Practical Indicators for Risk of Airborne Transmission in Shared Indoor Environments and Their Application to COVID-19 Outbreaks.

Some infectious diseases, including COVID-19, can undergo airborne transmission. This may happen at close proximity, but as time indoors increases, infections can occur in shared room air despite distancing. We propose two indicators of infection risk for this situation, that is, relative risk parameter (Hr) and risk parameter (H). They combine the key factors that control airborne disease transmission indoors: virus-containing aerosol generation rate, breathing flow rate, masking and its quality, ventilation and aerosol-removal rates, number of occupants, and duration of exposure. COVID-19 outbreaks show a clear trend that is consistent with airborne infection and enable recommendations to minimize transmission risk. Transmission in typical prepandemic indoor spaces is highly sensitive to mitigation efforts. Previous outbreaks of measles, influenza, and tuberculosis were also assessed. Measles outbreaks occur at much lower risk parameter values than COVID-19, while tuberculosis outbreaks are observed at higher risk parameter values. Because both diseases are accepted as airborne, the fact that COVID-19 is less contagious than measles does not rule out airborne transmission. It is important that future outbreak reports include information on masking, ventilation and aerosol-removal rates, number of occupants, and duration of exposure, to investigate airborne transmission.

School feeding for improving the physical and psychosocial health of disadvantaged elementary school children.

BACKGROUND: Early malnutrition and/or micronutrient deficiencies can adversely affect physical, mental, and social aspects of child health. School feeding programs are designed to improve attendance, achievement, growth, and other health outcomes. OBJECTIVES: The main objective was to determine the effectiveness of school feeding programs in improving physical and psychosocial health for disadvantaged school children. SEARCH STRATEGY: We searched a number of databases including CENTRAL (2006 Issue 2), MEDLINE (1966 to May 2006), EMBASE (1980 to May 2006), PsycINFO (1980 to May 2006) and CINAHL (1982 to May 2006). Grey literature sources were also searched. Reference lists of included studies and key journals were handsearched and we also contacted selected experts in the field. SELECTION CRITERIA: Data from randomized controlled trials (RCTs), non-randomised controlled clinical trials (CCTs), controlled before and after studies (CBAs), and interrupted time series studies (ITSs) were included. Feeding had to be done in school; the majority of participants had to be socio-economically disadvantaged. DATA COLLECTION AND ANALYSIS: Two reviewers assessed all searches and retrieved studies. Data extraction was done by one of four reviewers and reviewed by a second. Two reviewers independently rated quality. If sufficient data were available, they were synthesized using random effects meta-analysis, adjusting for clustering if needed. Analyses were performed separately for RCTs and CBAs and for higher and lower income countries. MAIN RESULTS: We included 18 studies. For weight, in the RCTs and CBAs from Lower Income Countries, experimental group children gained an average of 0.39 kg (95% C.I: 0.11 to 0.67) over an average of 19 months and 0.71 kg (95% C.I.: 0.48 to 0.95) over 11.3 months respectively. Results for weight were mixed in higher income countries. For height, results were mixed; height gain was greater for younger children. Attendance in lower income countries was higher in experimental groups than in controls; our results show an average increase of 4 to 6 days a year. Math gains were consistently higher for experimental groups in lower income countries; in CBAs, the Standardized Mean Difference was 0.66 (95% C.I. = 0.13 to 1.18). In short-term studies, small improvements in some cognitive tasks were found. AUTHORS' CONCLUSIONS: School meals may have some small benefits for disadvantaged children. We recommend further well-designed studies on the effectiveness of school meals be undertaken, that results should be reported according to socio-economic status, and that researchers gather robust data on both processes and carefully chosen outcomes.

"I don't know how I'm still standing" a Bakhtinian analysis of social housing and health narratives in East London.

Housing is a significant determinant of health and substandard housing is a public health issue. East London has long had a shortage of social and affordable housing, worsened in recent years by a combination of stressors. In one of East London's most deprived boroughs, Newham, changes brought about by the 2011 Localism Act and the unique demands of being the host Olympic borough in 2012 have brought considerable pressures to bear on social infrastructure. This paper examines how these pressures were experienced by local residents via their narratives of social housing and health. The data reported here are from a qualitative study comprising two waves of data collection. Narrative family interviews and go-along interviews were conducted with 40 Newham residents at wave one and 28 at wave two. A narrative analysis with a Bakhtinian interpretation was undertaken. This revealed that residents framed experiences of social housing in terms of an inherent system-level ideology based on notions of need and waiting. A particularly striking feature of this ideology was the extent to which descriptions of ill health and impairment were implicated in constructions of housing need; participants directly attributed a range of health complaints to their housing predicaments, including stress, depression, cancer scares, panic attacks and loss of sleep. Understanding the contested ideology of social housing can illuminate both the dynamic processes of social exclusion and the ways in which its subjects seek to resist it.

Combination of Novel Agents with Radiotherapy to Treat Rectal Cancer.

Neoadjuvant chemoradiotherapy with fluoropyrimidines is an established treatment in the management of locally advanced rectal cancer. There has been a great deal of research into improving patient outcomes by modifying this regimen by the addition of further radiosensitising agents. One of the difficulties in advancing new combination therapies has been lack of consensus on which surrogate measures best reflect clinically important outcomes. Here we review combinations of the cytotoxic, biological and other agents currently under scrutiny to improve clinical outcomes for patients with colorectal cancer. We also discuss advances in biomarkers that may ultimately result in an ability to tailor neoadjuvant chemoradiotherapy regimens to the somatic gene profile of individual patients.

"Everyone was looking at you smiling": East London residents' experiences of the 2012 Olympics and its legacy on the social determinants of health.

Mega-sporting event regeneration, as a specific approach to urban renewal, uses impending host-city status as a catalyst for revitalisation and has the potential to improve health both through addressing deprivation and by promoting increased sport and physical activity among the host-city's population. This qualitative study explored how hosting of the London 2012 Games impacted upon the way East London residents perceived and experienced the social determinants of health in their local neighbourhood. We conducted narrative family interviews, go-along interviews and video focus group workshops with 66 Newham residents, aged 12-55 years, immediately after the Games. A narrative analytic approach examined accounts of health and wellbeing experiences in terms of neighbourhood change and the spectacle of the Games. Participants of this qualitative study generally welcomed the respite and the unexpected chance to live in a cleaner, safer and more unified environment. However, this positivity was underscored by an acute awareness that this was a very temporary situation and one that was intended to support the event rather than residents.

RCGP Quality Team Development programme: an illuminative evaluation.

BACKGROUND: There is increasing interest in quality initiatives that are locally owned and delivered, team based, multiprofessional, and formative. The Royal College of General Practitioners' Quality Team Development (QTD) programme is one such initiative aimed at developing primary healthcare teams and their services. AIMS: To evaluate QTD from the perspective of participants and assessors. SETTING: UK primary health care. DESIGN AND METHOD: Twelve of 14 practices and all four primary care organisations (PCOs) approached agreed to participate. Thirty four semi-structured interviews were conducted with key stakeholders. The interviews were taped, transcribed, and analysed using the constant comparative method. RESULTS: The QTD programme appears to be highly valued by participating organisations. Practice based respondents perceived it as acceptable and feasible, and reported positive changes in teamwork and patient services. They valued its formative, participative, and multiprofessional nature, especially the peer review element. PCOs saw QTD as a method of delivering on prevailing national policies on clinical quality and modernization agendas as well as promoting interorganizational collaboration. The main concerns raised were the workload, particularly for assessors, and maintaining the quality of the assessments and the programme. CONCLUSION: This qualitative study suggests positive benefits for participants in the QTD programme. However, such practices are a self-selecting innovative minority. Further research is needed on more typical practices to identify barriers to their participation in QTD or other formative, team based quality improvement programmes.

Drug prescription and self-medication in India: an exploratory survey.

This paper reports a study of the prescribing and dispensing of drugs in India. The drugs supplied to 2400 patients by the public and private medical sectors and by private pharmacies (over the counter dispensing) were recorded, and were analysed with respect to the patient's presenting complaint and diagnosis. The main findings discussed in this paper are: 1. Large numbers of drugs are prescribed by doctors in the private sector. Combination preparations containing 'hidden' classes of drug are often given. Anti-infectives are widely and often inappropriately used. 2. Potentially dangerous drugs are sold over the counter and prescribed for trivial or bizzare indications. Drugs which have been withdrawn as dangerous in the West remain popular first line drugs in India. 3. Food supplements and tonics of dubious nutritional and pharmacological value make up a high proportion of the total drugs bill. It is concluded that a rational drugs policy and/or an essential drugs list will be useless unless accompanied by intensive efforts to improve the education and updating of doctors and pharmacists and to reduce the commercial pressures on doctors to prescribe unnecessary drugs.

Experiences of general practitioners and practice nurses of training courses in evidence-based health care: a qualitative study.

BACKGROUND: Clinical governance will require general practitioners (GPs) and practice nurses (PNs) to become competent in finding, appraising, and implementing research evidence--the skills of evidence-based health care (EBHC). AIM: To report the experiences of GPs and PNs in training in this area. METHOD: We held 30 in-depth, semi-structured interviews throughout North Thames region with three groups of informants: primary care practitioners recruited from the mailing lists of established EBHC courses; organizers and teachers on these courses; and educational advisers from Royal Colleges, universities, and postgraduate departments. Detailed qualitative analysis was undertaken to identify themes from each of these interview groups. RESULTS: At the time of the fieldwork for this study (late 1997), remarkably few GPs or PNs had attended any formal EBHC courses in our region. Perceived barriers to attendance on courses included inconsistency in marketing terminology, cultural issues (e.g. EBHC being perceived as one aspect of rapid and unwanted change in the workplace), lack of confidence in the subject matter (especially mathematics and statistics), lack of time, and practical and financial constraints. Our interviews suggested, however, that the principles and philosophy of EBHC are beginning to permeate traditional lecture-based continuing medical education courses, and consultant colleagues increasingly seek to make their advice 'evidence based'. CONCLUSION: We offer some preliminary recommendations for the organizers of EBHC courses for primary care. These include offering a range of flexible training, being explicit about course content, recognizing differences in professional culture between primary and secondary care and between doctors and nurses, and addressing issues of funding and accreditation at national level. Introducing EBHC through traditional topic-based postgraduate teaching programmes may be more acceptable and more effective than providing dedicated courses in its theoretical principles.

How to read a paper. Statistics for the non-statistician. II: "Significant" relations and their pitfalls.

It is possible to be seriously misled by taking the statistical competence (and/or the intellectual honesty) of authors for granted. Some common errors committed (deliberately or inadvertently) by the authors of papers are given in the final box.

Health beliefs and folk models of diabetes in British Bangladeshis: a qualitative study.

OBJECTIVE: To explore the experience of diabetes in British Bangladeshis, since successful management of diabetes requires attention not just to observable behaviour but to the underlying attitudes and belief systems which drive that behaviour. DESIGN: Qualitative study of subjects' experience of diabetes using narratives, semi-structured interviews, focus groups, and pile sorting exercises. A new qualitative method, the structured vignette, was developed for validating researchers' understanding of primary level culture. SUBJECTS: 40 British Bangladeshi patients with diabetes, and 10 non-Bangladeshi controls, recruited from primary care. RESULT: Several constructs were detected in relation to body image, cause and nature of diabetes, food classification, and knowledge of complications. In some areas, the similarities between Bangladeshi and non-Bangladeshi subjects were as striking as their differences. There was little evidence of a fatalistic or deterministic attitude to prognosis, and most informants seemed highly motivated to alter their diet and comply with treatment. Structural and material barriers to behaviour change were at least as important as "cultural" ones. CONCLUSION: Bangladeshi culture is neither seamless nor static, but some widely held beliefs and behaviours have been identified. Some of these have a potentially beneficial effect on health and should be used as the starting point for culturally sensitive diabetes education.

Protocol for an HTA report: Does therapeutic writing help people with long-term conditions? Systematic review, realist synthesis and economic modelling.

INTRODUCTION: Long-term medical conditions (LTCs) cause reduced health-related quality of life and considerable health service expenditure. Writing therapy has potential to improve physical and mental health in people with LTCs, but its effectiveness is not established. This project aims to establish the clinical and cost-effectiveness of therapeutic writing in LTCs by systematic review and economic evaluation, and to evaluate context and mechanisms by which it might work, through realist synthesis. METHODS: Included are any comparative study of therapeutic writing compared with no writing, waiting list, attention control or placebo writing in patients with any diagnosed LTCs that report at least one of the following: relevant clinical outcomes; quality of life; health service use; psychological, behavioural or social functioning; adherence or adverse events. Searches will be conducted in the main medical databases including MEDLINE, EMBASE, PsycINFO, The Cochrane Library and Science Citation Index. For the realist review, further purposive and iterative searches through snowballing techniques will be undertaken. Inclusions, data extraction and quality assessment will be in duplicate with disagreements resolved through discussion. Quality assessment will include using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Data synthesis will be narrative and tabular with meta-analysis where appropriate. De novo economic modelling will be attempted in one clinical area if sufficient evidence is available and performed according to the National Institute for Health and Care Excellence (NICE) reference case.