Diagnostic Challenges and Treatment Approach to Seronegative Autoimmune Encephalitis.

Seronegative autoimmune encephalitis (AE) is a rare, immune-mediated inflammatory syndrome that presents with a wide spectrum of neuropsychiatric symptoms, such as cognitive impairment, seizures, psychosis, focal neurological defects, and altered consciousness. This disease process presents with no identifiable autoimmune antibodies, which leads to uncertain diagnosis, delayed treatment, and prolonged hospital admissions. Early diagnosis and prompt treatment of AE should not be delayed, as early recognition and treatment leads to improved outcomes and disease reversibility for these patients. In this study, we present a case report of a 77-year-old male who presented with acutely altered mental status. This patient underwent an extensive workup and demonstrated no signs of clinical improvement throughout a prolonged hospital admission. The diagnostic challenges and treatment obstacles encountered during our care of this patient are described in this case report, along with recommendations for early diagnosis and prompt treatment for patients with suspected seronegative AE.

Factors Associated with Patient Adherence to Biofeedback Therapy Referral for Migraine: An Observational Study.

Biofeedback has Grade A evidence for the treatment of migraine, yet few studies have examined the factors associated with patients' decisions to pursue biofeedback treatment recommendations. We sought to examine reasons for adherence or non-adherence to referral to biofeedback therapy as treatment for migraine. Patients with migraine who had been referred for biofeedback by a headache specialist/behavioral neurologist were interviewed in person or via Webex. Patients completed an enrollment questionnaire addressing demographics and questions related to their headache histories. At one month, patients were sent a follow-up questionnaire via REDCap and asked if they had pursued the recommendation for biofeedback therapy, their reasons for their decision, and their impressions about biofeedback for those who pursued it. Nearly two-thirds (65%; 33/51) of patients responded at one month. Of these, fewer than half (45%, 15/33) had contacted biofeedback providers, and only 18% (6/33) completed a biofeedback session. Common themes emerged for patients who did not pursue biofeedback, including feeling that they did not have time, concern for financial obstacles (e.g., treatment cost and/or insurance coverage), and having difficulty scheduling an appointment due to limited provider availability. When asked about their preference between type of biofeedback provider (e.g., a physical therapist or psychologist), qualitative responses were mixed; many patients indicated no preference as long as they took insurance and/or were experienced, while others indicated a specific preference for a physical therapist or psychologist due to familiarity, or prior experiences with that kind of provider. Patients with migraine referred for biofeedback therapy face numerous obstacles to pursuing treatment.

Treatment Options for Posttraumatic Headache: A Current Review of the Literature.

PURPOSE OF REVIEW: We evaluate evidence-based treatments for posttraumatic headache (PTH), a secondary headache disorder resulting from traumatic brain injury (TBI), comprising nearly 4% of all symptomatic headache disorders. Utilizing recent publications, we aim to inform clinicians of current treatment methods. RECENT FINDINGS: There is limited research on PTH treatment. A randomized controlled trial (RCT) of metoclopramide with diphenhydramine for acute PTH found that the treatment group (N = 81) experienced more significant pain improvement than placebo by 1.4 points. For persistent PTH, an open-label study of erenumab (N = 89) found that 28% of participants reported ≥ 50% reduction in moderate-to-severe headache days, but an RCT of fremanezumab showed a non-significant reduction in moderate-to-severe headache days. A randomized crossover study of 40 patients with persistent PTH found that onabotulinum toxin-A decreased cumulative number of headaches/week by 43.3% in the treatment group and increased by 35.1% among placebos. In a study of military veterans with severe posttraumatic stress disorder and persistent/delayed onset PTH (N = 193), patients who received Cognitive Behavioral Therapy reported significant improvements in headache-related disability compared to usual care (aggregate mean HIT-6, -3.4). A transcranial magnetic stimulation (N = 24) study found that 58% of participants with mild TBI-related headache experienced a 50% reduction in headache frequency. New studies indicate promise in improving clinically important outcomes of PTH. However, more research is necessary to determine the optimal treatment and whether combining pharmacologic and nonpharmacologic treatment versus a single modality is more effective.

Episodic Migraine and Psychiatric Comorbidity: A Narrative Review of the Literature.

PURPOSE OF REVIEW: We evaluate the evolving evidence of psychiatric comorbidities associated with episodic migraine. Utilizing recent research publications, we aim to assess traditional treatment option considerations and discuss recent and evolving non-pharmacologic treatment progress for episodic migraine and related psychiatric conditions. RECENT FINDINGS: Recent findings indicate that episodic migraine is strongly linked to comorbid depression, anxiety, posttraumatic stress disorder, and sleep disorders. Not only do patients with episodic migraine have higher rates of psychiatric comorbidity, but a higher number of headache days reported is also strongly linked to an increased risk of developing a psychiatric disorder, indicating there may be a link between frequency and psychiatric comorbidity and that patients with high-frequency episodic migraine should be assessed for psychiatric comorbidity. Few migraine preventive medications have examined the effect of the medication on both migraine and psychiatric comorbidity though we discuss what has been reported in the literature. Non-pharmacologic-based treatments including behavioral therapies and mind-body interventions previously developed for psychiatric conditions, e.g., mindfulness-based CBT (MBCT), acceptance and commitment therapy (ACT), and mindfulness-based stress reduction (MBSR) therapy, have promising results for patients diagnosed with episodic migraine and may therefore be useful in treating migraine and comorbid psychiatric conditions. Psychiatric comorbidity may affect the efficacy of the treatment of episodic migraine. Thus, we must assess for psychiatric comorbidities to inform better treatment plans for patients. Providing patients with episodic migraine with alternate modalities of treatment may help to improve patient-centered care and increase patients' sense of self-efficacy.

Headache clinicians' perspectives on the remote monitoring of patients' electronic diary data: A qualitative study.

OBJECTIVE: We assessed headache clinicians' viewpoints on potential remote access to patients' digital headache diary data and the practicalities of data utilization. BACKGROUND: With the ubiquitous nature of electronic medical records and the existence of remote monitoring (RM) for many medical conditions, there is now the potential for remote symptom monitoring for patients with headache disorders. While patients are asked to utilize headache diaries, clinicians may or may not have access to the data before patient visits, and their perspectives regarding this emerging technology are currently unknown. METHODS: After recruiting participants from the National Institutes of Health Pain Consortium Network, the American Headache Society Special Interest Section listservs, and Twitter and Facebook social media platforms, we conducted 20 semi-structured qualitative interviews of headache providers across the United States from various types of institutions and asked them their perspectives on remote access to patient headache diary data. We transcribed the interviews, which were then coded by two independent coders. Themes and sub-themes were developed using inductive content analysis. RESULTS: All clinicians felt the RM data needed to be integrated into the electronic medical record. Six themes emerged from the interviews: (i) Clinician perspectives on how RM could be beneficial but at other times could create obstacles/challenges, (ii) operationally, data integration could benefit headache care, (iii) there should be initial logistical considerations for bringing RM into clinical care, (iv) education may need to be provided to both patients and clinicians, (v) there are likely research benefits associated with RM, and (vi) additional suggestions for considering potential integration of RM into practice. CONCLUSIONS: While headache clinicians had mixed opinions on the benefits/challenges that RM presents to patient care, patient satisfaction, and visit time, new ideas emerged that may help advance the field.

Headache providers' perspectives of headache diaries in the era of increasing technology use: a qualitative study.

Background: No matter what type of headache is being considered across various populations, one of the mainstays of headache medicine is headache tracking. This self-management tool enables patients and their providers to understand patients' underlying symptoms and the effects of treatments they have tried. This is important to determining whether headaches are related to menses for women's health, to determining the time of headache occurrence, e.g., hypnic headache, and the location and duration of symptoms, e.g., trigeminal autonomic cephalgia. Prior research has investigated what people with headaches perceive about headache diary use and how people with headaches utilize electronic headache diaries. However, headache providers' perspectives on the important factors related to headache diaries are less known. Previously, using the Modified Delphi Process, a panel of four experts opined what they perceived as the most important factors for a headache diary. We sought to better understand headache providers' perspectives about headache diary/app usage from providers working in various institutions nationwide. Methods: We conducted 20 semi-structured qualitative interviews of headache providers across the US from various institutions and asked them their perspectives on headache diary use. We transcribed the interviews, which two independent coders then coded. Themes and subthemes were developed using grounded theory qualitative analysis. Results: Six themes emerged: (1) Providers were generally agnostic regarding the headache tracking method, but nearly all recommend the use of smartphones for tracking; (2) Providers had concerns regarding the accessibility of headache trackers; (3) Providers noted benefits to integrating headache tracking data into the EMR but had mixed opinions on how this integration might be done; (4) Providers had mixed opinions regarding the utility and interpretation of the data, specifically regarding data accuracy and efficiency; (5) Providers generally felt that headache tracking lends itself to more collaborative plan management; (6) Providers recommend behavioral health apps for patients but stated that there are few digital behavioral health interventions for headache specifically. Conclusion: Interviews of headache providers, recommenders, and users of headache data are vital informants who can provide a robust amount of information about headache diary development, use in different populations, integration, and more.

Assessment of Smartphone Apps for Common Neurologic Conditions (Headache, Insomnia, and Pain): Cross-sectional Study.

BACKGROUND: There are thousands of apps for individuals struggling with headache, insomnia, and pain, but it is difficult to establish which of these apps are best suited for patients' specific needs. If clinicians were to have access to a platform that would allow them to make an informed decision on the efficacy and feasibility of smartphone apps for patient care, they would feel confident in prescribing specific apps. OBJECTIVE: We sought to evaluate the quality of apps for some of the top common, disabling neurologic conditions (headache, insomnia, and pain) based on principles derived from the American Psychiatric Association's (APA) app evaluation model. METHODS: We used the Mobile Health Index and Navigation database and expanded upon the database's current supported conditions by adding 177 new app entries. Each app was rated for consistency with the APA's app evaluation model, which includes 105 objective questions based on the following 5 major classes of consideration: (1) accessibility, (2) privacy and security, (3) clinical foundation, (4) engagement style, and (5) interoperability. These characteristics were evaluated to gain a broader understanding of the significant features of each app category in comparison against a control group. RESULTS: Approximately 90% (187/201) of all apps evaluated were free to download, but only 50% (63/201) of headache- and pain-related apps were truly free. Most (87/106, 81%) sleep apps were not truly free to use. The apps had similar limitations with limited privacy, accessibility, and crisis management resources. For example, only 17% (35/201) of the apps were available in Spanish. The apps offered mostly self-help tools with little tailoring; symptom tracking was the most common feature in headache- (32/48, 67%) and pain-related apps (21/47, 45%), whereas mindfulness was the most common feature in sleep-related apps (73/106, 69%). CONCLUSIONS: Although there are many apps for headache, pain, and insomnia, all 3 types of apps have room for improvement around accessibility and privacy. Pain and headache apps share many common features, whereas insomnia apps offer mostly mindfulness-based resources. Given the many available apps to pick from, clinicians and patients should seek apps that offer the highest-quality features, such as complete privacy, remedial features, and the ability to download the app at no cost. These results suggest that there are many opportunities for the improvement of apps centered on headache, insomnia, and pain.

A Curriculum for Enhancing Physician Teaching Skills: The Value of Physician-Educator Partnerships.

Developing as a physician requires an enormous amount of complex training, and quality of instruction greatly affects training outcomes. But while physicians are expected to teach trainees within the clinic, they often do not receive formal training in effective instructional practices. Providing faculty development programs is one way that institutions can help physicians develop teaching skills, but these programs often are developed without the input of educational specialists and not based in educational theory. In this methodology paper, we describe a 5-module curriculum that was developed in a cross-disciplinary collaboration between instructional designers and physician faculty. By merging educational and medical expertise and using adult learning theory with the Charlotte-Danielson educational framework, an essentials for clinical teaching educational endorsement program (ECTEEP) was created as a feature of the institutional curriculum within a large, urban teaching hospital. Here we describe how the program was developed through a physician-educator partnership, outline the program's key content, and highlight essential aspects of successful implementation. The ECTEEP incorporates active learning approaches within an abbreviated format, distilling 5 critical aspects of effective teaching that are relevant to the clinical environment: cultural humility and safe learning environments, instruction practices for engaging learners, instruction and assessment strategies, receiving and giving feedback, and mentorship and coaching. A central feature of the program is that facilitators actively model the teaching behaviors they are conveying, which underscores the critical importance of facilitator preparation and skill. Our curriculum is offered here as a basic template for institutions that may want to establish a program for enhancing physician teaching skill.

Visual Analytics Dashboard Promises to Improve Hypertension Guideline Implementation.

BACKGROUND: Primary care management of hypertension under new guidelines incorporates assessment of cardiovascular disease risk and commonly requires review of electronic health record (EHR) data. Visual analytics can streamline the review of complex data and may lessen the burden clinicians face using the EHR. This study sought to assess the utility of a visual analytics dashboard in addition to EHR in managing hypertension in a primary care setting. METHODS: Primary care physicians within an urban, academic internal medicine clinic were tasked with performing 2 simulated patient encounters for hypertension management: the first using standard EHR, and the second using EHR paired with a visual dashboard. The dashboard included graphical blood pressure trends with guideline-directed targets, calculated atherosclerotic cardiovascular disease risk score, and relevant medications. Guideline-appropriate antihypertensive prescribing, correct target blood pressure goal, and total encounter time were assessed. RESULTS: We evaluated 70 case simulations. Use of the dashboard with the EHR compared with use of the EHR alone was associated with greater adherence to prescribing guidelines (95% vs. 62%, P < 0.001) and more correct identification of blood pressure target (95% vs. 57%, P < 0.01). Total encounter time fell an average of 121 seconds (95% confidence interval 69-157 seconds, P < 0.001) in encounters that used the dashboard combined with the EHR. CONCLUSIONS: The integration of a hypertension-specific visual analytics dashboard with EHR demonstrates the potential to reduce time and improve hypertension guideline implementation. Further widespread testing in clinical practice is warranted.

Using a Frontline Staff Intervention to Improve Cervical Cancer Screening in a Large Academic Internal Medicine Clinic.

BACKGROUND: Cervical cancer is the third most common malignancy affecting women. Screening with Papanicolaou (Pap) tests effectively identifies precancerous lesions and early-stage cervical cancer. While the nationwide rate of cervical cancer screening (CCS) is 84%, our urban general internal medicine (GIM) clinic population had a CCS rate of 70% in 2016. OBJECTIVE: To improve our clinic's CCS rate to match or exceed the national average within 18 months by identifying barriers and testing solutions. DESIGN: A quality improvement project led by a multidisciplinary group of healthcare providers. PARTICIPANTS: Our GIM clinic includes 16 attending physicians, 116 resident physicians, and 20 medical assistants (MAs) with an insured and underserved patient population. INTERVENTION: Phase 1 lasted 9 months and implemented CCS patient outreach, patient financial incentives, and clinic staff education. Phase 2 lasted 9 months and involved a workflow change in which MAs identified candidates for CCS during patient check-in. Feedback spanned the entire study period. MAIN MEASURES: Our primary outcome was the number of Pap tests completed per month during the 2 study phases. Our secondary outcome was the clinic population's CCS rate for all eligible clinic patients. KEY RESULTS: After interventions, the average number of monthly Pap tests increased from 35 to 56 in phase 1 and to 75 in phase 2. Of 385 patients contacted in phase 1, 283 scheduled a Pap test and 115 (41%) completed it. Compared to baseline, both interventions improved cervical cancer screening (phase 1 relative risk, 1.86; 95% CI, 1.64-2.10; P < 0.001; phase 2 relative risk, 2.70; 95% CI, 2.40-3.02; P < 0.001). Our clinic's CCS rate improved from 70% to 75% after the 18-month intervention. CONCLUSIONS: The rate of CCS increased by 5% after a systematic 2-phase organizational intervention that empowered MAs to remind, identify, and prepare candidates during check-in for CCS.

ATP-mediated increase in H+ flux from retinal Müller cells: a role for Na+/H+ exchange.

Small alterations in extracellular H+ can profoundly alter neurotransmitter release by neurons. We examined mechanisms by which extracellular ATP induces an extracellular H+ flux from Müller glial cells, which surround synaptic connections throughout the vertebrate retina. Müller glia were isolated from tiger salamander retinae and H+ fluxes examined using self-referencing H+-selective microelectrodes. Experiments were performed in 1 mM HEPES with no bicarbonate present. Replacement of extracellular sodium by choline decreased H+ efflux induced by 10 µM ATP by 75%. ATP-induced H+ efflux was also reduced by Na+/H+ exchange inhibitors. Amiloride reduced H+ efflux initiated by 10 µM ATP by 60%, while 10 µM cariporide decreased H+ flux by 37%, and 25 µM zoniporide reduced H+ flux by 32%. ATP-induced H+ fluxes were not significantly altered by the K+/H+ pump blockers SCH28080 or TAK438, and replacement of all extracellular chloride with gluconate was without effect on H+ fluxes. Recordings of ATP-induced H+ efflux from cells that were simultaneously whole cell voltage clamped revealed no effect of membrane potential from -70 mV to 0 mV. Restoration of extracellular potassium after cells were bathed in 0 mM potassium produced a transient alteration in ATP-dependent H+ efflux. The transient response to extracellular potassium occurred only when extracellular sodium was present and was abolished by 1 mM ouabain, suggesting that alterations in sodium gradients were mediated by Na+/K+-ATPase activity. Our data indicate that the majority of H+ efflux elicited by extracellular ATP from isolated Müller cells is mediated by Na+/H+ exchange.NEW & NOTEWORTHY Glial cells are known to regulate neuronal activity, but the exact mechanism(s) whereby these "support" cells modulate synaptic transmission remains unclear. Small changes in extracellular levels of acidity are known to be particularly powerful regulators of neurotransmitter release. Here, we show that extracellular ATP, known to be a potent activator of glial cells, induces H+ efflux from retinal Müller (glial) cells and that the bulk of the H+ efflux is mediated by Na+/H+ exchange.

Effects of lifestyle intervention on soluble CD163, a macrophage activation marker, in patients with non-alcoholic fatty liver disease.

OBJECTIVE: Liver macrophages play an important role in the pathogenesis of non-alcoholic fatty liver disease (NAFLD). Soluble CD163 (sCD163), a macrophage-specific biomarker, reflects disease activity in the range of liver diseases. The impact of lifestyle intervention on sCD163 in adult NAFLD patients has not been investigated. MATERIAL AND METHODS: We assessed 126 NAFLD patients participating in a lifestyle intervention study for sCD163 concentrations at baseline, after the three-month intervention period, and at long-term follow-up after 12 and 24 months. RESULTS: The median sCD163 concentration at baseline was 2.59 mg/L (IQR = 1.78-3.63 mg/L). There was a significant decrease in sCD163 from baseline to three months follow-up (-0.64 mg/L, p < .001) with no difference between the four study groups (p = .6). At 12 and 24 months follow-up, the sCD163 concentrations had returned to baseline level (p = .3 and p = .1). Baseline sCD163 correlated with liver biomarkers and metabolic variables. There was a significantly greater decrease in sCD163 in patients who had a decrease in alanine aminotransferase (ALT) compared with patients with unchanged or increased ALT (-0.76 mg/L vs. -0.41 mg/L, p = .02), and in patients with a decrease in HOMA-IR compared with individuals with no decrease (-0.86 mg/L vs. -0.55 mg/L, p = .03). CONCLUSION: sCD163 is associated with markers of liver necro-inflammation and glucose homoeostasis in NAFLD. Participation in a lifestyle intervention programme resulted in a significant reduction in sCD163. Our data support the utility of sCD163 as a biomarker for monitoring the efficacy of therapeutic interventions in NAFLD.

Comprehensive sector-wide strategies to prevent and control obesity: what are the potential health and broader societal benefits? A case study from Australia.

AIM: Several countries have recently established multistakeholder strategies to prevent or control overweight and obesity; however, studies have not yet been done on their effectiveness and likely impact. This study's objectives were to (i) explore sector-wide benefits and impacts likely to accrue from implementing an obesity prevention strategy in the Australian state of New South Wales; (ii) discuss the wider implications of the findings for research and practice; and (iii) strengthen the case for sustained implementation of a comprehensive, intersectoral approach. METHOD: A case study approach, including evidence reviews and illustrative epidemiological models, was used to show potential benefits from meeting selected targets and objectives specified in the strategy. RESULTS: For adults, improved health outcomes potentially include reductions in all-cause mortality, cardiovascular disease, type 2 diabetes, various cancers, osteoarthritis, infant mortality and healthcare costs. Potential benefits beyond the health sector involve disability payments, absenteeism, worker productivity, workplace injuries and insurance claims. For children and adolescents, improved health outcomes potentially include metabolic risk factors, dental health, prehypertension/hypertension, cardiovascular disease risk factors, depression, rates of mortality in hospitalised children, bullying and otitis media. CONCLUSION: Sector-wide health, social and economic benefits from successful implementation of multisector obesity prevention strategies are likely to be substantial if specified targets are achieved. Epidemiological modelling described in this paper for selected examples provides illustrative rather than comprehensive evidence for potential benefits. Process evaluation of the extent of implementation of these multisectoral strategies, together with the accumulated data on intervention effectiveness, will determine their potential population health benefit. Quantifying the health and social benefits that are likely to accrue if comprehensive sector-wide obesity prevention and control strategies are established can strengthen advocacy for their sustained implementation.

Contribution of organized and nonorganized activity to children's motor skills and fitness.

BACKGROUND: To examine the associations between children's organized physical activity (OPA), nonorganized physical activity (NOPA), and health-related outcomes (fundamental movement skill [FMS] fitness). METHODS: Cross-sectional survey of children aged 10-16 years (N = 4273). Organized physical activity and NOPA were assessed by self-report, FMS by process-orientated criteria, and fitness by 20-m shuttle run test. RESULTS: Boys spent 97.5 minutes and girls 86.6 minutes in daily physical activity with the majority spent in OPA (boys, 56.3%; girls 60.5%). Organized physical activity increased with grade, whereas NOPA decreased. Organized physical activity and NOPA were associated with fitness, and OPA was consistently associated with FMS competency. Boys' fitness was associated with OPA and NOPA (adjusted odds ratio [AOR] 1.42, 95% confidence interval [CI]: 1.04, 1.94; AOR 1.26, 95% CI: 1.03, 1.54, respectively), FMS competency (side gallop leap, kick) with OPA and catch, and over-arm throw with both OPA and NOPA. Girls' fitness (AOR 2.62, 95% CI: 1.88, 3.66) and FMS competency were consistently associated with OPA. CONCLUSIONS: Both OPA and NOPA are important contributors to children's physical activity; however, for girls, OPA was more strongly associated with fitness and FMS competency. Our findings support the importance of providing children with opportunities to engage in daily OPA. School physical education programs are an ideal delivery vehicle for OPA and need to be central to education policy.

Reaching "an audience that you would never dream of speaking to": influential public health researchers' views on the role of news media in influencing policy and public understanding.

While governments and academic institutions urge researchers to engage with news media, traditional academic values of public disengagement have inhibited many from giving high priority to media activity. In this interview-based study, the authors report on the views about news media engagement and strategies used by 36 peer-voted leading Australian public health researchers in 6 fields. The authors consider their views about the role and importance of media in influencing policy, their reflections on effective or ineffective media communicators, and strategies used by these researchers about how to best retain their credibility and influence while engaging with the news media. A willingness and capacity to engage with the mass media was seen as an essential attribute of influential public health researchers.

The pattern of complaints about Australian wind farms does not match the establishment and distribution of turbines: support for the psychogenic, 'communicated disease' hypothesis.

BACKGROUND AND OBJECTIVES: With often florid allegations about health problems arising from wind turbine exposure now widespread, nocebo effects potentially confound any future investigation of turbine health impact. Historical audits of health complaints are therefore important. We test 4 hypotheses relevant to psychogenic explanations of the variable timing and distribution of health and noise complaints about wind farms in Australia. SETTING: All Australian wind farms (51 with 1634 turbines) operating 1993-2012. METHODS: Records of complaints about noise or health from residents living near 51 Australian wind farms were obtained from all wind farm companies, and corroborated with complaints in submissions to 3 government public enquiries and news media records and court affidavits. These are expressed as proportions of estimated populations residing within 5 km of wind farms. RESULTS: There are large historical and geographical variations in wind farm complaints. 33/51 (64.7%) of Australian wind farms including 18/34 (52.9%) with turbine size >1 MW have never been subject to noise or health complaints. These 33 farms have an estimated 21,633 residents within 5 km and have operated complaint-free for a cumulative 267 years. Western Australia and Tasmania have seen no complaints. 129 individuals across Australia (1 in 254 residents) appear to have ever complained, with 94 (73%) being residents near 6 wind farms targeted by anti wind farm groups. The large majority 116/129(90%) of complainants made their first complaint after 2009 when anti wind farm groups began to add health concerns to their wider opposition. In the preceding years, health or noise complaints were rare despite large and small-turbine wind farms having operated for many years. CONCLUSIONS: The reported historical and geographical variations in complaints are consistent with psychogenic hypotheses that expressed health problems are "communicated diseases" with nocebo effects likely to play an important role in the aetiology of complaints.

How the factoid of wind turbines causing 'vibroacoustic disease' came to be 'irrefutably demonstrated'.

OBJECTIVE: In recent years, claims have proliferated in cyberspace that wind turbines cause a large variety of symptoms and diseases. One of these, "vibroacoustic disease" (VAD) is frequently mentioned. The aim of this study is to examine the quality of the evidence on how VAD came to be associated with wind turbine exposure by wind farm opponents. METHODS: Searches of the web (Google advanced) and major research databases for papers on VAD and wind turbines. Self-citation analysis of research papers on VAD. RESULTS: Google returned 24,700 hits for VAD and wind turbines. Thirty-five research papers on VAD were found, none reporting any association between VAD and wind turbines. Of the 35 papers, 34 had a first author from a single Portuguese research group. Seventy-four per cent of citations to these papers were self-citations by the group. Median self-citation rates in science are around 7%. Two unpublished case reports presented at conferences were found asserting that VAD was "irrefutably demonstrated" to be caused by wind turbines. The quality of these reports was abject. CONCLUSIONS: VAD has received virtually no scientific recognition beyond the group who coined and promoted the concept. There is no evidence of even rudimentary quality that vibroacoustic disease is associated with or caused by wind turbines. IMPLICATIONS: The claim that wind turbines cause VAD is a factoid that has gone 'viral' in cyberspace and may be contributing to nocebo effects among those living near turbines.

Implementing workplace health promotion initiatives: who should we target?

BACKGROUND: With recent increase in focus on population-based interventions in workplaces, targeting lifestyle risk factors for chronic disease, there is a need to ensure that interventions maximise total reach while still reaching more disadvantaged groups within the workforce. This requires assembling information on NSW workforce and health risks data in a way that is useful to guide planning in health promotion. This paper aims to describe the NSW workforce by employer size, industry divisions, occupation classification, geographic location and risk factor prevalence. METHODS: Data from a unique combination of public and non-publicly available data sets was used to describe the NSW workforce by demographic, setting-specific variables and risk factor prevalence. RESULTS: NSW represents 31% of Australia's workforce. Large employers represent 1% of businesses but employ 33% of the NSW workforce. Reaching large numbers of NSW workers can be achieved by targeting large employers in metropolitan regions; however, a high proportion of workers with multiple health risks are located in non-metropolitan areas and industries that have a high proportion of small employers. CONCLUSIONS: The workplace as a setting for population based health promotion interventions provides a number of challenges due to the fragmented nature and dispersed distribution of the workforce.

Weight change in control group participants in behavioural weight loss interventions: a systematic review and meta-regression study.

BACKGROUND: Unanticipated control group improvements have been observed in intervention trials targeting various health behaviours. This phenomenon has not been studied in the context of behavioural weight loss intervention trials. The purpose of this study is to conduct a systematic review and meta-regression of behavioural weight loss interventions to quantify control group weight change, and relate the size of this effect to specific trial and sample characteristics. METHODS: Database searches identified reports of intervention trials meeting the inclusion criteria. Data on control group weight change and possible explanatory factors were abstracted and analysed descriptively and quantitatively. RESULTS: 85 trials were reviewed and 72 were included in the meta-regression. While there was no change in control group weight, control groups receiving usual care lost 1 kg more than control groups that received no intervention, beyond measurement. CONCLUSIONS: There are several possible explanations why control group changes occur in intervention trials targeting other behaviours, but not for weight loss. Control group participation may prevent weight gain, although more research is needed to confirm this hypothesis.