Decision-making for active living infrastructure in new communities: a qualitative study in England.

BACKGROUND: Urban design can influence population levels of physical activity and subsequent health impacts. This qualitative study investigates local level decision-making for 'active living' infrastructure (ALI)-walking and cycling infrastructure and open spaces in new communities. METHODS: Thirty-five semi-structured interviews with stakeholders, and limited ethnographic observations, were conducted with local government and private sector stakeholders including urban and transport planners, public health practitioners, elected councillors and developers. Interview transcripts were coded and analysed thematically. RESULTS: Public health practitioners in local government could act as knowledge brokers and leaders to motivate non-health stakeholders such as urban and transport planners to consider health when designing and building new communities. They needed to engage at the earliest stages and be adequately resourced to build relationships across sectors, supporting non-health outcomes such as tackling congestion, which often had greater political traction. 'Evidence' for decision-making identified problems (going beyond health), informed solutions, and also justified decisions post hoc, although case study examples were not always convincing if not considered contextually relevant. CONCLUSION: We have developed a conceptual model with three factors needed to bridge the gap between evidence and ALI being built: influential public health practitioners; supportive policies in non-health sectors; and adequate resources.

Effects of urban motorways on physical activity and sedentary behaviour in local residents: a natural experimental study.

BACKGROUND: There is little evidence on how changing the physical environment changes health-related behaviours. We studied the effects of the new M74 motorway (freeway) - opened in 2011 - and the existing M8 motorway in Glasgow, Scotland, on physical activity and sedentary behaviour among local residents. METHODS: This natural experimental study used baseline (T1; 2005) and follow-up data (T2; 2013) from a longitudinal cohort (N = 365) and two cross-sectional samples (T1 N = 980; T2 N = 978). Adult participants were recruited from three study areas: one surrounding the new motorway, one surrounding the existing motorway, and a third, control, area without a motorway. The outcomes were self-reported time spent sitting, walking, and in moderate-to-vigorous physical activity (MVPA). Motorway exposure was defined in terms of (1) study area and (2) distance from home to the nearest motorway junction. Outcomes were regressed on exposures in two-part (walking and MVPA) or linear (sedentary behaviour) cohort and repeat cross-sectional models, adjusted for baseline behaviour and sociodemographic covariates. RESULTS: Cohort participants living in the M8 area were less likely to participate in MVPA at follow-up than those living in the area without a motorway (OR 0.37; 95%CI 0.15, 0.91). Within the M8 area, those living closer to the motorway were also less likely to do so (OR 0.30; 95%CI 0.09, 0.97). No other statistically significant results were found. CONCLUSIONS: We found some evidence of a negative association between exposure to an existing urban motorway and MVPA. However, the behavioural impacts of motorways are likely to be complex and evolve over time.

Self-awareness of foot health status in patients with Type 2 diabetes: the Fremantle Diabetes Study Phase II.

AIMS: To determine self-awareness of diabetes-related foot problems and its associates in a community-based cohort of people with Type 2 diabetes. METHODS: A survey concerning diabetic foot problems was administered to 358 consecutive patients with Type 2 diabetes [mean ± SD age 67.4 ± 10.8 years, 56.1% males, median (interquartile range) diabetes duration 9.0 (3.9-16.8) years] attending for detailed clinical, biochemical and questionnaire assessment as part of the longitudinal observational Fremantle Diabetes Study Phase II. RESULTS: Compared with the 213 patients (59.5%) who considered their feet to be normal, the 145 (40.5%) who considered their feet to be abnormal were older, had longer diabetes duration and were more likely to have sensory neuropathic symptoms and self-reported poor circulation (P < 0.001). In those who considered their feet to be normal, 67.9% had peripheral sensory neuropathy (score >2/8 on the Michigan Neuropathy Screening Instrument clinical portion), 9.9% had an ankle-brachial index < 0.9, 6.1% had both peripheral sensory neuropathy and an ankle-brachial index < 0.90, and 86.9% had one or more features on inspection, such as deformity, dry skin, callus and fissures that could facilitate more serious complications, despite the majority having had at least one foot examination by a healthcare professional in the previous year. CONCLUSIONS: Self-assessment of diabetes-related foot problems by patients in the Fremantle Diabetes Study Phase II was unreliable. The present data suggest that self-perceived foot health should be assessed together with foot examination findings. Intensive education and monitoring may be necessary in those who consider their feet to be normal but who have neurovascular, structural and/or other precursors of serious foot pathology.

Anaesthetic records: an evaluation of variation across England.

We collected blank non-specialist anaesthetic records from 71 National Health Service Trusts in England. A data set was established by collating all data items found in an initial tranche of 28 records. All 71 records were subsequently analysed for each data item in this data set. We found significant variation: the most populated record included 216 data items and the least included 38 data items: a greater than five-fold variation. There was significant variation in the inclusion of data items commonly considered important to patient safety; 42% of records omitted documentation of fasting status, 72% omitted documentation of a discussion around the risk of accidental awareness during general anaesthesia, 92% omitted documentation of quantitative neuromuscular blockade monitoring and 63% omitted documentation for 'Stop Before You Block' when performing regional anaesthesia. The study highlights significant variability in the composition of anaesthetic records across England which may impact on its value as a data repository, an action trigger, a medicolegal account, and a tool to facilitate safe handover. Standardisation of the anaesthetic record or the establishment of standards of recording would help to allay potential risks to patient safety and assist in guiding future procurement of electronic solutions for anaesthetic records.

Patterns and implications of extensive heterochrony in carnivoran cranial suture closure.

Heterochronic changes in the rate or timing of development underpin many evolutionary transformations. In particular, the onset and rate of bone development have been the focus of many studies across large clades. In contrast, the termination of bone growth, as estimated by suture closure, has been studied far less frequently, although a few recent studies have shown this to represent a variable, although poorly understood, aspect of developmental evolution. Here, we examine suture closure patterns across 25 species of carnivoran mammals, ranging from social-insectivores to hypercarnivores, to assess variation in suture closure across taxa, identify heterochronic shifts in a phylogenetic framework and elucidate the relationship between suture closure timing and ecology. Our results show that heterochronic shifts in suture closure are widespread across Carnivora, with several shifts identified for most major clades. Carnivorans differ from patterns identified for other mammalian clades in showing high variability of palatal suture closure, no correlation between size and level of suture closure, and little phylogenetic signal outside of musteloids. Results further suggest a strong influence of feeding ecology on suture closure pattern. Most of the species with high numbers of heterochronic shifts, such as the walrus and the aardwolf, feed on invertebrates, and these taxa also showed high frequency of closure of the mandibular symphysis, a state that is relatively rare among mammals. Overall, caniforms displayed more heterochronic shifts than feliforms, suggesting that evolutionary changes in suture closure may reflect the lower diversity of cranial morphology in feliforms.

Thermographic imaging during nasal peanut challenge may be useful in the diagnosis of peanut allergy.

BACKGROUND: Double-blinded challenges are widely used for diagnosing food allergy but are time-consuming and cause severe reactions. Outcome relies on subjective interpretation of symptoms, which leads to variations in outcome between observers. Facial thermography combined with nasal peanut challenge was evaluated as a novel objective indicator of clinical allergy. METHODS: Sixteen children with positive blinded peanut challenge underwent nasal challenge with 10 µg peanut protein or placebo. Mean skin temperatures were recorded from the mouth and nose using infrared thermography over 18 min. RESULTS: The area under curve of nasal skin temperature was significantly elevated after peanut vs placebo (18.2 vs 4.8°Cmin). The maximum increase in temperature was also significantly greater after peanut: mean difference +0.9°C. CONCLUSION: This feasibility study shows thermography can detect inflammation caused by nasal challenges whilst employing one thousand-fold less peanut than an oral challenge. This novel technique could be developed to provide a rapid, safe and objective clinical allergy test.

Self-efficacy, imagery use, and adherence during injury rehabilitation.

Previous observational studies examining imagery, self-efficacy, and adherence during injury rehabilitation have been cross-sectional and thus have not provided a clear representation of what occurs over the course of the rehabilitation period. The objectives of this research were (1) to examine the temporal patterns of imagery, self-efficacy, and rehabilitation adherence during an 8-week rehabilitation program and (2) to identify the time-order relationships between imagery, self-efficacy, and adherence. The design of the study was prospective and observational. 90 injured people (n=57 males; n=33 females) aged 18-78 years attending an injury rehabilitation clinic participated. The main outcome measures were imagery (cognitive, motivational, and healing), self-efficacy (task and coping), and rehabilitation adherence (duration, quality, and frequency). Results indicated that task efficacy, imagery use, and adherence levels remained stable, while coping efficacy declined over time. During the course of rehabilitation, moderate to strong reciprocal relationships existed between self-efficacy and adherence to rehabilitation. Weak to moderate relationships were found between imagery use and rehabilitation adherence. The results of this study can be used to inform the development of interventions steeped in self-efficacy and imagery aimed at improving rehabilitation adherence and treatment outcome.

Guided imagery to improve functional outcomes post-anterior cruciate ligament repair: randomized-controlled pilot trial.

Imagery can improve functional outcomes post-anterior cruciate ligament repair (ACLR). Research is needed to investigate potential mechanisms for this effect. The aim of this study was to (a) evaluate the effectiveness of an imagery intervention to improve functional outcomes post-ACLR, and (b) explore potential mechanisms. A randomized-controlled pilot trial was conducted. Participants were randomized to guided imagery and standard rehabilitation or standard rehabilitation alone (control). The primary outcome was knee strength 6-month post-operatively. Secondary outcomes were knee laxity at 6-months, and change in psychological (self-efficacy) and neurohormonal (adrenaline, noradrenaline, dopamine) variables. Participants (n=21; 62% male) were 34.86 (SD 8.84) years. Following the intervention, no statistical differences between groups for knee strength extension at 180°/s (t=-0.43, P=0.67), or at 60°/s (t=-0.72, P=0.48) were found. A statistically significant effect was found for knee laxity, F=4.67, P<0.05, mean difference of -3.02 (95% CI -4.44 to -1.60), favoring the intervention. No differences were found for self-efficacy; however, an overall effect was found for noradrenaline, F(1, 19) 19.65, P<0.001, η(2) =0.52, and dopamine, F(1, 19) 6.23, P=0.02, η(2) =0.29, favoring the intervention. This imagery intervention improved knee laxity and healing-related neurobiological factors.

Delayed cystic fibrosis presentation in children in the absence of newborn screening.

Newborn cystic fibrosis (CF) screening facilitates early diagnosis and nutritional intervention, which prevents malnourishment and improves growth in childhood. To provide baseline information on the natural history of CF in the Republic of Ireland, where newborn screening has not yet been introduced and CF incidence is high (1:1353 live births), we examined the effect of presentation mode, symptom type and gender on age at diagnosis. Median age at diagnosis was calculated by gender and for presentation mode/symptom type for 601 CF registry children diagnosed 1986-2007. Modes of presentation were each significantly associated with delayed presentation. An adjusted odds ratio of 4.5 (95% CI: 1.8, 11.1) was determined for presentation with family history, 43.1 for gastrointestinal symptoms presentation (95% CI: 18.3, 101.4), 96.9 for both respiratory and gastrointestinal symptoms (95% CI: 38.6, 243,4), and 115.4 for respiratory symptoms (95% CI: 45.2, 294.7). Children with respiratory symptoms had the greatest likelihood of delayed diagnosis (median age: 20.4 months), followed by those with respiratory and gastrointestinal symptoms (9.2 months). Gender was not significantly associated with a delayed presentation when presentation mode was taken into account.

Diagnosis of cystic fibrosis in the Republic of Ireland: epidemiology and costs.

There were four objectives in this study: (1) determine the incidence of cystic fibrosis (CF) in Ireland; (2) estimate the cost of diagnosing CF; (3) clarify the characteristics and outcomes of the nationwide diagnostic efforts and (4) identify disparities. Surveys were conducted to determine the number, methods, costs and outcomes for sweat tests in Ireland from 2001 through 2003. The results allowed us to determine that Ireland's CF incidence is the world's highest at 1:1353. The average cost for diagnosis was Euro 2663 per patient. Analyses of data in The Cystic Fibrosis Registry of Ireland revealed longer delays when diagnosis followed respiratory symptoms, rather than gastrointestinal signs, and also in girls compared to boys, particularly those presenting with respiratory symptoms. Although expenditures for diagnosing of CF in Ireland are relatively modest, the high incidence and age of diagnosis, as well as gender-related disparities, are sufficient to warrant investment in national newborn screening.

In vivo image-guided (1)H-magnetic resonance spectroscopy of the serial development of hepatocarcinogenesis in an experimental animal model.

Histology on a core or open biopsy is considered the gold standard for the diagnosis of tumours. While the non-invasive technique of magnetic resonance imaging can direct some of the decision diagnostic making, it has limitations and disadvantages, that can be partly overcome with the use of in vivo magnetic resonance spectroscopy (MRS). In vivo MRS is able to provide a specific biochemical profile on tumour tissue, compared with normal tissue. The capability of this technique is demonstrated here by the long-term development of hepatocellular carcinoma in an animal model. It allows the observation of the biochemical changes that occur in tumour tissue during its progression from preneoplastic nodules to hepatocellular carcinoma. Specifically the changes in the lipid profiles of tumour tissue at various stages of development are observed with proton ((1)H) MRS. Significant increases occurred in the lipid acyl chain methylene and methyl hydrogens during the early developmental stages of hepatocarcinogenesis, whereas during later stages associated with tumour development there was a significant increase in the levels of olefinic acyl chain hydrogens from unsaturated lipids. It is anticipated that this model will precede the application of the same technology to the non-invasive diagnosis and grading of human hepatocellular carcinoma.

High susceptibility of human cancer xenografts with higher levels of cytidine deaminase to a 2'-deoxycytidine antimetabolite, 2'-deoxy-2'-methylidenecytidine.

2'-Deoxy-2'-methylidenecytidine (DMDC) is a new 2'-deoxycytidine (dCyd) antimetabolite. The present study compared its antitumor activities with those of 2',2'-difluorodeoxy-cytidine (gemcitabine) in 15 human cancer xenograft models. DMDC was highly resistant to cytidine (Cyd) deaminase, which deaminates the dCyd analogues to inactive molecules, whereas gemcitabine was susceptible to the enzyme. Given p.o., high antitumor activity with therapeutic index of more than 10 was found with DMDC in 7 of 15 xenograft lines. In contrast, gemcitabine given i.v. or p.o. was highly effective in 4 of 15 human cancer xenograft lines. The antitumor spectrum of these compounds was quite different, although their molecular targets are reported to be similar. DMDC was highly effective in tumors with higher levels of Cyd deaminase activity, whereas it showed only slight activity in those with lower levels of Cyd deaminase. In contrast, gemcitabine appeared to be less effective in tumors with high levels of Cyd deaminase. We also investigated the correlation with the susceptibility to the two dCyd antimetabolites and dCyd kinase activity in tumors, but none was observed. Cyd deaminase activity was found to be high in tumor tissues from various types of human cancers thus far tested, such as colorectal cancer and non-small cell lung cancer. Such cancer types or individual patients who have tumors with high activity of the enzyme may be targets for DMDC therapy.

X-ray structure of a novel matrix metalloproteinase inhibitor complexed to stromelysin.

A new class of matrix metalloproteinase (MMP) inhibitors has been identified by screening a collection of compounds against stromelysin. The inhibitors, 2,4,6-pyrimidine triones, have proven to be potent inhibitors of gelatinases A and B. An X-ray crystal structure of one representative compound bound to the catalytic domain of stromelysin shows that the compounds bind at the active site and ligand the active-site zinc. The pyrimidine triones mimic substrates in forming hydrogen bonds to key residues in the active site, and provide opportunities for placing appropriately chosen groups into the S1' specificity pocket of MMPS: A number of compounds have been synthesized and assayed against stromelysin, and the variations in potency are explained in terms of the binding mode revealed in the X-ray crystal structure.

Cost savings with nonthoracotomy implantable cardioverter-defibrillators.

We analyzed hospital and physician charges for 99 consecutive patients who underwent implantable cardioverter-defibrillator (ICD) implantation at our institution. Eighteen patients received an epicardial lead system and 81 were scheduled to receive a nonthoracotomy lead system, the generator being implanted either abdominally (n = 62) or pectorally (n = 19). The epicardial group had a significantly longer convalescent stay (11.6 +/- 2.5 days; mean +/- SEM) than the abdominal nonthoracotomy group, analyzed by intention to treat (4.6 +/- 0.5 days) or by treatment received (3.8 +/- 0.2 days; p <0.0001). Postoperative stay for the pectoral group was shorter still (2.9 +/- 0.4 days; p <0.033). Total charges for the epicardial group were $99,081 +/- $25,094, significantly higher than those for any of the nonthoracotomy groups (p <0.017). Total charges for the pectoral group were $44,128 +/- $2,465, significantly less than those for the abdominal nonthoracotomy group, analyzed by intention to treat ($59,961 +/- $1,369; p <0.05) or by treatment received ($56,679 +/- $635; p <0.05). Cost reductions in the nonthoracotomy groups were primarily due to decreased in-hospital convalescence period, lower surgeon and anesthesiologist fees, and lower procedure-day hospital charges in the pectoral group. The use of ICDs with nonthoracotomy leads can result in significantly shorter in-hospital convalescence and a reduction in total implant-related charges of 40% to 55%. The use of pectorally implanted ICDs results in further reduction in hospital stay and further cost reduction of 22% to 26%. The trend toward shorter convalescent stay without postimplant testing is likely to reduce further the overall costs of ICD implantation.

The interventricular extension of choroid plexus papillomas.

Four cases of choroid plexus papilloma extending through the foramen of Monro are presented. All four patients were evaluated by contrast-enhanced CT and two of these were also evaluated by neurosonography. No other intraventricular tumor commonly extends through a ventricular outlet. The radiographic demonstration of this extension of an intraventricular mass through the foramen of Monro, cerebral aqueduct, or foramen of Luschka or Magendie represents an ancillary diagnostic sign of choroid plexus papilloma.

The peanut orbit: a modified elliptical orbit for single-photon emission computed tomography imaging.

The front collimator surface of a conventional single-photon emission computed tomography (SPECT) detector system transcribing an elliptical orbit to approximate body contour could, under certain circumstances, penetrate the ellipse and make patient contact. The problem is associated both with the large front surface dimensions of tomographic cameras and the need to maintain the camera perpendicular to a radius through the axis of rotation. To aid in the development of an improved body contour orbit, software has been developed to simulate SPECT imaging systems. A major feature of the algorithms is a spatially calibrated graphic representation of the pallet, patient and orbit of the camera head. Based on computer simulations performed with this software, a modified elliptical orbit has been proposed for patient contour SPECT scanning on two different types of tomographic acquisition systems: a dual camera, rotating ring system and a single camera, multimotion stand system. This peanut orbit has the advantage of minimizing collimator patient distance, as does the elliptical orbit, but also compensates for camera motion that could potentially produce patient contact. Versions of the peanut orbit algorithms have been installed and are operational on clinical systems similar to those that were simulated. The ring-based gantry system (with cameras mounted on cantilevered arms) requires additional software to correct for translational shift in the field of view as a function of radial distance from the center of the system. This is done during uniformity correction. Standard unmodified backprojection software is used for reconstruction. The peanut orbit may represent an improved approach to body contour imaging in rotational SPECT.

Cerebrospinal fluid dynamics and hydrocephalus after experimental subarachnoid hemorrhage.

The effects of three sequential injections of cisternal blood on ventricular size, cerebrospinal fluid (CSF) pressure, CSF formation rate, and CSF absorption rate were evaluated in adult rabbits. Autologous blood was injected into the cisterna magna on Days 1, 4, and 8 and ventriculocisternal perfusion was done on Day 15. Control animals received artificial CSF injection at these intervals. For each rabbit, the mean CSF pressure was higher after three injections of blood than before: 13 animals after blood injection had a mean CSF pressure of 15.59 +/- 1.15 cm H2O (mean +/- SE); before blood injection, their pressure had been 11.14 +/- 1.43 cm H2O (all figures are means +/- SE). This is a significant increase in pressure (P less than 0.01, paired t-test). Further, the 13 rabbits with cisternal blood injection had a significantly higher CSF pressure than 5 control animals: 15.59 +/- 1.15 vs. 10.50 +/- 1.06 cm H2O. The animals with cisternal blood injection all developed some degree of hydrocephalus; the ventricle to brain percentage ratio was 9.84 +/- 0.56 in blood-injected animals and 2.38 +/- 0.21 in control animals (P less than 0.01, two-tailed t-test). CSF formation and absorption rates were not significantly different after subarachnoid hemorrhage. The CSF formation rates were 9.85 +/- 1.8 microliter/minute in the experimental group and 9.53 +/- 1.9 microliter/minute in the control group; CSF absorption at the animal's opening pressure was 13.30 +/- 2.06 microliter/minute in the animals with cisternal blood injection and 9.97 +/- 2.4 microliter/minute in the control animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Experimental normal-pressure hydrocephalus is accompanied by increased transmantle pressure.

This research was directed at the pathophysiology of normal-pressure hydrocephalus. The experimental method consisted of accurate and simultaneous measurement of the pressure within the ventricle and over the cerebral convexity in cats with hydrocephalus but normal ventricular pressure. Hydrocephalus was induced by the intracisternal injection of kaolin. Prior to the induction of hydrocephalus, the difference between the ventricular pressure and the pressure over the convexity (the transmantle pressure) was small (0.27 +/- 0.31 cm saline, mean +/- standard deviation). After the induction of normal-pressure hydrocephalus in seven animals, there was a statistically significant elevation of the transmantle pressure to 3.4 +/- 3.9 cm saline (p less than 0.05, Student's paired t-test). There was no similar increase in animals injected with lactated Ringer's solution. This finding supports the theory that it is the transmantle pressure, and not the ventricular pressure, that is the physiological determinant of ventricular dilatation. The theory explains why hydrocephalus can develop and persist despite normal ventricular pressure.

Morphological changes of the basilar artery, ventricles, and choroid plexus after experimental SAH.

Experimental subarachnoid hemorrhage (SAH) was induced in adult rabbits by three repeated cisterna magna injections of autologous nonheparinized blood. One week after the last blood injection the animals were sacrificed and examined for morphological change. No vasculopathy was noted in the basilar arteries and no periarterial thrombus was seen around the majority of these arteries. Gross and microscopic changes were observed in both the ventricles and choroid plexus. Ventricular changes included dilation of the lateral ventricles, destruction of ciliated ependymal cells, and deposition of small amounts of blood throughout the ventricular system. These ventricular changes are similar to the pathological sequelae of SAH in patients. Choroid plexus changes included electron-dense cytoplasmic inclusions and dilation of the lateral and subcellular spaces. The ventricular surface and the choroid plexus are both affected by the intracisternal injection of blood. The hydrocephalus that follows SAH may be potentiated by ependymal disruption and loss of ciliated activity in the ventricles. Changes in choroid plexus function may also occur.

Late-onset interface keratitis after uneventful laser in situ keratomileusis.

Although there have been many proposed etiologies for interface inflammation after laser in situ keratomileusis, the causative factor(s) remains an enigma. This case of late-onset interface inflammation suggests that the many previously suspected interface contaminants from the surgical environment were not involved. Transformation of a previously inert material to an inflammatory stimulus is proposed as a potential cause; however, a sample of inflammatory focus was not obtained because of the immediate and complete response to frequent topical steroid drops.