Development of a group structured education programme to support safe exercise in people with Type 1 diabetes: the EXTOD education programme.

AIM: To develop a structured education programme for individuals with Type 1 diabetes who are engaging in regular exercise. METHOD: A multidisciplinary team of experts in supporting exercise and physical activity for people with Type 1 diabetes, alongside researchers with experience of developing self-management education, developed an exercise programme using the Medical Research Council framework. The programme was informed by a review of the evidence relating to Type 1 diabetes and exercise, the behaviour change literature (including the behaviour change taxonomy), and qualitative interviews with stakeholders. The programme and supporting resources were refined using an iterative process of testing, delivery and collecting feedback from participants and the wider development team. RESULTS: The outcome of the intervention development was the design of a feasible and acceptable intervention for people with Type 1 diabetes to support safe exercise. The pilot allowed refinement of the intervention prior to testing in a two-site feasibility randomized controlled trial. Key findings from the pilot informed minor restructuring of the timetable (timings and order) and adaptation of supporting educational materials (participant handbook and teaching materials). CONCLUSION: The 'EXercise in people with Type One Diabetes' (EXTOD) education programme has been developed using robust methodology for the generation of educational interventions. It now needs testing in a randomized controlled trial.

Factors influencing improved attendance in the UK fire service.

BACKGROUND: Sickness absence rates in the UK continue to exceed those in much of the developed world, with an annual cost to employers of £29 billion. Rates of sickness absence in the public sector are higher than those in the private sector, with the exception of the fire service where they are consistently lower. AIMS: To understand the influences that increase attendance among operational firefighters. METHODS: A series of semi-structured interviews undertaken with operational staff to explore their attitudes to sickness absence. RESULTS: Review and analysis of participant responses identified a number of key themes, namely employee well-being, including physical fitness and mental health; employee engagement with the fire service as manifested by culture, experience, nature of the job and leadership; organizational factors including the staffing model and relationship with occupational health services and policy, which describes both refinements to and implementation of targeted policies. CONCLUSIONS: Previously observed factors such as improved fitness and the distinct firefighter culture play a role, yet other factors emerged that could explain the differences. These include the greater work-life balance offered by their shift patterns, the terms and conditions of employment and perhaps most importantly the evolution of precisely targeted policies that understand the unique nature of the operational fire service.

A qualitative exploration of the motives behind the decision to order a liver function test in primary care.

BACKGROUND: The number of tests ordered in primary care continues to increase influenced by a number of factors not all of which are concerned with diagnosis and management of disease. Liver function tests (LFTs) are a good example of inexpensive tests that are frequently ordered in patients with non-specific symptoms. They remain among the most frequently ordered tests despite their lack of specificity yet the full range of motives behind the decision to order an LFT remains unexplored. AIMS: To gain an understanding of the family practitioner's (FP) medical and non-medical motives for ordering an LFT and the influence of various social and technical factors on this decision. METHODS: We interviewed FPs across six practices who were participating in a prospective study of the efficacy of an abnormal LFT to indicate the development of a serious liver disease. Following content analysis of the data from the semi-structured interviews we used the 'attitude-social influence-efficacy' model to categorise the determinants of test ordering behaviour. RESULTS: Factors influencing an FP's decision to order a test were grouped into two broad categories; the first is 'internal' including expectation of efficacy and general attitude towards LFTs. The second group is 'external' and consists of themes of social influence, tests characteristics and defensive medicine. CONCLUSIONS: Whilst our sample acknowledged the clinical use of LFTs such as the routine monitoring of medication and liver-specific diagnostic purposes we also found that social and behavioural reasons are strong motivators to order an LFT and may take precedence over clinical factors.

Birmingham and Lambeth Liver Evaluation Testing Strategies (BALLETS): a prospective cohort study.

OBJECTIVE: To evaluate mildly abnormal liver function test (LFT) results in general practice among patients who do not have known liver disease. DESIGN: Prospective cohort study of people with abnormal LFT results identified in primary care. Participants were intensively investigated using a common protocol and followed up for 2 years. Substudies investigated the psychological sequelae of abnormal test results, clinicians' reasons for testing, decision options when LFT results were abnormal and early detection of liver fibrosis. SETTING: Eleven primary-care practices: eight in Birmingham and three in Lambeth. PARTICIPANTS: Adults with abnormal LFT results who did not have pre-existing or obvious liver disease. Eight analytes were included in the panel of LFTs. MAIN OUTCOME MEASURES: Statistical tests were used to identify the interactions between clinical features, the initial pattern of abnormal LFT results and (1) specific viral, genetic and autoimmune diseases, such as viral hepatitis, haemochromatosis and primary biliary cirrhosis; (2) a range of other serious diseases, such as metastatic cancer and hypothyroidism; (3) 'fatty liver' not associated with the above; and (4) the absence of detectable disease. RESULTS: Fewer than 5% of people with abnormal LFT results had a specific disease of the liver, and many of these were unlikely to need treatment. The diagnostic potential of the LFT panel is largely subsumed into just two analytes: alanine aminotransferase (ALT) and alkaline phosphatase (ALP). Gamma-glutamyltransferase (GGT) offers a small increase in sensitivity at the margin at the cost of a large loss of specificity. Eighty-four per cent of abnormal LFT results remain abnormal on retesting 1 month later. In many cases, carrying out a definitive or specific test will be more efficient than repeating LFTs, with a view to specific testing only if the test remains abnormal. An ultrasound diagnosis of 'fatty liver' was present in nearly 40% of patients with abnormal LFTs and a small amount of weight loss over 2 years was associated with a reduced incidence of liver fat. There was a J-shaped relationship between alcohol intake and fatty liver in men. An abnormal LFT result causes temporary anxiety, which does not appear to promote sustained behaviour change. CONCLUSIONS: Liver disease is rare among people with abnormal LFT results in primary care. Only two analytes (ALT and ALP) are helpful in identifying the majority of liver disease. GGT adds little information in return for a high false-positive rate but it is sensitive to alcohol intake. LFT results seldom revert from abnormal to normal over a 1-month period, and modelling shows that repeating an abnormal LFT panel, as recommended in the current guidelines, is inefficient. LFTs are often undertaken to meet perceived patient need for a blood test, but as they are neither specific nor indicative of any particular disease they are among the least suitable tests for this purpose. Obesity and raised ALT provide strong evidence for a presumptive diagnosis of 'fatty' liver. Abnormal LFTs and 'fatty' liver provoke only short-term anxiety and neither is associated with sustained weight loss. Even a small amount of weight loss reduces liver fat. FUTURE WORK RECOMMENDATIONS: (1) the cases of 'fatty liver' and controls should be followed up in the long term to identify features that predict development of hepatosteatosis and then cirrhosis; (2) the acceptability of replacing the traditional six- to eight-analyte LFT panel with a drop down menu including the ALT/ALP combination should be evaluated. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

Assessment of occupational exposure to radiofrequency fields and radiation.

The use of personal monitors for the assessment of exposure to radiofrequency fields and radiation in potential future epidemiological studies of occupationally exposed populations has been investigated. Data loggers have been developed for use with a commercially available personal monitor and these allowed personal exposure records consisting of time-tagged measurements of electric and magnetic field strength to be accrued over extended periods of the working day. The instrumentation was worn by workers carrying out tasks representative of some of their typical daily activities at a variety of radio sites. The results indicated significant differences in the exposures of workers in various RF environments. A number of measures of exposure have been examined with a view to assessing possible exposure metrics for epidemiological studies. There was generally a good correlation between a given measure of electric field strength and the same measure of magnetic field strength.