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OBJECTIVE Local health departments (LHDs) operate within complex, multisectoral organizational communication networks. Network composition may affect priorities, processes, and the reach of health information to key stakeholders. This study seeks to elucidate variation in local network structures to examine how different constellations may affect information sharing across audiences. DESIGN This study analyzes data from a 2016 US survey of 491 metropolitan LHDs and 556 nonmetropolitan LHDs. Researchers first conducted social network analysis of network density, defined as the total number of potential organizations contributing to a jurisdiction's health communication activities. Researchers then conducted logistic regression to compare the relationship between network density and reported health communication activities targeting 3 specific audiences: policy makers, lay publics, and mass media. RESULTS Three network types emerged on the basis of the number of organizations that contribute to health communication activities, with low-density Minimal networks more common in nonmetropolitan jurisdictions and higher-density Expanded and Robust networks more common in metropolitan jurisdictions. LHDs in Minimal networks were significantly less likely to communicate with policy makers, lay publics, and mass media than their counterparts in higher-density networks (P < .05). CONCLUSIONS LHDs are embedded in organizational communication networks that vary in both the number of communication partners and the types of audiences reached. Examining their own local organizational communication networks may provide insights into LHDs that wish to improve the effectiveness of public health messaging. By adding organizational communication partners and reaching new audiences, LHDs in Minimal networks can expand the reach of messages designed to help policy makers, communities, and individuals promote health and prevent disease.

We describe the London community testing programme developed for COVID-19, audit its effectiveness and report patient acceptability and patient adherence to isolation guidance, based upon a survey conducted with participants. Any patients meeting the Public Health England (PHE) case definition for COVID-19 who did not require hospital admission were eligible for community testing. 2,053 patients with suspected COVID-19 were tested in the community between January and March 2020. Of those tested, 75 (3.6%) were positive. 88% of patients that completed a patient survey felt safe and 82% agreed that community testing was preferable to hospital admission. 97% were able to remain within their own home during the isolation period but just 41% were able to reliably isolate from other members of their household. The London community testing programme allowed widespread testing for COVID-19 while minimising patient transport, hospital admissions and staff exposures. Community testing was acceptable to patients and preferable to admission to hospital. Patients were able to reliably isolate in their home but not from household contacts. The authors believe in the importance, feasibility and acceptability of community testing for COVID-19 as a part of a package of interventions to mitigate a second wave of infection.

Patients with some types of immunodeficiency can experience chronic or relapsing infection with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This leads to morbidity and mortality, infection control challenges, and the risk of evolution of novel viral variants. The optimal treatment for chronic coronavirus disease 2019 (COVID-19) is unknown.Our aim was to characterize a cohort of patients with chronic or relapsing COVID-19 disease and record treatment response.We conducted a UK physician survey to collect data on underlying diagnosis and demographics, clinical features, and treatment response of immunodeficient patients with chronic (lasting ≥21 days) or relapsing (≥2 episodes) of COVID-19.We identified 31 patients (median age 49 years). Their underlying immunodeficiency was most commonly characterized by antibody deficiency with absent or profoundly reduced peripheral B-cell levels; prior anti-CD20 therapy, and X-linked agammaglobulinemia. Their clinical features of COVID-19 were similar to those of the general population, but their median duration of symptomatic disease was 64 days (maximum 300 days) and individual patients experienced up to 5 episodes of illness. Remdesivir monotherapy (including when given for prolonged courses of ≤20 days) was associated with sustained viral clearance in 7 of 23 clinical episodes (30.4%), whereas the combination of remdesivir with convalescent plasma or anti-SARS-CoV-2 mAbs resulted in viral clearance in 13 of 14 episodes (92.8%). Patients receiving no therapy did not clear SARS-CoV-2.COVID-19 can present as a chronic or relapsing disease in patients with antibody deficiency. Remdesivir monotherapy is frequently associated with treatment failure, but the combination of remdesivir with antibody-based therapeutics holds promise.

Background The role of antibodies in coronavirus disease 2019 (COVID-19) in patients with X-linked agammaglobulinaemia (XLA) has yet to be characterised and clinical courses observed in this cohort of patients have been heterogeneous. Whilst some exhibit spontaneous recovery, others have experienced a more protracted disease length. Previous reports have described successful use of convalescent plasma, however there is a paucity of information around the use of the REGN-COV2 antibody cocktail in these patients. Case report A patient with XLA was admitted to hospital with COVID-19 and remained persistently symptomatic with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) swab positivity despite treatment with Remdesivir and dexamethasone. Attempts at modulating the immune response with anakinra were unsuccessful. Consent for compassionate use of REGN-COV2 was obtained with administration taking place on day 87 of his illness. This was followed by a period of convalescence and SARS-CoV-2 nasopharyngeal swab negativity. As a consequence of prolonged immunosuppression, the patient developed pneumocystis pneumonia. Conclusion This case highlights the role of antibodies in clearing SARS-CoV-2 in a hypogammaglobulinaemic host and demonstrates the consequences of prolonged immunosuppression and delayed treatment. We propose that this may be of particular significance given the capacity of SARS-CoV-2 to develop advantageous mutations in a chronically infected host.

OBJECTIVES:. We sought to validate prognostic scores in coronavirus disease 2019 including National Early Warning Score, Modified Early Warning Score, and age-based modifications, and define their performance characteristics. DESIGN:. We analyzed prospectively collected data from the Adaptive COVID-19 Treatment Trial. National Early Warning Score was collected daily during the trial, Modified Early Warning Score was calculated, and age applied to both scores. We assessed prognostic value for the end points of recovery, mechanical ventilation, and death for score at enrollment, average, and slope of score over the first 48 hours. SETTING:. A multisite international inpatient trial. PATIENTS:. A total of 1,062 adult nonpregnant inpatients with severe coronavirus disease 2019 pneumonia. INTERVENTIONS:. Adaptive COVID-19 Treatment Trial 1 randomized participants to receive remdesivir or placebo. The prognostic value of predictive scores was evaluated in both groups separately to assess for differential performance in the setting of remdesivir treatment. MEASUREMENTS AND MAIN RESULTS:. For mortality, baseline National Early Warning Score and Modified Early Warning Score were weakly to moderately prognostic (c-index, 0.60–0.68), and improved with addition of age (c-index, 0.66–0.74). For recovery, baseline National Early Warning Score and Modified Early Warning Score demonstrated somewhat better prognostic ability (c-index, 0.65–0.69); however, National Early Warning Score+age and Modified Early Warning Score+age further improved performance (c-index, 0.68–0.71). For deterioration, baseline National Early Warning Score and Modified Early Warning Score were weakly to moderately prognostic (c-index, 0.59–0.69) and improved with addition of age (c-index, 0.63–0.70). All prognostic performance improvements due to addition of age were significant (p < 0.05). CONCLUSIONS:. In the Adaptive COVID-19 Treatment Trial 1 cohort, National Early Warning Score and Modified Early Warning Score demonstrated moderate prognostic performance in patients with severe coronavirus disease 2019, with improvement in predictive ability for National Early Warning Score+age and Modified Early Warning Score+age. Area under receiver operating curve for National Early Warning Score and Modified Early Warning Score improved in patients receiving remdesivir versus placebo early in the pandemic for recovery and mortality. Although these scores are simple and readily obtainable in myriad settings, in our data set, they were insufficiently predictive to completely replace clinical judgment in coronavirus disease 2019 and may serve best as an adjunct to triage, disposition, and resourcing decisions.

Paediatric inflammatory multisystem syndrome—temporally associated with SARS-CoV-2 (PIMS-TS) is a recently described syndrome. We describe the case of a 17-year-old man presenting with a recent illness consistent with COVID-19 who presented with fever, chest pain and anterior uveitis. He was treated with aspirin, pulsed methylprednisolone and tocilizumab followed by oral steroids. On day 16 from initial presentation, he developed a facial nerve palsy. He was managed with ongoing steroids and the addition of valaciclovir. PIMS-TS is an under-recognised condition among adult physicians and may not be well known in adult neurology. It is important for adult physicians and neurologists to be aware of PIMS-TS and its possible sequelae.

SummaryBackgroundThe safety and immunogenicity profile of COVID-19 vaccines when administered concomitantly with seasonal influenza vaccines has not yet been reported.MethodsA sub-study on influenza vaccine co-administration was conducted as part of the phase 3 randomized trial of the safety and efficacy of NVX-CoV2373. The first ∼400 participants meeting main study entry criteria and with no contraindications to influenza vaccination were invited to join the sub-study. After randomization in a 1:1 ratio to receive NVX-CoV2373 (n=217) or placebo (n=214), sub-study participants received an age-appropriate, licensed, open-label influenza vaccine with dose 1 of NVX-CoV2373. Reactogenicity was evaluated via electronic diary for 7 days post-vaccination in addition to monitoring for unsolicited adverse events (AEs), medically-attended AEs (MAAEs), and serious AEs (SAEs). Influenza haemagglutination inhibition and SARS-CoV-2 anti-spike IgG assays were performed. Vaccine efficacy against PCR-confirmed, symptomatic COVID-19 was assessed. Comparisons were made between sub-study and main study participants.FindingsSub-study participants were younger, more racially diverse, and had fewer comorbid conditions than main study participants. Reactogenicity events more common in the co-administration group included tenderness (70.1% vs 57.6%) or pain (39.7% vs 29.3%) at injection site, fatigue (27.7% vs 19.4%), and muscle pain (28.3% vs 21.4%). Rates of unsolicited AEs, MAAEs, and SAEs were low and balanced between the two groups. Co-administration resulted in no change to influenza vaccine immune response, while a reduction in antibody responses to the NVX-CoV2373 vaccine was noted. Vaccine efficacy in the sub-study was 87.5% (95% CI: -0.2, 98.4) while efficacy in the main study was 89.8% (95% CI: 79.7, 95.5).InterpretationThis is the first study to demonstrate the safety, immunogenicity, and efficacy profile of a COVID-19 vaccine when co-administered with seasonal influenza vaccines. The results suggest concomitant vaccination may be a viable immunisation strategy.FundingThis study was funded by Novavax, Inc.Research in ContextEvidence before this studyWe searched PubMed for research articles published from December 2019 until 1 April 2021 with no language restrictions for the terms “SARS-CoV-2”, “COVID-19”, “vaccine”, “co-administration”, and “immunogenicity”. There were no peer-reviewed publications describing the simultaneous use of any SARS-CoV-2 vaccine and another vaccine. Several vaccine manufacturers had recent publications on phase 3 trials results (Pfizer/BioNTech, Moderna, AstraZeneca, Janssen, and the Gamaleya Research Institute of Epidemiology and Microbiology). Neither these publications nor their clinical trials’ protocols (when publicly available) described co-administration and they often had trial criteria specifically excluding those with recent or planned vaccination with any licenced vaccine near or at the time of any study injection.Added value of this studyImmune interference and safety are always a concern when two vaccines are administered at the same time. This is the first study to demonstrate the safety and immunogenicity profile and clinical vaccine efficacy of a COVID-19 vaccine when co-administered with a seasonal influenza vaccine.Implications of all the available evidenceThis study provides much needed information to help guide national immunisation policy decision making on the critical issue of concomitant use of COVID-19 vaccines with influenza vaccines.

BackgroundCovid-19 vaccines are urgently needed, especially against emerging variants. NVX-CoV2373 is a recombinant severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 rS) nanoparticle vaccine containing trimeric full-length SARS-CoV-2 spike glycoprotein and Matrix-M adjuvant.MethodsA phase 3, randomized, observer-blinded, placebo-controlled trial was conducted in adults 18-84 years old who received two intramuscular 5-µg doses, 21 days apart, of NVX-CoV2373 or placebo (1:1) across 33 sites in the United Kingdom. The primary efficacy endpoint was virologically confirmed symptomatic Covid-19 with onset 7 days after second vaccination in serologically negative participants.ResultsA total of 15,187 participants were randomized, of whom 7569 received NVX-CoV2373 and 7570 received placebo; 27.2% were 65 years or older, 44.7% had comorbidities and 4.2% had baseline serological evidence of SARS-CoV-2. There were 10 cases of Covid-19 among NVX-CoV2373 recipients and 96 cases among placebo recipients, with symptom onset at least 7 days after second vaccination; NVX-CoV2373 was 89.7% (95% confidence interval, 80.2 to 94.6) effective in preventing Covid-19, with no hospitalizations or deaths reported. There were five cases of severe Covid-19, all in the placebo group. Post hoc analysis revealed efficacies of 96.4% (73.8 to 99.5) and 86.3% (71.3 to 93.5) against the prototype strain and B.1.1.7 variant, respectively. Vaccine efficacy was similar across subgroups, including participants with comorbidities and those ≥65 years old. Reactogenicity was generally mild and transient. The incidence of serious adverse events was low and similar in the two groups.ConclusionA two-dose regimen of NVX-CoV2373 conferred 89.7% protection against a blend of prototype and variant Covid-19, demonstrated high efficacy against the B.1.1.7 variant, and had a reassuring safety profile.(Funded by Novavax, Inc. EudraCT number, 2020-004123-16).

This article focuses on landscape architect Karl Linn’s role in founding the Community Design movement. Acknowledged by his contemporaries as one of the first and most influential community designers, Linn used students to pilot techniques for hands-on, local, and empathetic engagement. Beginning in the early 1960s, the article follows Linn’s first experiment building neighborhood “Commons” in North Philadelphia. In Linn’s conception, Commons were parks and playgrounds that reused materials and incorporated volunteer labor. Initially, Linn felt that the Commons’ primary purpose was to produce positive self-identification within community members and design students. Encounters with Settlement Houses, black social workers, and volunteers challenged his original thinking. As a result, he shifted tactics to focus on work-training programs and the establishment of “process institutions.” Through War on Poverty legislation, workshops, and consultancies, Linn helped translate Progressive Era social work into a new model of advocacy and professional practice.

Urinary tract infections (UTIs) are highly prevalent, lead to considerable patient morbidity, incur large financial costs to health-care systems and are one of the most common reasons for antibiotic use worldwide. The growing problem of antimicrobial resistance means that the search for nonantibiotic alternatives for the treatment and prevention of UTI is of critical importance. Potential nonantibiotic measures and treatments for UTIs include behavioural changes, dietary supplementation (such as Chinese herbal medicines and cranberry products), NSAIDs, probiotics, D-mannose, methenamine hippurate, estrogens, intravesical glycosaminoglycans, immunostimulants, vaccines and inoculation with less-pathogenic bacteria. Some of the results of trials of these approaches are promising; however, high-level evidence is required before firm recommendations for their use can be made. A combination of these agents might provide the optimal treatment to reduce recurrent UTI, and trials in specific population groups are required.

NOTE: this is a preprint version of an article since published in the peer-reviewed Journal of Transport Geography. For the final version please visit https://www.sciencedirect.com/science/article/pii/S0966692321002477. In this article we examine equity in new active travel infrastructure in London, UK. We focus on Low Traffic Neighbourhood schemes (LTNs) introduced during Covid-19. These mainly involve ‘modal filters’ that restrict through motor traffic from residential streets. Such approaches to traffic management are traditional in the Netherlands, but relatively new in London and other global cities such as Barcelona. LTNs are often controversial, with one criticism being that they are implemented in affluent areas and hence benefit richer residents. London represents an excellent opportunity to investigate the extent to which these rapidly introduced schemes have so far been equitably distributed.We focused on LTNs introduced between March and September 2020 and still present at the end of October 2020. Having generated datasets representing these new LTN locations and their boundary roads, we matched these to Output Areas (OAs, administrative areas containing around 300 residents). We then examined the extent to which LTN implementation was associated with age, ethnicity, disability, employment and car ownership (Census 2011) and small-area deprivation (Index of Multiple Deprivation 2019). We estimated that 3.7% of all Londoners live inside a new LTN, and 8.8% live within 500m walking distance of a new modal filter. Across London as a whole, people in the most deprived quarter of OAs were 2.7 times more likely to live in a new LTN, compared to Londoners in the least deprived quarter. While overall Black, Asian and Minority Ethnic (BAME) people were slightly more likely than White Londoners to live in a new LTN, this varied by ethnic group. Specifically, Black Londoners were somewhat more likely, and Asian Londoners somewhat less likely than White people to live in a new LTN. Car-free households were more likely to live in a new LTN. Within London’s districts – which lead the implementation of LTNs - there was wide variation, with people in more deprived areas and/or ethnic minorities more likely to live in an LTN in some districts, less likely in others. In the median (‘typical’) district, people in more deprived areas were more likely to live in an LTN than people in less deprived areas, suggesting that, on average, individual districts have prioritised their more deprived areas. However, in the median district, BAME residents were slightly less likely to live in an LTN than White residents. Finally, at the micro level, residents living in LTNs were demographically similar to neighbours living in OAs that touched an LTN boundary road. We conclude that LTN implementation has been broadly equitable at the city level and at the micro level, but not always at the district level. Such metrics should be used in policy and research to monitor and improve the equity of active travel interventions.

Background The Pfizer-BioNTech (BNT162b2) and the Oxford-AstraZeneca (ChAdOx1 nCoV-19) COVID-19 vaccines have shown excellent safety and efficacy in phase 3 trials. We aimed to investigate the safety and effectiveness of these vaccines in a UK community setting. Methods In this prospective observational study, we examined the proportion and probability of self-reported systemic and local side-effects within 8 days of vaccination in individuals using the COVID Symptom Study app who received one or two doses of the BNT162b2 vaccine or one dose of the ChAdOx1 nCoV-19 vaccine. We also compared infection rates in a subset of vaccinated individuals subsequently tested for SARS-CoV-2 with PCR or lateral flow tests with infection rates in unvaccinated controls. All analyses were adjusted by age (≤55 years vs >55 years), sex, health-care worker status (binary variable), obesity (BMI

ObjectivesExamine longitudinal associations between modes of travel to school and adiposity.SettingThe UK.Participants8432 children surveyed at ages 7, 11 and 14 years from the UK Millennium Cohort Study.Primary and secondary outcomesObjective percentage body fat and body mass index (BMI). Transport mode was categorised as private motorised transport, public transport and active transport (walking or cycling). Socioeconomic position (SEP) was measured by household income group and occupational social class. We adjusted analyses for changes in the country of UK, frequency of eating breakfast, self-reported growth spurts, hours of screen time and days per week of moderate-to-vigorous physical activity. Longitudinal (panel) regression models adjusting for individual fixed effects examined associations in changes in mode of travel to school and adiposity, controlling for both time-varying and time-invariant potential confounders. Interaction tests and stratified analyses investigated differences by markers of SEP.ResultsAt age 14 years, 26.1% of children (2198) reported using private motorised transport, 35.3% (2979) used public transport and 38.6% (3255) used active transport to get to school. 36.6% (3083) of children changed mode two times between the three waves and 50.7% (4279) changed once. Compared with continuing to use private transport, switching to active transport was associated with a lower BMI (−0.21 kg/m2, 95% CI −0.31 to −0.10) and body fat (−0.55%, 95% CI −0.80% to −0.31%). Switching to public transport was associated with lower percentage body fat (−0.43%, 95% CI −0.75% to −0.12%), but associations with BMI did not reach statistical significance (−0.13 kg/m2, 95% CI −0.26 to 0.01). Interaction tests showed a trend for these effects to be stronger in more deprived groups, but these interactions did not reach statistical significance.ConclusionThis longitudinal study during a key life course period found switching to physically active forms of travel can have beneficial adiposity impacts; these associations may be more apparent for more disadvantaged children. Increasing active travel has potential to ameliorate inequalities.

We use vehicle registration data to examine whether active travel interventions in Outer London between 2015-2019 affected motor vehicle ownership, compared to other neighbourhoods. We find statistically significant reductions in car/van ownership in areas introducing ‘low traffic neighbourhoods’ (-6%, or 23 cars/vans per 1000 adults, after two years). We also find statistically significant but smaller reductions in areas introducing other infrastructure such as cycle tracks (-2%, or 7 cars/vans per 1000 adults, after 2 years). These effects increased after adjusting for the changing age profile of the intervention areas. Our findings indicate that active travel interventions can reduce motor-vehicle ownership, particularly interventions involving low traffic neighbourhoods.

This paper reports on analysis of impacts of active travel interventions in Outer London between 2016-19. We find larger effects (decreased car ownership and use, increased active travel) in intervention areas where Low Traffic Neighbourhoods (LTNs) were introduced. Decreased car ownership and use is only found in such areas. Sample size for LTN areas is small and hence uncertainty about effect magnitude is large, but effect direction is consistent. This suggests that to reduce car use as well as increase active travel, LTNs are an important part of the intervention toolbox.

In the midst of the COVID-19 pandemic, United States (U.S.) educational institutions must weigh incomplete scientific evidence to inform decisions about how best to re-open schools without sacrificing public health. While many communities face surging case numbers, others are experiencing case plateaus or even decreasing numbers. Simultaneously, some U.S. school systems face immense infrastructure challenges and resource constraints, while others are better positioned to resume face-to-face instruction. In this review, we first examine potential engineering controls to reduce SARS-CoV-2 exposures; we then present processes whereby local decision-makers can identify and partner with scientists, faculty, students, parents, public health officials, and others to determine the controls most appropriate for their communities. While no solution completely eliminates risks of SARS-CoV-2 exposure and illness, this mini-review discusses engaged decision and communication processes that incorporate current scientific knowledge, school district constraints, local tolerance for health risk, and community priorities to help guide schools in selecting and implementing re-opening strategies that are acceptable, feasible, and context-specific.

IntroductionAntimicrobial resistance is rising, largely due to the indiscriminate use of antimicrobials. The human gut is the largest reservoir of antibiotic resistant bacteria (ARB). Individuals colonised with ARB have the potential to spread these organisms both in the community and hospital settings. Infections with ARB such as extended spectrum beta-lactamase producing enterobacteriales (ESBL-E) and carbapenemase producing enterobacteriales (CPE) are more difficult to treat and are associated with an increased morbidity and mortality. Presently, there is no effective decolonisation strategy for these ARB. Faecal microbiota transplant (FMT) has emerged as a potential strategy for decolonisation of ARB from the human gut, however there is significant uncertainty about the feasibility, effectiveness and safety of using this approach.Methods and analysisProspective, randomised, patient-blinded, placebo-controlled feasibility trial of FMT to eradicate gastrointestinal carriage of ARB. Eighty patients with a recent history of invasive infection secondary to ESBL-E or CPE and persistent gastrointestinal carriage will be randomised 1:1 to receive encapsulated FMT or placebo. The primary outcome measure is consent rate (as a proportion of patients who fulfil inclusion/exclusion criteria); this will be used to determine if a substantive trial is feasible. Participants will be followed up at 1 week, 1 month, 3 months and 6 months and monitored for adverse events as well as gastrointestinal carriage rates of ARB after intervention.Ethics and disseminationResearch ethics approval was obtained by London—City and East Research Ethics Committee (ref 20/LO/0117). Trial results will be published in a peer-reviewed journal and presented at international conferences.Trial registration numberISRCTN registration number 34 467 677 and EudraCT number 2019-001618-41.

Background Asymptomatic eosinophilia is common in migrants and travellers returning from the tropics, and helminth infection is the most common identifiable cause. Most helminth infections have a benign course, but some carry a risk of serious disease which is relevant to the rheumatologist as administration of immunosuppression can trigger severe reactions such as the potentially fatal hyper infection syndrome in strongyloidiasis. Helminth infections are of increasing relevance in an era of growing migration from endemic regions. A recent audit performed at a central London hospital in HIV outpatients found that of those patients with asymptomatic eosinophilia that were investigated, 28.6% had serological evidence of strongyloidiasis. Unexplained eosinophilia should be evaluated prior to starting immunosuppressive medications, especially in those who have lived in regions endemic for helminth infections. In 2010 the British Infection Society (BIS) published guidelines on the investigation of migrants and returning travellers with asymptomatic eosinophilia. We set out to establish how often our unit investigated unexplained eosinophilia prior to initiating immunosuppressive medication. Methods All patients attending rheumatology outpatients at our centre were screened and included if they had a recorded eosinophilia of ≥ 0.8 X109/L between December 2016 to December 2018. Patients were excluded if they did not have a sustained eosinophilia ≥0.8 X109/L > 1 year or if another documented diagnosis was recognised as the cause of eosinophilia. Investigation of asymptomatic eosinophilia was compared to the best practice set out in British Infection Society guideline. Results 109 patients fulfilled the inclusion criteria. 64 patients did not have a sustained eosinophilia > 1 year and 16 had an alternate diagnosis to explain eosinophilia and so were excluded. The remaining 29 patients were included. 13 patients were male and 16 female. 16 (55%) had a diagnosis of rheumatoid arthritis. 19 (66%) had an eosinophil count > 1 X109/L and 7 (24%) > 2 X109/L. Despite this, eosinophilia was only noted in documentation for 4 (14%) patients. Five (17%) patients had a travel history documented and 4 of them had travelled to the tropics. 3 (10%) patients were investigated for eosinophilia and only 1 (3%) was investigated fully according to the BIS guideline. 14 (48%) patients were on bDMARDs and a further 6 (21%) were on cDMARDs. Of the 14 (48%) on bDMARDS, 7 had ethnic origin in the tropics. Median eosinophil count was 1.2 x109/L. One had travel history taken. All had a negative HIV test. None of the patients on biological therapy had investigations for eosinophilia. Conclusion This study confirms the local lack of awareness of eosinophilia. Most patients with unexplained eosinophilia were not identified or investigated, even prior to administration of immunosuppressive medication. With a growing migrant population, the likelihood of serious consequences of ignoring eosinophilia are rising. Disclosures: Z. Rutter-Locher: None. J. Galloway: None. B. Menon: None. A. Goodman: None.

Background Cycling has the potential to encourage physical activity as well as advancing societal goals such as reducing carbon emissions; encouraging cycling is therefore a policy goal in many contexts. We analysed individual level data from the whole of England on factors associated with cycling among adolescents, including cycle training delivered by the age of 11 years in primary schools. Methods Data came from the nationally representative Millennium Cohort Study collected when participants were aged 13–15 years (adolescents). We assessed frequency of cycling at least once per week (regular cycling) and used logistic regression to assess how this differed across characteristics including demographic, health and environmental factors, as well as receiving cycle training (‘Bikeability’) in primary school. Results We found that 21.0% of adolescents cycled at least once per week. In fully adjusted analyses, this was more common among boys than girls (32.5% vs. 9.4%, p, Highlights • Approximately one in five cycles regularly. • This was more common among boys, in rural areas and in areas with higher levels of adult cycle commuting. • Receiving cycle training at age 10/11 years is not linked to more cycling as an adolescent.

Staphylococcus aureus bacteraemia (SAB) continues to affect ∼25,000 patients in the UK per year with a high crude mortality of 30% at 90 days. Prompt source control improves outcomes in sepsis and SAB and is included in sepsis guidelines. A recent clinical trial of adjunctive antibiotic treatment in SAB found that the majority of recurrences of SAB were associated with a failure of source management. In this condition, the ability to control the source of infection may be limited by the ability to detect a focus of infection. Echocardiogram is now a routinely used tool to detect such unknown foci in the form of unexpected infectious vegetations. We review the literature to explore the utility of advanced imaging techniques, such as [18F]fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) and magnetic resonance imaging (including whole-body MRI), to detect foci which may otherwise be missed. As unknown foci are associated with increased mortality, we propose that increasing the detection of foci could enable improved source control and result in improved outcomes in SAB.

Summary Background Development of an effective vaccine against the pathogenic blood-stage infection of human malaria has proved challenging, and no candidate vaccine has affected blood-stage parasitemia following controlled human malaria infection (CHMI) with blood-stage Plasmodium falciparum. Methods We undertook a phase I/IIa clinical trial in healthy adults in the United Kingdom of the RH5.1 recombinant protein vaccine, targeting the P. falciparum reticulocyte-binding protein homolog 5 (RH5), formulated in AS01B adjuvant. We assessed safety, immunogenicity, and efficacy against blood-stage CHMI. Trial registered at ClinicalTrials.gov, NCT02927145. Findings The RH5.1/AS01B formulation was administered using a range of RH5.1 protein vaccine doses (2, 10, and 50 μg) and was found to be safe and well tolerated. A regimen using a delayed and fractional third dose, in contrast to three doses given at monthly intervals, led to significantly improved antibody response longevity over ∼2 years of follow-up. Following primary and secondary CHMI of vaccinees with blood-stage P. falciparum, a significant reduction in parasite growth rate was observed, defining a milestone for the blood-stage malaria vaccine field. We show that growth inhibition activity measured in vitro using purified immunoglobulin G (IgG) antibody strongly correlates with in vivo reduction of the parasite growth rate and also identify other antibody feature sets by systems serology, including the plasma anti-RH5 IgA1 response, that are associated with challenge outcome. Conclusions Our data provide a new framework to guide rational design and delivery of next-generation vaccines to protect against malaria disease. Funding This study was supported by USAID, UK MRC, Wellcome Trust, NIAID, and the NIHR Oxford-BRC., Graphical abstract, Highlights The RH5.1/AS01B vaccine is safe, well tolerated, and immunogenic in healthy adults A delayed fractional third dose significantly improves antibody response longevity In vivo blood-stage P. falciparum growth rate is significantly lower in vaccinees In vitro IgG-mediated growth inhibition activity is associated with challenge outcome, Context and significance A highly effective vaccine against the human malaria parasite Plasmodium falciparum is urgently needed. One vaccine strategy aims to prevent parasite growth in the blood, protecting against clinical disease; however, this has proved exceptionally challenging. Here we show that a candidate vaccine (reticulocyte-binding protein homolog 5.1 [RH5.1]/AS01B) is safe in a phase I/IIa clinical trial and identify a vaccination regimen that improves the durability of the human antibody response, which is critical for long-term protection. Following experimental challenge of vaccinated adults with malaria, we observed that the vaccine could reduce parasite growth in the blood and identified immune responses that could predict how well the vaccine performs. These data will help guide the design of improved vaccines in the future., Minassian et al. report that the RH5.1/AS01B vaccine against blood-stage Plasmodium falciparum malaria is safe and immunogenic in a phase I/IIa clinical trial. They demonstrate a significantly reduced blood-stage parasite growth rate in vaccinees following controlled human malaria infection and identify that in vitro antibody-mediated growth inhibition activity is associated with challenge outcome.

Aims: To investigate if early life characteristics and social mobility during childhood are associated with incident thrombotic stroke (TS), haemorrhagic stroke (HS) and other stroke (OS). Methods: Our study population consists of all live births at Uppsala University Hospital in 1915–1929 (Uppsala Birth Cohort; n = 14,192), of whom 5532 males and 5061 females were singleton births and lived in Sweden in 1964. We followed them from 1 January 1964 until first diagnosis of stroke (in the National Patient Register or Causes of Death Register), emigration, death, or until 31 December 2008. Data were analysed using Cox regression, stratifying by gender. Results: Gestational age was negatively associated with TS and OS in women only. Women had increased risk of TS if they were born early preterm (

With real-world relevance and translatability as important goals, applied methodological approaches have arisen along the participatory continuum that value context and empower stakeholders to partner actively with academics throughout the research process. Community-based participatory research (CBPR) provides the gold standard for equitable, partnered research in traditional communities. Practice-based research networks (PBRNs) also have developed, coalescing communities of practice and of academics to identify, study, and answer practice-relevant questions. To optimize PBRN potential for expanding scientific knowledge, while bridging divides across knowledge production, dissemination, and implementation, we elucidate how PBRN partnerships can be strengthened by applying CBPR principles to build and maintain research collaboratives that empower practice partners. Examining the applicability of CBPR partnership principles to public health (PH) PBRNs, we conclude that PH-PBRNs can serve as authentic, sustainable CBPR partnerships, ensuring the co-production of new knowledge, while also improving and expanding the implementation and impact of research findings in real-world settings.

Surviving sepsis and improving our timely management of it has been a major focus of our profession in the last two decades. Despite this, in 2011, Jack Adcock died from unrecognised group A streptococcal sepsis. Those individuals at the forefront of his medical care have been cited as providing ‘

This paper investigates the association between perinatal health and all-cause mortality for specific age intervals, assessing the contribution of maternal socioeconomic characteristics and the presence of maternal-level confounding. Our study is based on a cohort of 12,564 singletons born between 1915 and 1929 at the Uppsala University Hospital. We fitted Cox regression models to estimate age-varying hazard ratios of all-cause mortality for absolute and relative birth weight and for gestational age. We found that associations with mortality vary by age and according to the measure under scrutiny, with effects being concentrated in infancy, childhood or early adult life. For example, the effect of low birth weight was greatest in the first year of life and then continued up to 44 years of age (HR between 2.82 and 1.51). These associations were confirmed in within-family analyses, which provided no evidence of residual confounding by maternal characteristics. Our findings support the interpretation that policies oriented towards improving population health should invest in birth outcomes and hence in maternal health.

Highlights • Cycling trips doubled in London between 1992 and 2012. • The proportion of cyclist fatalities covered by media rose 13-fold over this period. • The increased coverage was specific to cyclists, and not seen for motorcyclists. • Such coverage may create complex feedback loops, inhibiting cycling growth. • The relative strength of such feedback loops is likely to vary between cities., Background Successfully increasing cycling across a broad range of the population would confer important health benefits, but many potential cyclists are deterred by fears about traffic danger. Media coverage of road traffic crashes may reinforce this perception. As part of a wider effort to model the system dynamics of urban cycling, in this paper we examined how media coverage of cyclist fatalities in London changed across a period when the prevalence of cycling doubled. We compared this with changes in the coverage of motorcyclist fatalities as a control group. Methods Police records of traffic crashes (STATS19) were used to identify all cyclist and motorcyclist fatalities in London between 1992 and 2012. We searched electronic archives of London's largest local newspaper to identify relevant articles (January 1992–April 2014), and sought to identify which police-reported fatalities received any media coverage. We repeated this in three smaller English cities. Results Across the period when cycling trips doubled in London, the proportion of fatalities covered in the local media increased from 6% in 1992–1994 to 75% in 2010–2012. By contrast, the coverage of motorcyclist fatalities remained low (4% in 1992–1994 versus 5% in 2010–2012; p = 0.007 for interaction between mode and time period). Comparisons with other English cities suggested that the changes observed in London might not occur in smaller cities with lower absolute numbers of crashes, as in these settings fatalities are almost always covered regardless of mode share (79–100% coverage for both cyclist and motorcyclist fatalities). Conclusion In large cities, an increase in the popularity (and therefore ‘newsworthiness’) of cycling may increase the propensity of the media to cover cyclist fatalities. This has the potential to give the public the impression that cycling has become more dangerous, and thereby initiate a negative feedback loop that dampens down further increases in cycling. Understanding these complex roles of the media in shaping cycling trends may help identify effective policy levers to achieve sustained growth in cycling.

Evaluations of ‘natural experiments’ in public policy are typically considered ‘weak’ evidence. Challenges include: making credible claims for causal inference (internal validity); generalizing beyond the case (external validity); and providing useful evidence for decision makers. In public health, where experimental evidence is encouraged by funders and enjoys a degree of rhetorical favour, in theory if not practice, current guidance for evaluating natural experiments focuses largely on methods for strengthening internal validity. Using a case study of the evaluation of free bus travel for young people in London, UK, we demonstrate a pragmatic approach to strengthening both internal and external validity in evaluations through integrating the logic of quasi-experimental methods with inductive qualitative analysis. Combining theoretical and inductive analysis in this way to address questions of policy interest through evaluations of natural experiments may be fruitful, and have methodological advantages over randomized designs.

Despite a large number of evidence-based health communication interventions tested in private, public, and community health settings, there is a dearth of research on successful secondary dissemination of these interventions to other audiences. This article presents the case study of "1-2-3 Pap," a health communication intervention to improve human papillomavirus (HPV) vaccination uptake and Pap testing outcomes in Eastern Kentucky, and explores strategies used to disseminate this intervention to other populations in Kentucky, North Carolina, and West Virginia. Through this dissemination project, we identified several health communication intervention design considerations that facilitated our successful dissemination to these other audiences; these intervention design considerations include (a) developing strategies for reaching other potential audiences, (b) identifying intervention message adaptations that might be needed, and (c) determining the most appropriate means or channels by which to reach these potential future audiences. Using "1-2-3 Pap" as an illustrative case study, we describe how careful planning and partnership development early in the intervention development process can improve the potential success of enhancing the reach and effectiveness of an intervention to other audiences beyond the audience for whom the intervention messages were originally designed.

Using 2014 and 2015 data from the UK Near Miss Project, this paper examines the stability of self-report incident rates for cycling near misses across these two years. It further examines the stability of the individual-level predictors of experiencing a near miss, including what influences the scariness of an incident. The paper uses three questions asked for only in 2015, which allow further exploration of factors shaping near miss rates and impacts of incidents. Firstly, a respondent's level of cycling experience; secondly, whether an incident was perceived as deliberate; and finally, whether the respondent themselves described the incident as a 'near miss' (as opposed to only a frightening and/or annoying non-injury incident). Using this data, we find a decline of almost a third in incident rates in 2015 compared to 2014, which we believe is likely to be largely an artefact due to differences in reporting rates. This suggests caution about interpreting small fluctuations in subjectively reported near miss rates. However, in both years near miss rates are many times more frequent than injury collisions. In both years of data collection our findings are very similar in terms of the patterning of incident types, and how frightening different incident categories are, which increases confidence in these findings. We find that new cyclists experience very high incident rates compared to other cyclists, and test a conceptual model explaining how perceived deliberateness, near-miss status, and scariness are connected. For example, incidents that are perceived to be deliberate are more likely to be experienced as very frightening, independent of their 'near miss' status.

Development and growth in utero has been suggested to influence bone health. However, the relationship with risk of fracture in old age is largely unknown. Using Cox proportional hazards regression ...

Bicycle sharing systems are increasingly popular around the world and have the potential to increase the visibility of people cycling in everyday clothing. This may in turn help normalise the image of cycling, and reduce perceptions that cycling is ‘risky’ or ‘only for sporty people’. This paper sought to compare the use of specialist cycling clothing between users of the London bicycle sharing system (LBSS) and cyclists using personal bicycles. To do this, we observed 3594 people on bicycles at 35 randomly-selected locations across central and inner London. The 592 LBSS users were much less likely to wear helmets (16% vs. 64% among personal-bicycle cyclists), high-visibility clothes (11% vs. 35%) and sports clothes (2% vs. 25%). In total, 79% of LBSS users wore none of these types of specialist cycling clothing, as compared to only 30% of personal-bicycle cyclists. This was true of male and female LBSS cyclists alike (all p>0.25 for interaction). We conclude that bicycle sharing systems may not only encourage cycling directly, by providing bicycles to rent, but also indirectly, by increasing the number and diversity of cycling ‘role models’ visible., Highlights • Many potential cyclists are put off as they perceive cycling as too risky or sporty. • This may be reinforced if existing cyclists are seen to wear safety or sports clothes. • Bicycle sharing systems (BSS) may encourage cycling in everyday clothing. • London BSS users are less likely to wear helmets, high-viz or sports clothes. • BSS have the potential to normalise the image of cycling, and so promote cycling.

Birth characteristics predict a range of major physical and mental disorders, but findings regarding eating disorders are inconsistent and inconclusive. This total-population Swedish cohort study identified 2,015,862 individuals born in 1975-1998 and followed them for anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified until the end of 2010. We examined associations with multiple family and birth characteristics and conducted within-family analyses to test for maternal-level confounding. In total, 1,019 males and 15,395 females received an eating disorder diagnosis. Anorexia nervosa was independently predicted by multiple birth (adjusted hazard ratio = 1.33, 95% confidence interval: 1.15, 1.53) for twins or triplets vs. singletons) and lower gestational age (adjusted hazard ratio = 0.96, 95% confidence interval: 0.95, 0.98) per extra week of gestation, with a clear dose-response pattern. Within-family analyses provided no evidence of residual maternal-level confounding. Higher birth weight for gestational age showed a strong, positive dose-response association with bulimia nervosa (adjusted hazard ratio = 1.15, 95% confidence interval: 1.09, 1.22, per each standard-deviation increase), again with no evidence of residual maternal-level confounding. We conclude that some perinatal characteristics may play causal, disease-specific roles in the development of eating disorders, including via perinatal variation within the normal range. Further research into the underlying mechanisms is warranted. Finally, several large population-based studies of anorexia nervosa have been conducted in twins; it is possible that these studies considerably overestimate prevalence.

Kentucky experiences some of the nation’s worst health outcomes related to obesity, diabetes, high blood pressure, and other age-related chronic diseases linked with oxidative stress and inflammation, which in turn are associated with poor diet, lack of physical activity, and exposure to certain environmental pollutants. In the Commonwealth, deteriorating infrastructure, inappropriate waste disposal, and potential occupational injury related to mining, agriculture, and other regionally important industries exacerbate the need for residents to have basic knowledge of potential environmental health threats. Unfortunately, community-level understanding of the complex connections between environmental exposures and health is limited, with many Kentuckians unaware that the Commonwealth is home to 13 hazardous waste sites included in the United States Environmental Protection Agency Superfund National Priorities List (NPL). The NPL highlights priority sites for long-term remedial action to reduce environmental contaminants. To enhance the understanding of environmental health and protective actions, the University of Kentucky Superfund Research Center Community Engagement Core developed a 9-lesson extension curriculum “Body Balance: Protect Your Body from Pollution with a Healthy Lifestyle” (Body Balance) and partnered with Kentucky’s Family and Consumer Sciences (FCS) Cooperative Extension Service to pilot the curriculum in Kentucky communities. FCS agents in 4 Kentucky counties delivered the Body Balance pilot study (18-31 participants per lesson). Pre- and post-lesson questionnaires revealed increased knowledge and awareness of the effects of environmental pollution on health and the protective role of dietary strategies. Focus group participants (n = 18) self-reported positive behavior changes because of increases in knowledge and leadership from their FCS agent. The Body Balance curriculum appeared to be a promising mechanism for raising environmental health and diet knowledge, as well as for promoting positive behavior changes among white, middle/older-aged women in rural Kentucky communities.

Purpose – The purpose of this paper is to provide an update on the progress of the Campaign to End Loneliness, and aims to illustrate how commissioners can be influenced to address loneliness in their localities. Design/methodology/approach – The paper is a case study that draws upon an external evaluation of the Campaign to End Loneliness by Charities Evaluation Services, a review of local government strategies and case studies of good practice. Findings – This paper focuses on the design, implementation and progress of Loneliness Harms Health, a series of local campaigns targeting health and wellbeing boards. It provides a case study of how evidence-based campaigning influenced newly formed health and wellbeing boards to address loneliness in their localities, and identifies implications for commissioner and provider practice. Practical implications – This paper demonstrates how to successfully influence commissioning practice using a “pincer” movement of local campaigning, top-down advice and information. It highlights examples of good practice uncovered by the Campaign over the past 18 months including measurement of, and partnership working around, the issue of loneliness in older age. Three recommendations are made for local service providers and commissioners wishing to address loneliness: it should be linked to other priorities, cross-agency partnerships are vital and asset-based approaches can save money. It concludes with information about the future of the Campaign to End Loneliness and information on how to get involved. Originality/value – This paper provides a detailed analysis of an innovative, policy-based, campaigning strategy to influence commissioning and practice around the issue of loneliness in older age. It is an issue which can be easily overlooked by care, public health and NHS professionals, but early results indicate the newly formed health and wellbeing boards can play a significant role in addressing it.

Objective To examine whether a relationship exists between active commuting and physical and mental wellbeing. Method In 2009, cross-sectional postal questionnaire data were collected from a sample of working adults (aged 16 and over) in the Commuting and Health in Cambridge study. Travel behaviour and physical activity were ascertained using the Recent Physical Activity Questionnaire (RPAQ) and a seven-day travel-to-work recall instrument from which weekly time spent in active commuting (walking and cycling) was derived. Physical and mental wellbeing were assessed using the Medical Outcomes Study Short Form survey (SF-8). Associations were tested using multivariable linear regression. Results An association was observed between physical wellbeing (PCS-8) score and time spent in active commuting after adjustment for other physical activity (adjusted regression coefficients 0.48, 0.79 and 1.21 for 30–149 min/week, 150–224 min/week and ≥ 225 min/week respectively versus, Highlights • We assessed the relationship between active commuting and physical and mental wellbeing. • Greater active commuting was associated with higher levels of physical wellbeing. • The strongest association occurred with at least 45 min of active commuting per day. • There was no significant association between active commuting and mental wellbeing.

This paper uses qualitative data from interviews with 118 young Londoners (age 12-18) to examine how the universal provision of free bus travel has affected young people's independent mobility. Drawing on Sen's capabilities approach, we argue that free bus travel enhanced young Londoners' capabilities to shape their daily mobility, both directly by increasing financial access and indirectly by facilitating the acquisition of the necessary skills, travelling companions and confidence. These capabilities in turn extended both opportunity freedoms (e.g. facilitating non-'necessary' recreational and social trips) and process freedoms (e.g. feeling more independent by decreasing reliance on parents). Moreover, the universal nature of the entitlement rendered buses a socially inclusive way for groups to travel and spend time together, thereby enhancing group-level capabilities. We believe this attention to individual and group capabilities for self-determination provides the basis for a broader and more child-centred view of independent mobility than the typical research focus upon travelling without an adult and acquiring parental permissions. © 2013 © 2013 Taylor & Francis.

Both child and adult socio-economic position (SEP) predict adult mortality, but little is known about the variation in the impact of SEP across the life course. The Uppsala Birth Cohort Study is a representative birth cohort born 1915-1929 in Uppsala, Sweden. For the 5,138 males and 5,069 females alive in 1980, SEP was available at birth; in adulthood (age 31-45); and in later life (age 51-65). Follow-up for mortality (all-cause, and circulatory disease) was from 1980 to 2002. To test which life course model best described the association between SEP and mortality, we compared the fit of a series of nested Cox proportional hazards regression models (representing either the critical, accumulation or sensitive period models) with a fully saturated model. For all-cause mortality in both genders, the sensitive period model best described the influence of SEP across the life course with a heightened effect in later adult life (males: Hazard Ratio (95 % CI) for advantaged SEP: 0.89 (0.81-0.97) at birth, 0.90 (0.81-0.98) in adulthood, 0.74 (0.67-0.82) in later life; females: 0.87 (0.78-0.98), 0.95 (0.86-1.06), 0.73 (0.64-0.83)). The effect of SEP on circulatory diseases mortality in males was cumulative (HR: 0.84 (0.80-0.87) per unit time in advantaged SEP). For circulatory disease mortality among females, a sensitive period model was selected due to SEP in later adult life (HR: 0.64 (0.52-0.80)). These findings suggest that reducing inequality throughout the life course might reduce all-cause and circulatory disease mortality.

Introduction:Risk communication can help reduce exposures to environmental contaminants, mitigate negative health outcomes, and inform community-based decisions about hazardous waste sites. While communication best practices have long guided such efforts, little research has examined unintended consequences arising from such guidelines. As rhetoric informs stakeholder sensemaking, the language used in and reinforced by these guidelines can challenge relationships and exacerbate stakeholder tensions.Objectives:This study evaluates risk communication at a U.S. Superfund site to identify unintended consequences arising from current risk communication practices.Methods:This qualitative case study crystallizes data spanning 6 years from three sources: 1) local newspaper coverage of site-related topics; 2) focus-group transcripts from a multi-year project designed to support future visioning of site use; and 3) published blog entries authored by a local environmental activist. Constant comparative analysis provides the study’s analytic foundation, with qualitative data analysis software QSR NVivo 8 supporting a three-step process: 1) provisional coding to identify broad topic categories within datasets, 2) coding occurrences of sensemaking constructs and emergent intra-dataset patterns, and 3) grouping related codes across datasets to examine the relationships among them.Results:Existing risk communication practices at this Superfund site contribute to a dichotomous conceptualization of multiple and diverse stakeholders as members of one of only two categories: the government or the public. This conceptualization minimizes perceptions of capacity, encourages public commitment to stances aligned with a preferred group, and contributes to negative expectations that can become self-fulfilling prophecies.Conclusion:Findings indicate a need to re-examine and adapt risk communication guidelines to encourage more pluralistic understanding of the stakeholder landscape.

Objectives: Increasing walking and cycling, and reducing motorised transport, are health and environmental priorities. This paper examines levels and trends in the use of different commute modes in England and Wales, both overall and with respect to small-area deprivation. It also investigates whether commute modal share can serve as a proxy for travel behaviour more generally. Methods: 23.7 million adult commuters reported their usual main mode of travelling to work in the 2011 census in England and Wales; similar data were available for 1971–2001. Indices of Multiple Deprivation were used to characterise socio-economic patterning. The National Travel Survey (2002–2010) was used to examine correlations between commute modal share and modal share of total travel time. These correlations were calculated across 150 non-overlapping populations defined by region, year band and income. Results: Among commuters in 2011, 67.1% used private motorised transport as their usual main commute mode (−1.8 percentage-point change since 2001); 17.8% used public transport (+1.8% change); 10.9% walked (−0.1% change); and 3.1% cycled (+0.1% change). Walking and, to a marginal extent, cycling were more common among those from deprived areas, but these gradients had flattened over the previous decade to the point of having essentially disappeared for cycling. In the National Travel Survey, commute modal share and total modal share were reasonably highly correlated for private motorised transport (r = 0.94), public transport (r = 0.96), walking (r = 0.88 excluding London) and cycling (r = 0.77). Conclusions: England and Wales remain car-dependent, but the trends are slightly more encouraging. Unlike many health behaviours, it is more common for socio-economically disadvantaged groups to commute using physically active modes. This association is, however, weakening and may soon reverse for cycling. At a population level, commute modal share provides a reasonable proxy for broader travel patterns, enhancing the value of the census in characterising background trends and evaluating interventions.

OBJECTIVE: To assess the impact of introducing and embedding a structured geriatric liaison service, Proactive care of Older People undergoing Surgery (POPS)-Urology, using comprehensive geriatric assessment methodology, on an inpatient urology ward. PATIENTS AND METHODS: A phased quality improvement project was undertaken using stepwise interventions. Phase 1 was a before-and-after study with initiation of a daily board round, weekly multidisciplinary meeting, and targeted geriatrician-led ward rounds for elective and emergency urology patients aged ≥65 years admitted over two 1-month periods. Outcomes were recorded from medical records and discharge documentation, including length of inpatient stay, medical and surgical complications, and 30-day readmission and mortality rates. Phase 2 was a quality improvement project involving Plan-Do-Study-Act cycles and qualitative staff surveys in order to create a Geriatric Surgical Checklist (GSCL) to standardize the intervention in Phase 1, improve equity of care by extending it to all ages, improve team-working and streamline handovers for multidisciplinary staff. RESULTS: Phase 1 included 112 patients in the control month and 130 in the intervention month. The length of inpatient stay was reduced by 19% (mean 4.9 vs 4.0 days; P = 0.01), total postoperative complications were lower (risk ratio 0.24 [95% confidence interval 0.10, 0.54]; P = 0.001). A non-significant trend was seen towards fewer cancellations of surgery (10 vs 5%; P = 0.12) and 30-day readmissions (8 vs 3%; P = 0.07). In Phase 2, the GSCL was created and incrementally improved. Questionnaires repeated at intervals showed that the GSCL helped staff to understand their role better in multidisciplinary meetings, improved their confidence to raise issues, reduced duplication of handovers and standardized identification of geriatric issues. Equity of care was improved by providing the intervention to patients of all ages, despite which the time taken for the daily board round did not lengthen. CONCLUSION: This is the first known paper describing the benefits of daily proactive geriatric intervention in elective and emergency urological surgery. The results suggest that using a multidisciplinary team board round helps to facilitate collaborative working between surgical and geriatric medicine teams. The GSCL enables systematic identification of patients who require a focused comprehensive geriatric assessment. There is potential to transfer the GSCL package to other surgical specialties and hospitals to improve postoperative outcomes.

Background England’s national cycle training scheme, ‘Bikeability’, aims to give children in England the confidence to cycle more. There is, however, little evidence on the effectiveness of cycle training in achieving this. We therefore examined whether delivering Bikeability was associated with cycling frequency or with independent cycling. Methods We conducted a natural experimental study using information on children aged 10–11 years participating in the nationally-representative Millennium Cohort Study. We identified Cohort participants whose schools had offered Bikeability in 2011–2012 using operational Bikeability delivery data (children in London excluded, as delivery data not available). Our natural experimental design capitalised on the fact that Cohort participants were surveyed at different times during 2012 and were also offered Bikeability at different times during 2012. This allowed us to compare cycling levels between children whose schools delivered Bikeability before their survey interview (‘intervention group’, N = 2563) and an otherwise comparable group of children whose schools delivered Bikeability later in the year (‘control group’, N = 773). Parents reported whether their child had completed formal cycle training; their child’s cycling frequency; whether their child ever made local cycling trips without an adult; and other child and family factors. We used Poisson regression with robust standard errors to examine whether cycling behaviour differed between the intervention and control groups. Results Children whose school had offered Bikeability were much more likely to have completed cycle training than the control group (68 % vs. 28 %, p

Purpose The ‘Bikeability’ cycle training scheme, a flagship policy of the government in England, aims to give children the skills and confidence to cycle more safely and more often. Little, however, is known about the scheme׳s reach. This paper examined which schools offer Bikeability, and which children participate in cycle training. Methods We used operational delivery data to examine which primary schools in England offered Bikeability. Predictors included the deprivation level of the student body and the local prevalence of cycling. We then examined cycle training participation using data from 6986 participants (age 10–11) in the nationally-representative Millennium Cohort Study. Parents reported whether their child had completed formal cycle training, along with other child and family factors. We used operational data to identify children whose school had previously delivered Bikeability. Results 55% of schools offered Bikeability to the cohort of children leaving primary school in 2012; this fell to 48% in schools in the top tenth for student deprivation. Among Millennium Cohort participants, 47% of children had completed cycle training; this proportion rose to 68% among children whose schools had offered Bikeability. In adjusted robust Poisson regression models, participation rates were lower among minority ethnic children, particularly South Asians; among children who played sport less often; and among children whose parents were poorer or less educated. The magnitude of these differences was largest among children whose schools had not offered Bikeability (all p≤0.02 for interaction, except for income where p=0.09), although trends in the same direction were observed in schools that had offered Bikeability. Conclusions Offering high-quality cycle training free of charge in English schools reduced but did not eliminate inequalities in cycle training participation. Further promoting the scheme to parents and schools, particularly in deprived areas, would be expected to increase uptake and help reduce current inequalities in participation., Highlights • Around half of children in England receive “Bikeability” cycle training in school. • Schools with a more deprived student body offer Bikeability slightly less often. • Cycle training participation is higher in children who are White, affluent or sporty. • These differences in participation rates are smaller in schools offering Bikeability. • Further promoting Bikeability could reduce but not necessarily eliminate inequalities.

BackgroundMigration has been implicated as a risk factor for autism, but evidence is limited and inconsistent.AimsTo investigate the relationship between parental migration status and risk of autism spectrum disorder, taking into consideration the importance of region of origin, timing of migration and possible discrepancies in associations between autism subtypes.MethodRecord-linkage study within the total child population of Stockholm County between 2001 and 2007. Individuals with high- and low-functioning autism were defined as having autism spectrum disorder with and without comorbid intellectual disability, and ascertained via health and habilitation service registers.ResultsIn total, 4952 individuals with autism spectrum disorder were identified, comprising 2855 children with high-functioning autism and 2097 children with low-functioning autism. Children of migrant parents were at increased risk of low-functioning autism (odds ratio (OR) = 1.5, 95% CI 1.3–1.7); this risk was highest when parents migrated from regions with a low human development index, and peaked when migration occurred around pregnancy (OR = 2.3, 95% CI 1.7–3.0). A decreased risk of high-functioning autism was observed in children of migrant parents, regardless of area of origin or timing of migration. Parental age, income or obstetric complications did not fully explain any of these associations.ConclusionsEnvironmental factors associated with migration may contribute to the development of autism presenting with comorbid intellectual disability, especially when actingin utero.High- and low-functioning autism may have partly different aetiologies, and should be studied separately.

Background England has a highly detailed and prescriptive transport appraisal process for active mode (walking, cycling) projects, guided by the Department for Transport Guidance. Current guidance is based on the relative risks adopted from the previous version of the World Health Organization (WHO) Health economic assessment tools (HEAT). The benefits are estimated for age group 15-64 by using average mortality for this age, and benefits are converted into economic outcomes. In this study we developed a new method to inform the future update of the guidance. Methods We developed an approach in which we used data on current pedestrians and cyclists to predict the demographic characteristics of new cyclists, and the distance and speed of their trips. Specifically the age and gender distribution of the new active travelers were assumed to be same with the existing cyclists and pedestrians, calculated from the National Travel Survey. Rather than using whole population averages we used age and gender specific travel distance, speed and background mortality data to estimate behavioural change and mortality for four different age groups (20-49, 50-64, 65-80 and 80+) and sex. The changes in premature mortality were estimated using four different dose-response function (DRF) methods, including the one used in current appraisal. The numbers of deaths were converted to Years of Life Lost (YLLs) and to economic benefits using costs per life year method. The impact of parameter and model uncertainties to the results was tested using Monte Carlo based sensitivity analyses methods. Results The developed method provided slightly smaller health benefits if we used the original age and gender assumptions that exclude older adults. However, when we based our calculation on empirical evidence on the likelihood of cycling by age, benefits were higher. The results for four different DRF methods were similar with 24% difference between smallest and highest benefits. The model was more sensitive to assumptions related to potential decrease or increase of the usage over time and assumed number of walking and cycling days per year. Conclusions The new method provides good background for further development of the Transport Analysis Guidance. It highlights the importance of using empirical data on propensity to cycle among different groups rather than assuming that some groups never cycle. Sensitivity analysis indicates that main uncertainties are related to usage of the new infrastructure rather than the DRFs indicating opportunities for future research.

Background The Propensity to Cycle Tool (PCT) is a publicly accessible planning support system and modelling project funded by the English Department for Transport (DfT). It calculates cycling potential at area, route and route network level currently, and under different scenarios of cycling uptake, with estimates of health and carbon reduction benefits. Led by an academic team, the PCT is in use by a range of local authorities across England. This talk presents results from case studies in which the PCT was used to assess cycling potential and inform interventions in a range of English urban and rural settings. Methods The PCT uses data on current travel patterns at the origin-destination level to generate scenarios, based on route distance and hilliness. Source data is currently the 2011 English Census on commuting desire lines, allocated to the transport network by CycleStreets.net. The PCT is open source code. The results are freely available online via an interactive web interface (www.pct.bike). Regional data can be downloaded for use by practitioners, campaigners and 'citizen scientists'. Results The results show that the PCT can provide a localised evidence base to improve cycle planning. A key finding is that the places and routes with the highest potential are not necessarily those that currently have the most cycling. This is illustrated at the area level in Bodmin, Cornwall, and at the route level in Ealing, London. The 'Ebike' scenario (representing uptake of electric cycles) highlights the importance of new technologies for boosting cycling potential in hilly and rural areas. Our Ebike scenario (which adds to Dutch cycling propensities an assumption that people use Ebikes for some longer and hillier trips, based on Swiss and Dutch data) indicates substantial additional potential in such contexts, for example in rural West Sussex. Analysis of a proposed bridge (since approved) in Rotherhithe, London, is used to show demonstrated the large additional cycling potential unlocked by replacing a (slow, expensive) ferry with a bridge, substantially shortening many journeys. Finally, case study results from Preston illustrate the health and environmental benefits that achieving scenario potential would provide. These results show that health gains and CO 2 reduction, while both substantial across the case study area, vary geographically and do not always correspond to absolute cycling potential. Conclusion The PCT represents a new approach to cycle planning. It is already influencing transport planning decisions, helping raise ambitions and identify priority areas and routes to prioritise investment in cycling.

Studying biological and social determinants of mortality and fertility provides insight into selective pressures in a population and the possibility of trade-offs between short- and long-term reproductive success. Limited data is available from post-demographic transition populations. We studied determinants of reproductive success using multi-generational data from a large, population-based cohort of 13,666 individuals born in Sweden between 1915 and 1929. We studied the effects of birthweight for gestational age, preterm birth, birth multiplicity, birth order, mother's age, mother's marital status and family socioeconomic position (SEP) upon reproductive success, measured as total number of children and grandchildren. We further tested the hypothesis that number of grandchildren would peak at intermediate family size, as predicted by some life history explanations for fertility limitation. Reproductive success was associated with both social and biological characteristics at birth. In both sexes, a higher birthweight for gestational age, a term birth and a younger mother were independently associated with a greater number of descendants. A married mother and higher family SEP were also associated with a greater number of descendants in males (but not in females), while higher birth order was associated with a greater number of descendents in females (but not males). These effects were mediated by sex-specific effects upon the probability of marriage. Marriage was also affected by other early life characteristics including birthweight, indicating how 'biological' characteristics may operate via social pathways. Number of grandchildren increased with increasing number of children in both sexes, providing no evidence for a trade-off between quantity of offspring and their subsequent reproductive 'quality'. © 2009 Elsevier Inc. All rights reserved.

BACKGROUND: High pre-pregnancy body mass index (BMI) and inappropriate gestational weight gain (GWG) are associated with adverse short and long-term maternal and neonatal outcomes and may act as modifiable risk factors on the path to overweight/obesity, but their social patterning is not well established. This study investigates the association of education with BMI and GWG across two consecutive pregnancies. METHODS: The study includes 163,352 Swedish women, having their first and second singleton birth in 1982-2010. In both pregnancies, we investigated the association of women's education with (1) pre-pregnancy weight status and (2) adequacy of GWG. We used multinomial logistic regression, adjusting for child's birth year, mother's age and smoking status. RESULTS: Overall, the odds of starting either pregnancy at an unhealthy BMI were higher among women with a low education compared to more highly-educated women. Lower education also predicted a greater increase in BMI between pregnancies, with this effect greatest among women with excessive GWG in the first pregnancy (p

Getting people cycling is an increasingly common objective in transport planning institutions worldwide. A growing evidence base indicates that high quality infrastructure can boost local cycling rates. Yet for infrastructure and other cycling measures to be effective, it is important to intervene in the right places, such as along 'desire lines' of high latent demand. This creates the need for tools and methods to help answer the question 'where to build?'. Following a brief review of the policy and research context related to this question, this paper describes the design, features and potential applications of such a tool. The Propensity to Cycle Tool (PCT) is an online, interactive planning support system which was initially developed to explore and map cycling potential across England (see www.pct.bike). Based on origin-destination data, it models and visualises cycling levels at area, desire line, route and route network levels, for current levels of cycling, and for scenario-based 'cycling futures'. Four scenarios are presented, including 'Go Dutch' and 'Ebikes', which explore what would happen if English people cycled as much as Dutch people and the potential impact of electric cycles on cycling uptake. The cost effectiveness of investment depends not only on the number of additional trips cycled, but on wider impacts such as health and carbon benefits. The PCT reports these at area, desire line, and route level for each scenario. The PCT is open source, facilitating the creation of additional scenarios and its deployment in new contexts. We conclude that the PCT illustrates the potential of online tools to inform transport decisions and raises the wider issue of how models should be used in transport planning., Comment: Paper submitted for peer review. 9 figures