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Background: High early postnatal weight gain has been associated with childhood adiposity; however, the mechanism remains unknown. DNA methylation is a hypothesised mechanism linking early life exposures and subsequent disease. However, epigenetic changes associated with high early weight gain have not previously been investigated. Our aim was to investigate the associations between early weight gain, peripheral blood DNA methylation, and subsequent overweight/obese. Data from the UK Avon Longitudinal study of Parents and Children (ALSPAC) cohort were used to estimate associations between early postnatal weight gain and epigenome-wide DNA CpG site methylation (Illumina 450 K Methylation Beadchip) in blood in childhood (n = 125) and late adolescence (n = 96). High weight gain in the first year (a change in weight z‐scores > 0.67), both unconditional (rapid weight gain) and conditional on birthweight (rapid thrive), was related to individual CpG site methylation and across regions using the meffil pipeline, with and without adjustment for cell type proportions, and with 5% false discovery rate correction. Variation in methylation at high weight gain-associated CpG sites was then examined with regard to body composition measures in childhood and adolescence. Replication of the differentially methylated CpG sites was sought using whole-blood DNA samples from 104 children from the UK Southampton Women's Survey. Results: Rapid infant weight gain was associated with small (+ 1% change) increases in childhood methylation (age 7) for two distinct CpG sites (cg01379158 (NT5M) and cg11531579 (CHFR)). Childhood methylation at one of these CpGs (cg11531579) was also higher in those who experienced rapid weight gain and were subsequently overweight/obese in adolescence (age 17). Rapid weight gain was not associated with differential DNA methylation in adolescence. Childhood methylation at the cg11531579 site was also suggestively associated with rapid weight gain in the replication cohort. Conclusions: This study identified associations between rapid weight gain in infancy and small increases in childhood methylation at two CpG sites, one of which was replicated and was also associated with subsequent overweight/obese. It will be important to determine whether loci are markers of early rapid weight gain across different, larger populations. The mechanistic relevance of these differentially methylated sites requires further investigation. [ABSTRACT FROM AUTHOR]

Background:Despite marked improvements in childhood leukaemia survival, 20% still die within 5 years of diagnosis. The aim of this study was to evaluate the relationship between socioeconomic status, as assessed by paternal occupation at birth, and survival from childhood leukaemia in children, using data from the Northern Region Young Persons Malignant Disease Registry.Methods:All 1007 cases of leukaemia in children aged 0-14 years, diagnosed between 1968 and 2010 and registered with the Registry were studied. Paternal occupational social class at the time of the child's birth was obtained and analysed in relation to survival using Cox-proportional regression.Results:Compared with the most advantaged group (I/II), those in the middle group (IIIN/M) had a 68% increased risk of death, while those in the least advantaged group (IV/V) had 86% higher risk for acute lymphoblastic leukaemia. While the survival advantage of children in class I/II was apparent from the time of diagnosis, survival for children in groups IIIN/M and IV/V were comparable until 3-4 years after diagnosis, when they began to minimally diverge.Conclusion:The existence of such socioeconomic disparities cannot be attributed to accessibility to health care in the United Kingdom. Further research into the likely factors underlying these disparities is required. [ABSTRACT FROM AUTHOR]

Despite great potential benefits, there are concerns about the possible harm from medical imaging including the risk of radiation-related cancer. There are particular concerns about computed tomography (CT) scans in children because both radiation dose and sensitivity to radiation for children are typically higher than for adults undergoing equivalent procedures. As direct empirical data on the cancer risks from CT scans are lacking, the authors are conducting a retrospective cohort study of over 240 000 children in the UK who underwent CT scans. The main objective of the study is to quantify the magnitude of the cancer risk in relation to the radiation dose from CT scans. In this paper, the methods used to estimate typical organ-specific doses delivered by CT scans to children are described. An organ dose database from Monte Carlo radiation transport-based computer simulations using a series of computational human phantoms from newborn to adults for both male and female was established. Organ doses vary with patient size and sex, examination types and CT technical settings. Therefore, information on patient age, sex and examination type from electronic radiology information systems and technical settings obtained from two national surveys in the UK were used to estimate radiation dose. Absorbed doses to the brain, thyroid, breast and red bone marrow were calculated for reference male and female individuals with the ages of newborns, 1, 5, 10, 15 and 20 y for a total of 17 different scan types in the pre- and post-2001 time periods. In general, estimated organ doses were slightly higher for females than males which might be attributed to the smaller body size of the females. The younger children received higher doses in pre-2001 period when adult CT settings were typically used for children. Paediatric-specific adjustments were assumed to be used more frequently after 2001, since then radiation doses to children have often been smaller than those to adults. The database here is the first detailed organ-specific paediatric CT scan database for the UK. As well as forming the basis for the UK study, the results and description of the methods will also serve as a key resource for paediatric CT scan studies currently underway in other countries. [ABSTRACT FROM AUTHOR]

Socio-economic variations in health exist for a wide range of health outcomes, including oral health and oral-health-related quality of life (OHRQoL). Less is known regarding how socio-economic trajectories may influence oral health and OHRQoL. This study examined whether social mobility is related to the number of teeth retained by age 50 years and OHRQoL measured at the same time, using data from the Newcastle Thousand Families Study, a birth cohort established in 1947. Women remaining in the non-manual class had the greatest tooth retention. While promotion of a healthier lifestyle and continued improvements in oral hygiene throughout life appear to be the public health interventions most likely to improve oral health into middle age, there may be sub-groups of the population on which different approaches in terms of public health interventions need to be focused. [ABSTRACT FROM AUTHOR]

Objective:Not all overweight and obese individuals appear to be at equal risk of developing metabolic abnormalities. We sought to examine the effect of factors from different stages of life on risk of metabolic abnormalities at age 50 years in overweight and obese adults.Design and subjects:Longitudinal study of all persons born in Newcastle upon Tyne, UK in May and June 1947 and followed to age 50 years when a clinical examination took place and a detailed questionnaire on health and lifestyle was completed. Participants in this study (n=223) were those defined as being overweight or obese with a body mass index (BMI) greater than or equal to 25 at age 50 years. Subjects were defined as ‘metabolically normal’ if they had normal lipids, glucose and blood pressure.Results:Lower BMI was the strongest predictor of remaining metabolically normal in both men and women. After adjusting for BMI, lower levels of cigarette smoking and higher levels of physical activity were independently associated with being metabolically normal in men. No other factors were independently associated with being metabolically normal in women. A stronger inverse relationship between BMI and metabolic status was found in men (Odds ratio (OR) per unit increase in BMI=0.65, 95% confidence intervals (95% CI) 0.52–0.81) than in women (OR=0.90, 95% CI 0.82–0.99). No association was seen for factors operating in fetal, infant and childhood life.Conclusions:Adult factors made a greater contribution to remaining metabolically normal than birth or childhood factors in this sample of overweight and obese adults. A lower adult BMI appeared to reduce the risk in men and women and lower cigarette smoking and higher level of physical activity also independently reduced the risk in men. Public health policy to reduce the burden of morbidity associated with obesity should continue to encourage weight loss, physical activity and smoking cessation.International Journal of Obesity (2006) 30, 970–976. doi:10.1038/sj.ijo.0803213; published online 17 January 2006 [ABSTRACT FROM AUTHOR]

To investigate the contribution of polymorphic variation in genes involved in the folatedependent homocysteine pathway in the aetiology of neural tube defects (NTD). The MTHFR 677C→T polymorphism was shown to represent a risk factor in NTD cases (CC v CT+π odds ratio (OR) 2.03 [95% confidence interval (CI) 1.09, 3.79] p = 0.025) and the MTRR 66A→G polymorphism was shown to exert a protective effect in NTD cases (AA v AG+GG OR 0.31 [95% CI 0.10, 0.94] p=0.04). When statistical tests for interaction were conducted, three genotype combinations in cases (MTRR/GCPII; MTHFR 677/CβS; MTHFR 677/MTRR) and one combination in case mothers (CβS/RFC-1) were shown to elevate NTD risk. Maternal-fetal interaction was also detected when offspring carried the MTHFR 677C→T variant and mothers carried the MTRR 66A→G variant, resulting in a significantly elevated risk of NTD. Both independent genetic effects and gene-gene interaction were observed in relation to NTD risk. Multi-locus rather than single locus analysis might be preferable to gain an accurate assessment of genetic susceptibility to NTD. [ABSTRACT FROM AUTHOR]

Presents several letters to the editor published in the 'British Medical Journal' as of February 1985. Issues in the interpretation on the outbreak of acquired immune deficiency syndrome; Suggestions to enhance the prescribing directives set by the Department of Health Social Security; Comments on the implementation of the NHS limited drug lists.

Over the past few years there has been a significant increase in the number of dentists and dental care professionals (registrants) having conditions placed on their practice either by the General Dental Council or NHS area teams. There are a number of reasons for this including the fact that patients complain more often, colleagues are now expected to alert the authorities if poor practice is detected and the demographics of the dental profession in the UK are changing. Steps have already been taken to prevent dentists getting into difficulty, such as the development of requirements for continued professional development by the GDC and past initiatives at a local level set up to assist dentist in difficulty. The regional offices of Health Education England and equivalent organisations in Wales and Scotland assist registrants in difficulty in meeting these conditions. Little published research has been carried out into this important service which has had to develop rapidly over the past few years. There is a need to investigate the current service, the views of those dental professionals being assisted and those providing the support to inform the further development of the service. This paper provides an introduction to a planned series of research papers reporting on our investigation into the service provided by HEE teams. [ABSTRACT FROM AUTHOR]

Objective To investigate the relative influences of factors acting throughout life on breast tissue density at age 49-58 years. Design Follow-up of the Newcastle Thousand Families birth cohort study. Setting In 1947, all 1142 babies born in May and June to mothers resident in the city of Newcastle-upon- Tyne were recruited into the Newcastle Thousand Families birth cohort. This study details a sample of women from this cohort who returned for follow-up 49+ years later, and is therefore drawn from throughout the UK and beyond. Participants At age 50, 574 study members returned a self-completion questionnaire. The 307 surviving women who returned questionnaires at age 50 were sent a questionnaire asking for details of mammographic screening and for details of their reproductive and contraceptive history. 199 women who gave access to their previous mammograms and had completed both questionnaires were included in this analysis. Main outcome measures Breast tissue density patterns were coded into Wolfe categories (N1=lowest risk, P1=low risk, P2=high risk, PY=highest risk). This was analysed, by ordinal logistic regression, in relation to a range of variables at different stages of life, including birthweight, gestational age, duration breast fed, age at menarche, gravidity, age at first pregnancy, menopausal status, breast feeding history, hormonal contraceptive history, use of hormone replacement therapy, cigarette smoking history, alcohol consumption, height, body mass index, physical activity levels, age at scan, and socio-economic status both at birth and in adulthood. Results Eleven % (n=22) of women were classified in the lowest Wolfe category of risk (N1), 20% (n=39) as low risk (P1), 48% (n=95) as high risk (P2), and 22% (n=43) as being in the highest category of risk (PY). Increased standardised birthweight (adjusted odds ratio, aOR 1.42 (95% CI 1.08 to 1.87), p=0.01) and not having entered the menopause (aOR, compared to perimenopausal women 3.99 (95% CI 1.78 to 8.97), p=0.001) were both significant independent predictors of being in a higher density group. In contrast, increasing body mass index was independently predictive of being in a lower density group (aOR 0.85 (0.80 to 0.91), p<0.001). Conclusions After adjustment for factors acting throughout life, this study identified a significant association between increased birthweight, standardised for sex and gestational age, and increased breast tissue density in adulthood. This observation is consistent with previous research suggesting that heavier babies have an increased risk of breast cancer in later life. [ABSTRACT FROM PUBLISHER]

Objectives Refugees are most vulnerable to mental health problems of all migrant groups, and an understanding of the role of postdisplacement social factors in refugee emotional well-being can help to shape the future interventions for this group. We aimed to investigate the effect of social determinants, such as employment, language ability and accommodation, on mental health in refugees in the UK. Study design This prospective longitudinal cohort study was set in the UK. The study population of new UK refugees was drawn from an existing data set of the Longitudinal Survey of New Refugees (n = 5678), in which all new UK refugees (2005-2007) were sent a postal questionnaire at four time points across 2 years. Methods Ordered logistic regression models were used to evaluate associations between social determinants and the dependent variables, emotional well-being or change in emotional well-being, using a question from the Short Form-36 Health Survey Questionnaire. Results Refugees who were unemployed in the UK, could not speak English well or were unsatisfied with their accommodation had significantly higher odds of poorer emotional well-being in the cross-sectional analysis (P < 0.05 at all time points measured). Conclusions Postdisplacement social factors, including language ability, employment status and accommodation satisfaction, were important determinants of refugee emotional well-being. Changes in these social determinants have the potential to improve refugee mental health, making them legitimate, modifiable targets for important public health interventions. Accounting for this, further research into how to improve refugee well-being is crucial given the increase in refugee numbers around the developed world. [ABSTRACT FROM AUTHOR]

Objectives: To investigate which five activity interference categories out of pain, fatigue, mood, dryness and brain fog/mental fatigue scored highest in patients with primary Sjögren's syndrome (pSS) and to investigate the association between activity interference and mood and physical functioning in these patients., Methods: The Comprehensive Pain Evaluation Questionnaire (CPEQ) assessed activity interference (actions performed in daily life that are hindered) in 149 UK pSS patients. This was modified to include four additional symptoms (fatigue, mood, dryness and brainfog/mental fatigue). Functional impairment was measured using the Hospital Anxiety and Depression Scale (HADS) and the Improved Health Assessment Questionnaire (Improved HAQ). Univariable linear regression models were estimated to investigate the association between CPEQ results and the outcome scores obtained from the HADS and Improved HAQ. Multivariable linear regression models were estimated adjusting for patient age and length of disease., Results: Fatigue had the biggest impact on seven activity domains: physical exercise (mean score of 3.49 out of 5 [s.d. 1.26]), performing household chores (mean 3.14 [s.d. 1.18]), gardening or shopping (mean 3.18 [s.d. 1.20]), socializing with others (mean 2.62 [s.d. 1.24]), recreation/hobbies (mean 2.88 [s.d. 1.20]), sexual relations (mean 3.00 [s.d. 1.52]), and mental efficacy (mean 2.69 [s.d. 1.17]). Regression analysis showed a positive correlation in which every point increase in an activity interference category saw the overall mood and physical functioning scores increase., Conclusion: Fatigue has the largest impact on pSS patients' daily activities in this cohort. Length of disease reduced the impact of activity interference on patients' overall health score., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Background: Current physical activity guidelines do not distinguish between activity accumulated in different behavioural domains but some studies suggest that occupational physical activity (OPA) may not confer health benefits and could even be detrimental. The purpose of this study was to investigate associations between OPA and mortality outcomes., Methods: From baseline (2006-2010), 460,901 UK Biobank participants (aged 40-69 years) were followed for a median 12.0 (IQR: 11.3-12.7) years. OPA was categorised by cross-tabulating degree of manual work and walking/standing work amongst those in paid employment (n = 267,765), and combined with categories of occupational status for those not in paid employment (n = 193,136). Cox proportional hazards models were used to estimate sex-stratified hazard ratios (HR) and 95% confidence intervals (CI) for mortality from all causes, CVD, and cancer by occupational group, and for working hours/week and non-occupational physical activity stratified by occupational group. Models included adjustment for age and a range of lifestyle, socio-economic and health-related covariates., Results: During 5,449,989 person-years of follow-up, 28,740 deaths occurred. Compared to those reporting no heavy manual or walking/standing work (e.g. sedentary office workers) and adjusting for covariates, retirement was associated with lower mortality in women (HR = 0.62, CI: 0.53-0.72) and men (HR = 0.80, CI: 0.71-0.90), whereas unemployment was associated with higher mortality in men only (HR = 1.24, CI: 1.07-1.45). Within the working population, there was no evidence of differences in all-cause, CVD or cancer mortality by OPA group when comparing those reporting higher levels of OPA to the lowest OPA reference group for both women and men. Working < 35 h/week versus 35-40 h/week was associated with lower mortality in women (HR = 0.85, CI: 0.79-0.92) and men (HR = 0.83, CI: 0.78-0.89), with no interaction by OPA. Non-occupational physical activity was associated with lower mortality in working women (HR = 0.89 per 5 kJ/day/kg, CI: 0.84-0.95) and men (HR = 0.87 per 5 kJ/day/kg, CI: 0.84-0.91), with no interaction by OPA group., Conclusions: Jobs classified as higher levels of OPA may not be as active as reported, or the types of physical activity performed in those jobs are not health-enhancing. Irrespective of OPA category or employment status, non-occupational physical activity appears to provide health benefits., (© 2021. The Author(s).)

Background: UK Biobank is a large prospective cohort study containing accelerometer-based physical activity data with strong validity collected from 100,000 participants approximately 5 years after baseline. In contrast, the main cohort has multiple self-reported physical behaviours from > 500,000 participants with longer follow-up time, offering several epidemiological advantages. However, questionnaire methods typically suffer from greater measurement error, and at present there is no tested method for combining these diverse self-reported data to more comprehensively assess the overall dose of physical activity. This study aimed to use the accelerometry sub-cohort to calibrate the self-reported behavioural variables to produce a harmonised estimate of physical activity energy expenditure, and subsequently examine its reliability, validity, and associations with disease outcomes., Methods: We calibrated 14 self-reported behavioural variables from the UK Biobank main cohort using the wrist accelerometry sub-cohort (n = 93,425), and used published equations to estimate physical activity energy expenditure (PAEE SR ). For comparison, we estimated physical activity based on the scoring criteria of the International Physical Activity Questionnaire, and by summing variables for occupational and leisure-time physical activity with no calibration. Test-retest reliability was assessed using data from the UK Biobank repeat assessment (n = 18,905) collected a mean of 4.3 years after baseline. Validity was assessed in an independent validation study (n = 98) with estimates based on doubly labelled water (PAEE DLW ). In the main UK Biobank cohort (n = 374,352), Cox regression was used to estimate associations between PAEE SR and fatal and non-fatal outcomes including all-cause, cardiovascular diseases, respiratory diseases, and cancers., Results: PAEE SR explained 27% variance in gold-standard PAEE DLW estimates, with no mean bias. However, error was strongly correlated with PAEE DLW (r = -.98; p < 0.001), and PAEE SR had narrower range than the criterion. Test-retest reliability (Λ = .67) and relative validity (Spearman = .52) of PAEE SR outperformed two common approaches for processing self-report data with no calibration. Predictive validity was demonstrated by associations with morbidity and mortality, e.g. 14% (95%CI: 11-17%) lower mortality for individuals meeting lower physical activity guidelines., Conclusions: The PAEE SR variable has good reliability and validity for ranking individuals, with no mean bias but correlated error at individual-level. PAEE SR outperformed uncalibrated estimates and showed stronger inverse associations with disease outcomes.

Objective: To evaluate the value of fetal scalp blood sampling (FBS) as an adjunct test to cardiotocography, to predict adverse neonatal outcomes., Study Design: A multicentre service evaluation observational study in forty-four maternity units in the UK. We collected data retrospectively on pregnant women with singleton pregnancy who received FBS in labour using a standardised data collection tool. The primary outcome was prediction of neonatal acidaemia diagnosed as umbilical cord arterial pH < 7.05, the secondary outcomes were the prediction of Apgar scores<7 at 1st and 5th minutes and admission to the neonatal intensive care unit (NICU). We evaluated the correlation between the last FBS blood gas before birth and the umbilical cord blood and adjusted for time intervals. We constructed 2 × 2 tables to calculate the sensitivity, specificity, positive (PPV) and negative predictive value (NPV) and generated receiver operating curves to report on the Area Under the Curve (AUC)., Results: In total, 1422 samples were included in the analysis; pH values showed no correlation (r = 0.001, p = 0.9) in samples obtained within an hour (n = 314), or within half an hour from birth (n = 115) (r=-0.003, p = 0.9). A suboptimal FBS pH value (<7.25) had a poor sensitivity (22%) and PPV (4.9%) to predict neonatal acidaemia with high specificity (87.3%) and NPV (97.4%). Similar performance was noted to predict Apgar scores <7 at 1st (sensitivity 14.5%, specificity 87.5%, PPV 23.4%, NPV 79.6%) and 5th minute (sensitivity 20.3%, specificity 87.4%, PPV 7.6%, NPV 95.6%), and admission to NICU (sensitivity 20.3%, specificity 87.5%, PPV 13.3%, NPV 92.1%). The AUC for FBS pH to predict neonatal acidaemia was 0.59 (95%CI 0.59-0.68, p = 0.3) with similar performance to predict Apgar scores<7 at 1st minute (AUC 0.55, 95%CI 0.51-0.59, p = 0.004), 5th minute (AUC 0.55, 95%CI 0.48-0.62, p = 0.13), and admission to NICU (AUC 0.58, 95%CI 0.52-0.64, p = 0.002). Forty-one neonates had acidaemia (2.8%, 41/1422) at birth. There was no significant correlation in pH values between the FBS and the umbilical cord blood in this subgroup adjusted for sampling time intervals (r = 0.03, p = 0.83)., Conclusions: As an adjunct tool to cardiotocography, FBS offered limited value to predict neonatal acidaemia, low Apgar Scores and admission to NICU., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Since our previous publication of organ dose for the pediatric CT cohort in the UK, there have been questions about the magnitude of uncertainty in our dose estimates. We therefore quantified shared and unshared uncertainties in empirical CT parameters extracted from 1073 CT films (1978-2008) from 36 hospitals in the study and propagated these uncertainties into organ doses using Monte Carlo random sampling and NCICT organ dose calculator. The average of 500 median brain and marrow doses for the full cohort was 35 (95% confidence interval: 30-40) mGy and 6 (5-7) mGy, respectively. We estimated that shared uncertainty contributed ~99% of coefficient of variation of median brain doses in brain scans compared to unshared uncertainty (1% contribution). We found that the previous brain doses were slightly underestimated for <1990 and overestimated for >1990 compared to the results in the current study due to the revised CTDI models based on CT films., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Many studies have found an increased risk of pulmonary tuberculosis (PTB) among those with diabetes mellitus (DM). However, evidence on whether the association is bidirectional remains sparse. This study investigates DM rates among those with and without prior tuberculosis (TB) disease as well as the reverse., Methods: Data on a UK general practice population, between 2003 and 2009, were obtained from The Health Improvement Network database. A series of retrospective cohort studies were completed. Individuals were successively classified as 'exposed' or 'unexposed' to TB, PTB, extrapulmonary TB (EPTB) or DM. Multivariate negative binomial regression was used to calculate incidence rate ratios (IRR) among each exposure group for outcomes of interest (TB, PTB, EPTB or DM in turn) adjusting for plausible confounding variables (age, sex, region, Townsend quintile and smoking status). Potential confounding due to ethnicity was adjusted for using McNamee's external method., Results: DM risk was substantially raised among individuals with a history of TB disease (IRR 5.65 (95% CI 5.19 to 6.16)), PTB (IRR 5.74 (95% CI 5.08 to 6.50)) and EPTB (IRR 4.66 (95% CI 3.94 to 5.51)) compared with those without; results were attenuated after external adjustment for ethnicity (IRR 2.33 (95% CI 2.14 to 2.53)). TB risk was raised modestly among individuals with DM (IRR 1.50 (95% CI 1.27 to 1.76)) and was attenuated slightly after adjustment for ethnicity (IRR 1.26 (95% CI 1.07 to 1.48))., Conclusion: DM risk was raised among those with previous TB disease; this finding has implications for follow-up and screening of patients with TB, who may be at high risk of developing DM or related complications., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Parents tend to visually assess children to determine their weight status and typically underestimate child body size. A visual tool may aid parents to more accurately assess child weight status and so support strategies to reduce childhood overweight. Body image scales (BIS) are visual images of people ranging from underweight to overweight but none exist for children based on UK criteria. Our aim was to develop sex- and age-specific BIS for children, based on British growth reference (UK90) criteria., Methods: BIS were developed using 3D surface body scans of children, their associated weight status using UK90 criteria from height and weight measurements, and qualitative work with parents and health professionals., Results: Height, weight and 3D body scans were collected (211: 4-5 years; 177: 10-11 years). Overall, 12 qualitative sessions were held with 37 participants. Four BIS (4-5-year-old girls and boys, 10-11-year-old girls and boys) were developed., Conclusions: This study has created the first sex- and age-specific BIS, based on UK90 criteria. The BIS have potential for use in child overweight prevention and management strategies, and in future research. This study also provides a protocol for the development of further BIS appropriate to other age groups and ethnicities.