretary’s second directive. Methods The Walter Reed Army Institute of Research Institutional Review Board approved the R4 study. The study employed a repeated measurements in pre/post quasi-experimental design, including a nonequivalent but comparable business-as-usual control group. The R4 intervention consisted of the R4 tools, accompanying instructions, and an orientation. Samples were drawn from two geographically separated U.S. Army divisions in the continental United States, each composed of four comparable brigades. Study implementation consisted of three phases and three data collections over the course of 12 months. Soldiers completed anonymous survey instruments to assess a range of health factors, behaviors, characteristics, tool-related decision-making processes, and the frequency, type, and quality of interactions between soldiers and leaders. Results The R4 study commenced on May 6, 2019, and concluded on June 4, 2020. Sample size goals were achieved for both the divisions at all three data collection time points. Conclusions The methodology of the R4 study is critical for the U.S. Army from both a precedential and an outcome-based standpoint. Despite the use of many previous tools and programs for suicide prevention, this is the first time the Army has been able to empirically test the effectiveness of tool-supported decision-making among Army units in a rigorous fashion. The methodology of such a test is a critical marker for future interventional inquiries on the subject of suicide in the Army, and the results will allow for more informed decision-making by leaders when approaching these ongoing challenges.

Objectives Sleep deprivation is an occupational hazard for members of the armed forces, and has potential consequences not only for the sleep-deprived individuals, but also for the people around them. Perhaps the most consistently sleep-deprived population in the US Army are drill sergeants, who lead intense cycles of initial training for new soldiers. In the first systematic assessment of drill sergeants, the current study examined sleep deprivation and its relationship to falling asleep in two hazardous contexts: while driving, and while co-supervising recruit trainings. Design In total 856 drill sergeants across all Army basic training sites completed surveys. Sleep-related items measured sleep quantity, sleep problems, exhaustion, and stress due to lack of sleep. Results Drill sergeants reported working long hours (M = 14.74 hours, SD = 2.53), and being at work 6.42 (SD = 0.6) days per week, while obtaining low levels of sleep (75% reported five hours or less per night). Many (27%) met criteria for moderate or severe clinical insomnia. A substantial proportion (42%) reported having fallen asleep at the wheel at least once during their time as a drill sergeant. Further, the likelihood of this occurring was associated with obtaining low amounts of sleep and with meeting criteria for clinical insomnia. Similar rates of occurrence and associations with sleep issues were observed for falling asleep during recruit trainings. Conclusions Results highlight the importance of ensuring drill sergeants acquire adequate sleep in order to reduce the risk of accidents involving this population and those in their care.

The bystander intervention model is one approach utilized to reduce risky behaviors within the U.S. Army; however, it is unclear how frequently soldiers experience opportunities to intervene and whether they already intervene in such situations. The present analysis aims to ascertain frequencies for opportunities to intervene and the rates at which soldiers intervene when presented with such opportunities. Soldiers ( N = 286) were asked whether they had witnessed particular risky behavior scenarios of interest to the Army (i.e., suicide-related behaviors, alcohol misuse, or sexual harassment/assault) during the previous 2 months and whether they had intervened in those scenarios. Prevalence rates within this sample were calculated to determine the frequency of such situations and subsequent interventions. Logistic regression was used to ascertain any differences in witnessing scenarios by demographic groups. Nearly half (46.8%) of the soldiers reported witnessing at least one scenario involving risky behaviors. Most soldiers who witnessed an event relating to suicide or alcohol misuse also reported consistently intervening (87.9% and 74.4%, respectively), whereas just half consistently intervened in response to scenarios relating to sexual harassment/assault (49.2%). Lower ranking soldiers were twice as likely as higher ranks to witness scenarios involving alcohol misuse (odds ratio = 2.18, 95% confidence interval [1.11, 4.26]) and sexual harassment/assault (odds ratio = 2.21, 95% confidence interval [1.05, 4.62]). These data indicate that soldiers regularly encounter opportunities to intervene in risky behaviors, and while a majority intervened in such scenarios, more training is warranted, particularly around sexual assault and harassment. This supports the notion that bystander intervention training is a worthwhile investment for the Army.

BackgroundUntil recently, evidence that protection from the bacillus Calmette–Guérin (BCG) vaccination lasted beyond 10 years was limited. In the past few years, studies in Brazil and the USA (in Native Americans) have suggested that protection from BCG vaccination against tuberculosis (TB) in childhood can last for several decades. The UK’s universal school-age BCG vaccination programme was stopped in 2005 and the programme of selective vaccination of high-risk (usually ethnic minority) infants was enhanced.ObjectivesTo assess the duration of protection of infant and school-age BCG vaccination against TB in the UK.MethodsTwo case–control studies of the duration of protection of BCG vaccination were conducted, the first on minority ethnic groups who were eligible for infant BCG vaccination 0–19 years earlier and the second on white subjects eligible for school-age BCG vaccination 10–29 years earlier. TB cases were selected from notifications to the UK national Enhanced Tuberculosis Surveillance system from 2003 to 2012. Population-based control subjects, frequency matched for age, were recruited. BCG vaccination status was established from BCG records, scar reading and BCG history. Information on potential confounders was collected using computer-assisted interviews. Vaccine effectiveness was estimated as a function of time since vaccination, using a case–cohort analysis based on Cox regression.ResultsIn the infant BCG study, vaccination status was determined using vaccination records as recall was poor and concordance between records and scar reading was limited. A protective effect was seen up to 10 years following infant vaccination [p = 0.396). The analyses of the protective effect of infant BCG vaccination were adjusted for confounders, including birth cohort and ethnicity. For school-aged BCG vaccination, VE was 51% (95% CI 21% to 69%) 10–15 years after vaccination and 57% (95% CI 33% to 72%) 15–20 years after vaccination, beyond which time protection appeared to wane. Ascertainment of vaccination status was based on self-reported history and scar reading.LimitationsThe difficulty in examining vaccination sites in older women in the high-risk minority ethnic study population and the sparsity of vaccine record data in the later time periods precluded robust assessment of protection from infant BCG vaccination > 10 years after vaccination.ConclusionsInfant BCG vaccination in a population at high risk for TB was shown to provide protection for at least 10 years, whereas in the white population school-age vaccination was shown to provide protection for at least 20 years. This evidence may inform TB vaccination programmes (e.g. the timing of administration of improved TB vaccines, if they become available) and cost-effectiveness studies. Methods to deal with missing record data in the infant study could be explored, including the use of scar reading.FundingThe National Institute for Health Research Health Technology Assessment programme. During the conduct of the study, Jonathan Sterne, Ibrahim Abubakar and Laura C Rodrigues received other funding from NIHR; Ibrahim Abubakar and Laura C Rodrigues have also received funding from the Medical Research Council. Punam Mangtani received funding from the Biotechnology and Biological Sciences Research Council.

This paper reports on the findings of Delivering Inclusive Access to Disabled and Elderly Members of the community (DIADEM), a 3-year project, funded by the European Commission’s Sixth Framework Programme, to assist older adults when accessing, completing, and submitting online forms, by developing web-based assistive technologies that adapt the online form according to users’ needs. A user-centred approach is adopted to gain insights into the challenges faced by 80 older adults in three European countries as they interact with a representative sample of public service-based online forms. A thematic analysis is then carried out on the data, which revealed five over-arching themes that relate to the challenges faced by users: assistance, trust, layout, the technology paradigm, and language. From these themes, 23 online form design guidelines are derived, which provide valuable guidance for the development of the DIADEM application and for e-Government online form design for an ageing population in general.

The biparietal diameters (BPD) and occipitofrontal diameters (OFD) were measured in a group of 203 newborn infants weighing 501 to 2000g, and at intervals until the age of three years. The heads of 96 normal-birthweight children were also measured. 11 per cent of the low-birthweight group had marked early narrowing, i.e. OFD/BPD (a/b) ratios of greater than 1.55. These babies were lighter and less mature, but by three years of age there was no significant difference in head shape or developmental quotient between these babies and the rest of the group. Intracranial pathology did not appear to affect head shape. At all ages the low-birthweight children showed greater head narrowing than those of normal birthweight.

Animals readily acquire positive odor-taste hedonic associations, but evidence for this in humans remains weak and was explored further. Retronasal pairing of odors with sucrose or salty stimuli (Experiment 1) increased the rated sweetness of sucrose-paired odors without altering liking, although changes in odor pleasantness correlated with sucrose liking. Experience of odors with sucrose or quinine by sweet likers (Experiment 2) found increased pleasantness and sweetness for sucrose-paired odors, whereas quinine-paired odors became less liked and more bitter. Odor-sucrose pairings in sweet likers and dislikers (Experiment 3) found increased sweetness in both groups but increased odor liking only in likers. These data suggest that evaluative and sensory learning are dissociable and that evaluative changes are sensitive to individual differences in sweet liking.

Previous laboratory studies have reported that moderate caffeine consumers develop a liking for the flavour of a novel caffeinated drink. The present study tested whether results from laboratory studies are applicable to real-life situations. Forty moderate caffeine consumers were randomly allocated to four conditions ( n = 10). Three of these conditions involved consumption of two novel flavoured fruit drinks, one caffeinated (100 mg) and one without caffeine, at different times of the participants’ daily routine (breakfast, anytime, night). Participants in the final (control) condition evaluated the drinks on the three test days only. Those participants who received the drinks at breakfast showed a significant increase in liking for the flavour of the caffeinated drink, whereas those who consumed the drinks at night showed a significant decrease in liking for the same flavour. Results imply that the post-ingestive effect of caffeine may depend on the time and condition during which the caffeinated flavour is consumed.

Objective: To investigate the relationship between primary immunisation status and MMR uptake. Design: Nationally representative Millennium Cohort Study. Setting: Children born in the UK, 2000–2002. Participants: 14 578 children with immunisation data. Main outcome measures: MMR status at 3 years, defined as immunised with MMR, immunised with at least one single antigen vaccine or unimmunised. Results: 88.6% of children had been immunised with MMR, 5.2% had received at least one of the single antigen vaccines and 6.1% were unimmunised against measles, mumps and rubella at age 3 years. Children who were unimmunised with the primary vaccines at ages 9 months (1.2%, n = 168) and 3 years (0.4%, n = 67) were 13 (95% CI 10.8 to 14.7) and 17 (95% CI 14.6 to 19.7) times more likely to be unimmunised against measles, mumps and rubella compared with children who were fully immunised. They were also more likely to be immunised with at least one of the single antigen vaccines with risk ratios of 2.8 (95% 1.2 to 6.1) and 4.3 (95% CI 1.8 to 10.1). Similar but smaller associations were observed if children were partially immunised with the primary vaccines at 9 months (3.4%, n = 502) and 3 years (3.6%, n = 522) with risk ratios of 4.0 (95% 3.2 to 4.9) and 5.2 (95% 4.2 to 6.1) for no MMR immunisation, and 2.0 (95% C 1.1 to 3.6) and 1.6 (95% CI 1.1 to 2.5) for single antigen vaccine use. Conclusion: Children who remain unimmunised with primary vaccines are also more likely not to receive MMR. More work is needed to determine how best to target this group.

BACKGROUND: Recent evidence suggests that the duration of protection by bacillus Calmette-Guerin (BCG) may exceed previous estimates with potential implications for estimating clinical and cost-efficacy. OBJECTIVES: To estimate the protection and duration of protection provided by BCG vaccination against tuberculosis, explore how this protection changes with time since vaccination, and examine the reasons behind the variation in protection and the rate of waning of protection. DATA SOURCES: Electronic databases including MEDLINE, Excerpta Medica Database (EMBASE), Cochrane Databases, NHS Economic Evaluation Database (NHS EED), Database of Abstracts of Reviews of Effects (DARE), Web of Knowledge, Biosciences Information Service (BIOSIS), Latin American and Caribbean Health Sciences Literature (LILACs), MEDCARIB Database, Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched from inception to May 2009. Index to Theses, System for Information on Grey Literature in Europe (SIGLE), Centre for Agricultural Bioscience International (CABI) Abstracts, Scopus, Article First, Academic Complete, Africa-Wide Information, Google Scholar, Global Health, British National Bibliography for Report Literature, and clinical trial registration websites were searched from inception to October 2009. REVIEW METHODS: Electronic databases searches, screening of identified studies, data extraction and analysis were undertaken. Meta-analysis was used to present numerical and graphical summaries of clinical efficacy and efficacy by time since vaccination. Evidence of heterogeneity was assessed using the tau-squared statistic. Meta-regression allowed the investigation of observed heterogeneity. Factors investigated included BCG strain, latitude, stringency of pre-BCG vaccination tuberculin testing, age at vaccination, site of disease, study design and vulnerability to biases. Rate of waning of protection was estimated using the ratio of the measure of efficacy after 10 years compared with the efficacy in the first 10 years of a study. RESULTS: Study selection. A total of 21,030 references were identified, providing data on 132 studies after abstract and full-text review. Efficacy. Protection against pulmonary tuberculosis in adults is variable, ranging from substantial protection in the UK MRC trial {rate ratio 0.22 [95% confidence interval (CI) 0.16 to 0.31]}, to absence of clinically important benefit, as in the large Chingleput trial [rate ratio 1.05 (95% CI 0.88 to 1.25)] and greater in latitudes further away from the equator. BCG vaccination efficacy was usually high, and varied little by form of disease (with higher protection against meningeal and miliary tuberculosis) or study design when BCG vaccination was given only to infants or to children after strict screening for tuberculin sensitivity. High levels of protection against death were observed from both trials and observational studies. The observed protective effect of BCG vaccination did not differ by the strain of BCG vaccine used in trials. DURATION: Reviewed studies showed that BCG vaccination protects against pulmonary and extrapulmonary tuberculosis for up to 10 years. Most studies either did not follow up participants for long enough or had very few cases after 15 years. This should not be taken to indicate an absence of effect: five studies (one trial and four observational studies) provided evidence of measurable protection at least 15 years after vaccination. Efficacy declined with time. The rate of decline was variable, with faster decline in latitudes further from the equator and in situations where BCG vaccination was given to tuberculin-sensitive participants after stringent tuberculin testing. LIMITATIONS: The main limitation of this review relates to quality of included trials, most of which were conducted before current standards for reporting were formulated. In addition, data were lacking in some areas and the review had to rely on evidence from observational studies. CONCLUSIONS: BCG vaccination protection against tuberculosis varies between populations, to an extent that cannot be attributed to chance alone. Failure to exclude those already sensitised to mycobacteria and study latitude closer to the equator were associated with lower efficacy. These factors explained most of the observed variation. There is good evidence that BCG vaccination protection declines with time and that protection can last for up to 10 years. Data on protection beyond 15 years are limited; however, a small number of trials and observational studies suggest that BCG vaccination may protect for longer. Further studies are required to investigate the duration of protection by BCG vaccination. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Objective: Assess the current BCG vaccination policies and delivery pathways for immunisation in Primary Care Trusts (PCTs) in England since the 2005 change in recommendations. Design: A survey of key informants across PCTs using a standardised, structured questionnaire. Setting: 152 PCTs in England. Results: Complete questionnaires were returned from 127 (84%) PCTs. Sixteen (27%) PCTs reported universal infant vaccination and 111 (73%) had selective infant vaccination. Selective vaccination outside infancy was also reported from 94 (74%) PCTs. PCTs with selective infant policy most frequently vaccinated on postnatal wards (51/102, 50%), whereas PCTs with universal infant vaccination most frequently vaccinated in community clinics (9/13, 69%; p=0.011). To identify and flag up eligible infants in PCTs with targeted infant immunisation, those who mostly vaccinate on postnatal wards depend on midwives and maternity records, whereas those who vaccinate primarily in the community rely more often on various healthcare professionals. Conclusions: Targeted infant vaccination has been implemented in most PCTs across the UK. PCTs with selective infant vaccination provide BCG vaccine via a greater variety of healthcare professionals than those with universal infant vaccination policies. Data on vaccine coverage would help evaluate the effectiveness of delivery. Interruptions of delivery noted here emphasise the importance of not just an agreed, standardised, local pathway, but also a named person in charge.

The growth of 171 seven-year-old children, free from major disability, with a birth weight of 2000 g or less was examined and compared with that of their own parents and of normal-birth-weight peers. Measurements included height, weight, occipitofrontal circumference, biparietal, occipitofrontal and bi-iliac diameters, triceps and subscapular skinfold thickness. Low-birth-weight children were shorter than their parents whereas those of normal birth weight were taller. For all parameters, particularly weight, the low-birth-weight children were significantly less well grown. There was no significant relationship between occipitofrontal circumference and intellectual ability.

Delivering Inclusive Access to Disabled and Elderly Members of the community (DIADEM) is a three year Framework 6 European Union (EU) funded project. The primary goal is to develop the DIADEM application, a plug-in to a web browser that adapts the online-form interface according to users’ needs, making the content more accessible for cognitively impaired older adults. After providing some background information relating to the DIADEM project and the DIADEM application, a trial protocol is presented. As one of the main contributions of this paper, the protocol has been specifically designed to identify cognitively impaired older-adults and to evaluate the usability of online-form content from an older adult user’s perspective. To demonstrate the applicability of the trial protocol within the context of an ongoing research project, details of a set of pan-European trials involving 77 eligible users, who evaluated DIADEM enabled online-forms according to the trial protocol, are also presented. Results of the trials reveal a number of online-form design guidelines, which will be incorporated into future versions of the DIADEM application. Although these guidelines have been developed specifically for the DIADEM application, they also represent valuable guidelines for online-form developers more generally, and if adhered to, will ensure that content is more usable for the cognitively impaired older adult user group. This paper concludes by discussing the lessons learned from implementing the trial protocol and how the implications of the findings of the DIADEM user trials may be incorporated into future versions of the DIADEM application.

The coordination and laterality of a group of 171 seven-year-old children, free from major disability, with a birthweight of 2000 g or less, were examined and compared with those of normal birthweight peers. More low birthweight children were left-handed and of mixed or undetermined hand, foot and eye dominance. Left-handedness may adversely affect some areas of performance of normal birthweight but not of low birthweight children. Low birthweight children performed significantly less well in tests of both fine and gross motor coordination. Girls tended to perform better than boys in fine motor tests. In the low birthweight group there was a correlation between IQ and coordination.

In order to inform local action for health improvement, this pilot study used multiple methods to explore children's perspectives of environmental influences on their eating and physical activity. Thirty-nine children aged 9-11 years from a North London local authority took photos, drew maps, and attended focus groups. We found that the approach engaged children and that each of the methods returned useful, complementary information. The results highlighted a number of areas for local policymakers and practitioners to consider when developing work to prevent childhood obesity. We conclude that these methods of gaining children's views should be further developed and tested.

The RCPCH Child Protection Companion provides guidance on medical report writing. We wanted to audit local medical reports against this guidance. Reports are shared with social care and police child abuse investigation team (CAIT), contributing to decision making for children. We therefore wished to determine whether our local social care and CAIT teams felt the opinions in the reports were helpful to their decision making. A retrospective audit of reports of 24 children seen in the first half of 2014 was undertaken, using section 16 of the RCPCH companion as standards. 3 reports from each of the 8 consultants were chosen at random. CAIT and social care reviewed the same 24 reports and completed a proforma regarding key aspects of the medical opinion. Patients’ details, consultation time/place, specific concerns, appearance of the child, past medical, family and developmental history were completed in all reports. 75% gave the child’s own words where applicable, 89% gave information regarding school/nursery and 64% commented on parent/carer interaction. Most reports commented on the need for section 47 investigation but made no direct statement on whether it was safe for the child to return home. Social care and CAIT thought 19 and 16 reports respectively were helpful in decision making. Reported unhelpful factors were non-committal wording on the likelihood of NAI, ambiguity around sibling cases and lack of documentation regarding evidence for neglect concerns. Clear documentation of patients’ and consultation details reflects local strong administrative support. Key areas for child protection, notably the words of the child and child parent interaction were lacking and should be highlighted in training. Paediatricians may have made verbal recommendations during the medical but documentation of this is imperative. The satisfaction of CAIT/social care with reports depends upon their expectations as well as the doctor’s clarity. In some cases the doctor could not have given a ‘clear’ opinion based on what was in front of them. It is valuable for local audits of child protection reports to involve local CAIT and social care to optimise the usefulness of reports in safeguarding of children.

In this paper we describe how different types of constraints can affect the performance of genetic algorithms (GAs). The success of a GA application depends on efficient constraints to provide a clear direction for GA search. Our application integrates geometrical constraints with a GA to guide the pattern matching process for image registration and object location. Two types of constraints, namely, local and global constraints are considered Although both types of constraints are useful in constraining the pattern matching search space, the former type is less effective than the latter type. Intuitively one would expect that the combination of both types of constraints should be more powerful than each of them used alone. Yet our experimental result proves to the contrary. We describe the whole process of integrating geometrical constraints with a GA for pattern matching and analyse the results.

A new algorithm is described for propagating constraints over ordered domains. The method is particularly suitable for applications where variables may be restricted to a sequence of contiguous values within a domain. By describing the characteristics of the domains, and adding variables and constraints, it is possible to specify a wide variety of problems in a simple and intuitive way. The algorithm may then be invoked to limit the solution space. It is particularly suitable for interactive use, with the user modifying the ranges of variables and then invoking constraint propagation to establish all consequences. >

Describes a novel application of the CMAC (Cerebellar Model Articulation Controller) neural network. We have identified CMAC as an adaptive fuzzy system that can extract fuzzy rules from training data and use these rules for classifying a unknown input of a class. The extracted fuzzy rules are stored in the CMAC's memory table and they do not need to be translated explicitly to be used for classification. We have also discovered that the CMAC's network operations are equivalent to fuzzy operations. This means that the CMAC, which has so far only been recognized as a controller and a function modeller, is in fact also a neuro-fuzzy recognition system.

There is a pressing need for very large collections of training data if cursive script recognition research is to become a commercial success. However, the construction and proofing of such databases is extremely laborious. This paper describes the use of a tool which facilitates this process, and which has enabled the authors to construct a useful collection of data which is available to the research community. The structure of the database is an important consideration in making it useful to other researchers, and this is described along with a range of access functions and tools.

Children are a priority in “Vision 2020”, the World Health Organization's recently launched global initiative for the prevention of avoidable visual impairment by the year 2020.1Successful implementation in the United Kingdom will depend to a greater extent on improvements in secondary and tertiary preventive strategies, to treat and rehabilitate affected children, than on the currently limited primary preventive approaches to the major paediatric eye diseases. Early detection is important to the successful management of children with ophthalmic disorders. In recognition of this, over the past few decades in the UK diverse activities have been implemented to promote early detection of specific ophthalmic conditions in children as well as to monitor their visual development. These comprise physical examinations by various health professionals and effectively form a continuum of screening and surveillance whose purpose and value is best considered in terms of sequential gain. Although now well established, these practices have arisen haphazardly and few have been subject to rigorous evaluation of their benefits. Indeed the scientific basis of some has been seriously questioned.2 In the UK they are undertaken within the broader context of a national programme of child health surveillance.3 Changes in this, such as the increased emphasis on health promotion,3 increasing responsibilities of general practitioners,4 and reconsideration of the roles of health visitors and school nurses,5 consequently have implications for ophthalmological screening and surveillance. The Children's Sub-Group of the National Screening Committee (NSC) of the UK has recently reviewed screening for ophthalmic disorders and visual deficits in children for the first time. The NSC categorised existing activities into five separate screening programmes for retinopathy of prematurity (ROP) in preterm/low birthweight infants; congenital cataract and other ocular anomalies in newborn and young infants; amblyopia and impaired vision in preschool age children; impaired vision, …

The author has developed software in the past that segments hand-printed characters using simple heuristics, normalises them, extracts features and recognises them using a quadratic discriminant function. He concluded that correct segmentation was the area that needed major research effort. If this could be done correctly then the recognition results would be reasonably impressive using existing software. He has developed software for producing outlines, and then strokes (or vectors) from scanned images. The original application was the capture of engineering drawings. The outlining is a crack-following approach. A sequence of mergelets forms a word. Finding the best sequence of mergelets is the formulation of the segmentation problem.

The reproduction of a scanned document should include not only the optical character recognition of text, but also the structure of that text on the page and the appearance of that text itself (i.e. font recognition). This is paper presents an algorithm which structurally recognises the text of a page image. The method is based upon the "Docstrum plot" algorithm by L.O'Gorman (1993). Modifications have been made to O'Gorman's algorithm which render very good results at identifying paragraphs and lines in particular. The algorithm implementation can, to a limited degree, describe the logical relationship of the text elements of the original page. The limitations of the algorithm are due to the lack of information available without OCR and font technology incorporated into the algorithm implementation. The algorithm implementation has a graphical interface which portrays the state of the algorithm during the process of decomposition.

Correction for gestational age continues to make a difference to the height SD score (SDS) to the age of seven years in very preterm babies. The height SDS for children born at 28 weeks' gestation increased by 0.25 SDS when postconceptual age was used instead of real age. Extrapolating from these results, the effect of correction would be an increase of approximately 0.32 SDS for a seven-year-old of 24 weeks' gestation. Unsatisfactory growth may be masked by a steady or increasing real age SDS in a few children. The risks of stopping using postconceptual age at two or three years include both false confidence in genuine cases of growth retardation and misinterpretation of a decrease in height SDS as evidence of growth retardation. As the number of very preterm babies who survive increases so does the importance of these observations.

Editor—In responding to Jefferson’s editorial about vaccination and its adverse effects Classen and Classen say that present immunisation schedules may exacerbate the development of type 1 diabetes and that early immunisation with a cocktail of vaccines may prevent the development of diabetes.1,2 The authors cite their unpublished reanalysis of the Finnish trial of Haemophilus influenzae type b vaccine.3 Their conclusions are at odds with the analyses and conclusions of the investigator (JT) presented at a National Institutes of Health workshop and were published recently.4 The Finnish investigators’ review of the data could not attribute the risk of type 1 diabetes in Finnish children to differences in the timing of childhood vaccination in the vaccine trial. The incidence of type 1 diabetes in Finland has risen over several decades, and the risk seems to have been almost linear since the early 1950s. Given the disparity of conclusions, it was suggested that Classen and Classen’s analysis be sent to an independent statistician. We are not aware that this has been done. The authors quote the aim of the National Institutes of Health workshop as being “to discuss our data” when in fact the title was “an evaluation of the possible role of vaccines and infectious diseases in insulin dependent (type 1) diabetes mellitus.” Two independent reviews of available data specific to vaccines were presented by the Cochrane reviewers and the Johns Hopkins Vaccine Safety Institute; neither found an association such as that reported, and both indicated concerns about methodological issues in statistical analysis and the design and conduct of these studies. The conclusion of the workshop, presented in June 1998, was that studies in humans do not indicate an increase in type 1 diabetes attributable to any vaccine or the timing of immunisation. Dr J B Classen has filed a European and American patent on his schedule that may have widespread implications should his views be implemented. He applies for a patent on immunisation schedules to be administered from birth, both to reduce the likelihood of type 1 diabetes developing and to protect individuals from communicable diseases.5 The safety or efficacy of one particular paediatric schedule (annex 5 of the application5) has not been shown. The applications can be obtained for a small fee from the Search and Advisory Service, Patent Office, Cardiff Road, Newport, Gwent NP9 1RH. The full list of references for this letter is on the BMJ’s website.6 We agree that the public should be made aware of what is going on.

OBJECTIVE--To review the neonatal screening programme during 1984-8. DESIGN--Analysis of data from screening laboratories and paediatricians. SUBJECTS--All live births in United Kingdom. MAIN OUTCOME MEASURES--Structure of programme; number of infants tested and number with phenylketonuria; number of infants missed; ages at testing and treatment. RESULTS--The proportion of infants tested approached 100%. The incidence of phenylketonuria was 11.7/100,000 births (445 subjects): 273 had classic phenylketonuria and three had defects of cofactor metabolism. One child with phenylketonuria was known to have been missed compared with three in 1979-83 and six in 1974-8. Seven subjects had been missed over the 15 years due to negative test results. All seven had been tested with the bacterial inhibition assay, although only 53% of infants had been so tested; the difference between the expected and observed proportion was significant (Fisher's exact test, p = 0.017). Eleven infants with classic phenylketonuria were not tested by 14 days of age and 23 (8%) did not start treatment until after 20 days, an improvement compared with 36 (15%) in 1979-83. There were, however, wide regional variations (0% to 27% treated after 20 days). CONCLUSION--The screening programme achieves high coverage and effectiveness, although some children are still missed. A national practice for screening may help reduce regional variations.