Evidence into action: implementing alcohol screening and brief interventions in the UK Armed Forces.

INTRODUCTION: Alcohol-related harm continues to represent a major public health problem and previous evidence suggests that alcohol misuse within the UK Armed Forces is higher than in the general population. The aim was to introduce a population-level primary care intervention with an existing evidence base to identify and support Service Personnel whose drinking places them at greater risk of harm. IMPLEMENTATION: Following successful piloting, the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) brief screening tool was introduced as part of routine dental inspections by Defence Primary Healthcare (DPHC) dentists. Alcohol brief intervention (ABI) advice and signposting to support services was offered to personnel identified as being at increased risk and recorded in the patient's electronic health record. ACHIEVEMENTS TO DATE: Patients attending DPHC Dental Centres are now routinely offered AUDIT-C with 74% (109 459) personnel screened in the first 12 months rising to over 276 000 at 24 months, representing the single largest use of AUDIT-C and ABIs in a military population to date. DISCUSSION: Introduction of AUDIT-C has seen Defence successfully deliver a whole population alcohol initiative, overcoming implementation barriers to demonstrate the flexibility of a dental workforce to deliver a public health intervention at scale and contributing towards promoting positive attitudes towards alcohol use. The initiative represents a first step towards the goal of a standardised alcohol screening and treatment pathway across DPHC while recognising that the Defence Medical Services are only one aspect of the broader public health approach required to tackle alcohol-related harm in Service Personnel.

Strong Dependence of Atmospheric Feedbacks on Mixed-Phase Microphysics and Aerosol-Cloud Interactions in HadGEM3.

We analyze the atmospheric processes that explain the large changes in radiative feedbacks between the two latest climate configurations of the Hadley Centre Global Environmental model. We use a large set of atmosphere-only climate change simulations (amip and amip-p4K) to separate the contributions to the differences in feedback parameter from all the atmospheric model developments between the two latest model configurations. We show that the differences are mostly driven by changes in the shortwave cloud radiative feedback in the midlatitudes, mainly over the Southern Ocean. Two new schemes explain most of the differences: the introduction of a new aerosol scheme and the development of a new mixed-phase cloud scheme. Both schemes reduce the strength of the preexisting shortwave negative cloud feedback in the midlatitudes. The new aerosol scheme dampens a strong aerosol-cloud interaction, and it also suppresses a negative clear-sky shortwave feedback. The mixed-phase scheme increases the amount of cloud liquid water path (LWP) in the present day and reduces the increase in LWP with warming. Both changes contribute to reducing the negative radiative feedback of the increase of LWP in the warmer climate. The mixed-phase scheme also enhances a strong, preexisting, positive cloud fraction feedback. We assess the realism of the changes by comparing present-day simulations against observations and discuss avenues that could help constrain the relevant processes.

Enhancing evidence use in public health nutrition policymaking: theoretical insights from a New Zealand case study.

BACKGROUND: Enhancing the use of evidence in policymaking is critical to addressing the global burden of nutrition-related disease. Whilst the public health nutrition community has embraced evidence-informed policymaking, their approach of defining relevant evidence and evaluating policy has not brought about major shifts in policymaking. This article uses a public health nutrition case study to refine a novel theory-informed framework for enhancing the use of evidence in government public health nutrition policymaking. Our aim is to contribute insights from evidence-informed policy to the emerging paradigm in public health nutrition policymaking. METHODS: An enquiry framework informed by three groups of theories underpinning evidence-informed policy was used to explore the role of socially mediated processes on the use of evidence. A public health nutrition case study on food marketing to New Zealand children was conducted to refine the framework. Interview data collected from 54 individuals representing four key policy stakeholder groups, policymakers, academics, and food industry and non-government organisations were analysed using deductive and inductive thematic analysis. To enhance theoretical robustness, an alternative hypothesis of political explanations for evidence use was explored alongside the enquiry framework. RESULTS: We found the prevailing political climate influenced the impact of advocacy for evidence inclusive processes at the meta-policy and policymaking process levels and in policy community relationships. Low levels of awareness of the impact of these processes on evidence use and uncoordinated advocacy resulted in the perpetuation of ad hoc policymaking. These findings informed refinements to the enquiry framework. CONCLUSION: Our study highlights the role advocates can play in shifting government public health nutrition policymaking systems towards enhanced use of evidence. Our Advocacy for Evidence Use framework argues for a three-channel approach to advocacy for using evidence in the public interest. The framework provides a means for building a constituency for evidence use in public health nutrition and adds understanding about advocacy to the field of evidence-informed policy. Future research should examine the impact of coordinated advocacy on public health nutrition policymaking systems.

Axon diameters and conduction velocities in the macaque pyramidal tract.

Small axons far outnumber larger fibers in the corticospinal tract, but the function of these small axons remains poorly understood. This is because they are difficult to identify, and therefore their physiology remains obscure. To assess the extent of the mismatch between anatomic and physiological measures, we compared conduction time and velocity in a large number of macaque corticospinal neurons with the distribution of axon diameters at the level of the medullary pyramid, using both light and electron microscopy. At the electron microscopic level, a total of 4,172 axons were sampled from 2 adult male macaque monkeys. We confirmed that there were virtually no unmyelinated fibers in the pyramidal tract. About 14% of pyramidal tract axons had a diameter smaller than 0.50 µm (including myelin sheath), most of these remaining undetected using light microscopy, and 52% were smaller than 1 µm. In the electrophysiological study, we determined the distribution of antidromic latencies of pyramidal tract neurons, recorded in primary motor cortex, ventral premotor cortex, and supplementary motor area and identified by pyramidal tract stimulation (799 pyramidal tract neurons, 7 adult awake macaques) or orthodromically from corticospinal axons recorded at the mid-cervical spinal level (192 axons, 5 adult anesthetized macaques). The distribution of antidromic and orthodromic latencies of corticospinal neurons was strongly biased toward those with large, fast-conducting axons. Axons smaller than 3 µm and with a conduction velocity below 18 m/s were grossly underrepresented in our electrophysiological recordings, and those below 1 µm (6 m/s) were probably not represented at all. The identity, location, and function of the majority of corticospinal neurons with small, slowly conducting axons remains unknown.

Fetal and neonatal exposure to AZT and low-protein diet affects glucose homeostasis: a model with implications for AIDS prevention.

Zidovudine (AZT) lowers the perinatal transmission of HIV but can impair mitochondrial function by depleting mitochondrial DNA (mtDNA). AZT therapy and perinatal nutritional deprivation affect the body fat distribution, which influences glucose tolerance. We sought to model intrauterine exposure to AZT in humans to determine whether it interacts with low-protein diet (LPD) to impact on birth weight and glucose homeostasis in the offspring. Pregnant dams and their offspring were given AZT, an LPD, or AZT and an LPD (LPD + AZT). AZT reduced mtDNA copy number in liver and birth weight in the offspring and increased their fasting glucose and insulin (P = 0.021, 0.03, 0.001, and 0.011 respectively) at 6-8 wk of age. LPD decreased litter size and birth weight (P = 0.01 and 0.012). In the LPD + AZT group, birth weight and litter size were reduced compared with untreated controls, and fasting blood glucose and insulin were raised. There was a significant interaction between LPD and AZT on fasting insulin levels (P = 0.025). Islet size was not significantly affected, but the mean beta-cell area/islet was reduced in the LPD + AZT group compared with controls (P < 0.05). Early exposure to AZT interacts with LPD to impair fetal development in this model. This combination appeared to impair the supply of insulin and, hence, glucose homeostasis, perhaps as a result of impaired mitochondrial function. Although it is not certain that this can be extrapolated to humans, maternal nutritional deprivation combined with AIDS therapy could influence both birth weight and onset of diabetes.

Theory of growth by differential sedimentation, with application to snowflake formation.

A simple model of irreversible aggregation under differential sedimentation of particles in a fluid is presented. The structure of the aggregates produced by this process is found to feed back on the dynamics in such a way as to stabilize both the exponents controlling the growth rate, and the fractal dimension of the clusters produced at readily predictable values. The aggregation of ice crystals to form snowflakes is considered as a potential application of the model.

Is Doppler ultrasound sufficient as the sole investigation before carotid endarterectomy?

BACKGROUND AND AIMS: Doppler ultrasound (DU) of the extracranial carotid arteries has been advocated as the sole imaging modality in carotid endarterectomy (CE) candidates. However this approach fails to identify patients with potentially significant intracranial disease, at high risk of stroke and death. Therefore, many stroke clinicians recommend angiography after screening DU. We aimed to identify the proportion of cases referred for CE in whom the identification of intracranial disease could have altered management. METHODS: Two neuroradiologists, blinded to the clinical history, reviewed the films of 111 CE candidates, predominantly of Caucasian background, who had undergone carotid angiography after screening DU. Intracranial stenoses >50% luminal diameter, incidental aneurysms and non-atherosclerotic lesions were documented. Demographic and epidemiological data were collected. RESULTS: Of the 111 patients, 87 had >50% extracranial stenoses although two thirds were asymptomatic. Intracranial stenotic lesions were recorded in 29% of patients. Over half of these were tandem lesions, distal to an extracranial stenosis. Aneurysms were found in 4.5% of patients. CONCLUSIONS: DU alone would have failed to detect significant intracranial disease in nearly a third of cases. These patients are at high risk of stroke. The identification of this group allows more aggressive stroke prevention therapy.

The chemically treated bovine ureter--clinical performance of a novel biological vascular prosthesis.

AIM: This paper describes the rationale, development and clinical performance of a novel small-diameter vascular prosthesis of non-vascular animal tissue origin. METHOD: Durable conduits suitable for coronary and peripheral arterial reconstruction are prepared for the first time from non-vascular animal tissue. Australian bovine ureters from young steers from protected herds are processed to form strong, bloodflow-compatible and non-immunogenic biologic grafts ('Flonova', Bionova International Pty Ltd, Melbourne). Fifty-six patients lacking suitable autogenous veins received 62 prostheses (32 bypasses were implanted above knee and 30 below knee). Determination of patency and function included Doppler ultrasound, duplex scanning and angiography. FINDINGS: The primary patency rate at 1, 2 and 5 years, respectively was 67, 59 and 52% and the secondary patency for the same time frames was 88, 73 and 61%. There were no occlusions as a result of intimal hyperplasia. Dilatation of the wall was diagnosed in one prosthesis at 3.5 years, and one at 7 years, and a false aneurysm of unknown aetiology occurred in another at 3 months. There were no primary graft infections. CONCLUSION: This evaluation shows the chemically treated bovine ureter (CTBU) is a viable medium-term alternative to the currently available artificial vascular prostheses for peripheral revascularisation.

Tandem lesions of the carotid circulation: combined extracranial endarterectomy and intracranial transluminal angioplasty.

A case series is presented demonstrating a unique approach to the treatment of tandem atherosclerotic lesions of the internal carotid artery. Between 1994 and 1999 eight patients with tandem lesions of the internal carotid artery were treated by combined carotid endarterectomy for the proximal lesion and intraoperative angioplasty of the distal intracranial lesion via the carotid arteriotomy. The success and complication rates were evaluated. A 100% technical success rate was achieved with one post procedural complication by ipsilateral stroke within 24 h. The advantages of this technique include the treatment of tandem lesions by the one procedure, improved transluminal access to the intracranial lesion and the ability to reduce the risk of embolism by flow control during balloon inflation.

Defining an exacerbation of pulmonary disease in cystic fibrosis.

Despite the importance of pulmonary exacerbations in CF in both clinical and research settings, both published evidence and consensus are lacking concerning the criteria used to define an exacerbation. The use of hospitalization as a surrogate measure presupposes uniformity among clinicians in diagnosis and treatment of exacerbations. Our aims were to evaluate consensus among clinicians about the variables considered helpful in diagnosing an exacerbation requiring treatment. A comprehensive list of symptoms, signs, and investigations used to define exacerbations was compiled from published trials. A written self-administered questionnaire included the list in age-appropriate groups to survey opinion about the helpfulness of each item, and the estimated proportion of patients admitted within a month of diagnosis of an exacerbation. This was sent to all clinicians managing CF patients in Australia. There were replies from 59/91 clinicians (65%), 41/60 (68%) from those managing children and 18/31 (58%) from those managing adults. Responses of those managing children and adults differed for 7/32 variables (Mann-Whitney test, P < 0.05). Clinic grouping did not show greater consensus among responses of pediatricians (Kruskal-Wallis test, P = 0.362). Consensus, >74% or <26% of respondents rating a variable helpful/very helpful, was found in only 50% of variables listed. Estimated admission rate within a month of diagnosis was 61% (30-100%) for those managing adults and 48% %5-100%) for pediatricians. A lack of consensus was found among clinicians managing CF about the variables considered in diagnosing an exacerbation. The estimated proportion admitted within a month of diagnosis was very variable. This demonstrated inhomogeneity in approach to diagnosis and management of an exacerbation suggests a significant heterogeneity of clinical care.

Adherence of human saphenous vein endothelial cell monolayers to tissue-engineered biomatrix vascular conduits.

This study investigates the adherence and retention under in vitro flow conditions of endothelium grown on the luminal surface of 4-mm-internal-diameter, biomatrix vascular conduits. The biomatrix vascular conduits are produced in living animals and consist of a naturally formed extracellular matrix wall incorporating a polyester mesh. We propose that the microarchitecture of the luminal surface may be conducive to endothelial cell (EC) seeding and to the formation of a firmly adherent endothelium without prior treatment of the surface with cell adhesives. ECs were isolated from segments of human saphenous vein and grown to confluence in a culture. Cultured cells were characterized by morphology and immunocytochemistry with anti-CD31, Von Willebrand factor, smooth muscle actin, cytokeratin, and the lectin Ulex Europaeus agglutinin. After culture, ECs were seeded (1 x 10(6) cell/mL) by rotation onto the luminal surface of 20-cm-long, biomatrix vascular conduits (n = 3). The seeded conduits were incubated for 72 h, and at set time points postseeding (1, 24, 48, and 72 h), the morphology, percentage luminal surface cover, and cell density (cell/cm(2)) were determined from en face preparations and histological cross sections. After 72 h in culture, the seeded conduits were subjected to a nonpulsatile flow for 1 h with culture media. A flow rate of 480 mL/min generated physiological-range shear stresses of 12 dyn/cm(2) on the endothelialized surface. After the flow, the conduits were fixed for histology, and the EC morphology and percentage luminal surface cover were determined. Quantification of the extent of luminal surface endothelialization, preflow and postflow, and cell densities at confluence was performed with digital imaging light microscopy and image analysis software. An analysis of the results demonstrated that confluent EC monolayers may be established on the luminal surface of biomatrix vascular conduits within 48 h. The formed endothelium was firmly adherent and was retained under physiological-range flow.

Treatment of renovascular disease with percutaneous stent insertion: long-term outcomes.

Renal artery stenosis is a common, progressive cause of hypertension and renal impairment, and is frequently treated with percutaneous transluminal dilatation and stenting. The outcome of this procedure is still being evaluated. The records of 198 consecutive patients who had stents inserted at the Royal Melbourne Hospital were analysed retrospectively, and adequate follow-up information on 148 (75%), in whom a total of 182 renal arteries had been treated was obtained. Technical success was achieved in 144 patients (97%). Complications occurred in 19 patients (13.3%), with major complications occurring in 10 (7.0%) and one death occurring in relation to the procedure. A fall in average systolic blood pressure of 13.2 mmHg (12.1-14.3 mmHg) was seen and a fall in diastolic blood pressure of 10.1 mmHg (9.3-10.9 mmHg), without an increase in the number of antihypertensive drugs used. Renal function remained stable in the majority of patients, particularly those who had minimal baseline renal impairment. Restenosis was common after 6 months, occurring eventually in 29% of screened patients, but was not shown to affect clinical outcomes. Insertion of renal artery stents is a safe and effective treatment for renal artery stenosis.

Decreased hepatic expression of the low-density lipoprotein (LDL) receptor and LDL receptor-related protein in aging rats is associated with delayed clearance of chylomicrons from the circulation.

Aging in both humans and rats is associated with the development of insulin resistance and the ensuing alterations in the plasma lipoprotein profile. In this study, young (2 months) and old (15 months) Sprague-Dawley (SD) rats were used to investigate age-related alterations in the chylomicron clearance pathway. Clearance from the blood of an intravenously injected bolus of 14C-labeled cholesterol ester (CE) and 3H-labeled triacylglycerol (TAG) lymph chylomicrons was markedly delayed in the old rats (P < .05). Hepatic expression of the two principal receptors of chylomicron remnant removal, the low-density lipoprotein (LDL) receptor and LDL receptor-related protein (LRP), was determined by ligand blotting and immunoblotting. The old rats expressed 43%+/-7% of the level of LDL receptor in the young animals (P < .05) and 45%+/-16% of the corresponding level of LRP (P < .05). The results suggest that the delayed clearance of chylomicron remnants in this animal model of aging and insulin resistance is due, at least in part, to a decrease in the hepatic expression of LDL receptor and LRP.

Comparison of a commercial enzyme-linked immunosorbent assay with immunofluorescence and complement fixation tests for detection of Coxiella burnetii (Q fever) immunoglobulin M.

A commercially available enzyme-linked immunosorbent assay (ELISA) for the diagnosis of Q fever (PanBio Coxiella burnetii immunoglobulin M [IgM] ELISA, QFM-200) was compared to the indirect fluorescent antibody test (IFAT) for C. burnetii IgM and the complement fixation test (CFT). The ELISA demonstrated 92% agreement with the reference method (IFAT), and gave a sensitivity of 99% (69 of 70 samples) and a specificity of 88% (106 of 121). Specificity can be increased with confirmation by IFAT. CFT was found to have a specificity of 90% (107 of 119), although it was lacking in sensitivity (73%; 51 of 70). No cross-reactivity was observed in the ELISA with serum samples from patients with mycoplasma (n = 6), chlamydia (n = 5), or legionella (n = 4) infections, although 2 of 5 patients with leptospirosis and 1 of 4 samples containing rheumatoid factor (RF) demonstrated positive results in the ELISA. Results indicate that the performance of the PanBio C. burnetii (Q fever) IgM ELISA (F = 187) is superior to that of CFT (F = 163), and consequently the ELISA should be a useful aid in the diagnosis of acute Q fever.

A quality assurance review of outpatient care of children with life-threatening asthma exacerbations.

OBJECTIVES: A hospital admission for asthma represents an opportunity to address and improve asthma control. The aims of this study were to compare the ambulatory care of children admitted to the intensive care unit (ICU) following a life-threatening asthma exacerbation with published guidelines of asthma management and to identify areas that could be targeted for change. METHODS: A retrospective review of case notes of children admitted to the ICU with asthma over a 6-month period. Variables recorded were: demographic; asthma history (including prior pattern of asthma, hospital admissions, interval treatment and managing doctor); admission details (consultation of respiratory team and asthma educator); and discharge management. RESULTS: There were 40 admissions of 38 children (24 males) with mean age 5.7 years (range 1.1-14 years). The majority (58%) had previous admissions for asthma (55 admissions in 22 children), with 23% of these to ICU. Sixty three per cent of those with previous admissions had persistent asthma, but only 29% were on inhaled corticosteroid (ICS). Most (60%) were managed by their local medical officer (LMO). Use of ICS was more likely if managed by a paediatrician. A respiratory subspecialist was consulted in 42% and the asthma educator in 70% of ICU admissions. Discharge medication included ICS in 74%, with no interval treatment in 18% of admissions. Follow up was by a respiratory subspecialist in 25% of cases. CONCLUSION: Asthma management before and after admission with life-threatening asthma did not conform to available guidelines. Persistent asthma was under-treated. Paediatricians were more likely to use interval treatment than LMO. We identified areas in which quality of care and outcome could be improved in this vulnerable group of asthmatics.

Non-government organisations to combine for work on chronic disease in Aboriginal peoples, Torres Strait Islanders and rural and remote populations.

As a result of the National Health Priority Area Report on Cardiovascular Health and in particular, its remote and indigenous section, a consortium of five organisations ran a national workshop in Townsville in October 1999 on heart disease in Aboriginal peoples, Torres Strait Islanders and rural and remote populations. One of the priority areas identified at this workshop was the need for a more coordinated approach to chronic diseases and for the formation of an alliance of non-government organisations (NGOs) to work towards this and to undertake a lobbying and advocacy role. A meeting of a wide range of NGOs working in chronic disease, led by the National Heart Foundation of Australia, was held in Sydney in May 2000. At the Sydney meeting it was agreed that an alliance of NGOs could be formed for the development of a chronic disease strategy for Aboriginal peoples, Torres Strait Islanders and rural and remote populations. The NGOs drafted a 'Statement of Intent', which would inform their work on both heart disease and on broader work to address chronic preventable disease in the target populations. There is a considerable amount of procedural work to be done before the proposed alliance becomes a reality but the prospect of closer collaboration between the NGOs working in chronic disease has much to offer, especially for the population groups that were the focus of the Townsville workshop. This 'alliance' initiative comes at a time when there are national and State/Territory moves on broader aspects of what could become a 'national chronic disease prevention and management strategy'.