A mixed method evaluation of adult tier 2 lifestyle weight management service provision across a county in Northern England.

Adult obesity in the UK remains a public health priority. Current guidance recommends local areas provide multicomponent interventions to treat adults with overweight and obesity; however, there is currently a dearth of published evidence on the evaluation of these programmes. This study reports on a mixed method evaluation of seven tier 2 weight management programmes funded by a local authority in the North of England through their public health grant (a lifestyle multicomponent weight management programme for the treatment of adults with overweight and obesity, but not severe obesity, or obesity with severe co-morbidities). Data collected from over 2000 participants demonstrated that the proportion of participants achieving 5% initial body weight loss was comparable to that reported in recent UK weight management trials. Two services exceeded national criteria of 30% of participants achieving 5% initial body weight loss at 12 weeks, although long term data was limited. Greater weight loss was also observed in participants aged 35-44 and those without co-morbidities. This study provides important learning points for improvements in real world weight management services, these include: standardised data collection and management tools; staff training and communication requirements; the importance of programmes that are joined up to wider support services; and the importance of providing ongoing peer and provider support, continuous monitoring and feedback, and physical activities tailored to user needs.

The success of battlefield surgical airway insertion in severely injured military patients: a UK perspective.

BACKGROUND: The insertion of a surgical airway in the presence of severe airway compromise is an uncommon occurrence in everyday civilian practice. In conflict, the requirement for insertion of a surgical airway is more common. Recent military operations in Afghanistan resulted in large numbers of severely injured patients, and a significant proportion required definitive airway management through the insertion of a surgical airway. OBJECTIVE: To examine the procedural success and survival rate to discharge from a military hospital over an 8-year period. METHODS: A retrospective database and chart review was conducted, using the UK Joint Theatre Trauma Registry and the Central Health Records Library. Patients who underwent surgical airway insertion by UK medical personnel from 2006 to 2014 were included. Procedural success, demographics, Injury Severity Score, practitioner experience and patient survival data were collected. Descriptive statistics were used for data comparison, and statistical significance was defined as p<0.05. RESULTS: 86 patients met the inclusion criterion and were included in the final analysis. The mean patient age was 25 years, (SD 5), with a median ISS of 62.5 (IQR 42). 79 (92%) of all surgical airways were successfully inserted. 7 (8%) were either inserted incorrectly or failed to perform adequately. 80 (93%) of these procedures were performed either by combat medical technicians or General Duties Medical Officers (GDMOs) at the point of wounding or Role 1. 6 (7%) were performed by the Medical Emergency Response Team. 21 (24%) patients survived to hospital discharge. DISCUSSION: Surgical airways can be successfully performed in the most hostile of environments with high success rates by combat medical technicians and GDMOs. These results compare favourably with US military data published from the same conflict.

Systematic review of long-term lifestyle interventions to prevent weight gain and morbidity in adults.

The aim of this article is to determine the effectiveness of long-term lifestyle interventions for the prevention of weight gain and morbidity in adults. Prevention of weight gain is important in adults who are of normal weight, overweight and obese. A systematic review of controlled trials of lifestyle interventions in adults with a body mass index of less than 35 kg m(-2) with at least 2 years of follow-up was carried out. Eleven of 39 comparisons produced significant improvement in weight between groups at 2 years or longer with mean difference weight change ranging from -0.5 to -11.5 kg. Effective interventions included a 600 kcal/day deficit diet deficit/low-fat diet (with and without meal replacements), low-calorie diet, Weight Watchers diet, low-fat non-reducing diet, diet with behaviour therapy, diet with exercise, diet with exercise and behaviour therapy. Adding meal replacements to a low-fat diet (with and without exercise and behaviour therapy) produced significant improvement in weight. Head-to-head interventions failed to show significant effect on weight with the exception of a Mediterranean diet with behaviour therapy compared with low-fat diet. Diet with exercise and/or behaviour therapy demonstrated significant reduction in hypertension and improvement in risk of metabolic syndrome and diabetes compared with no treatment control. Lifestyle interventions demonstrated significant improvement in weight, reduction in hypertension and reduction in risk of type 2 diabetes and the metabolic syndrome.

A profile of the belief system and attitudes to end-of-life decisions of senior clinicians working in a National Health Service Hospital in the United Kingdom.

There is evidence from outside the United Kingdom to show that physicians' religious beliefs influence their decision making at the end of life. This UK study explores the belief system of consultants, nurse key workers and specialist registrars and their attitudes to decisions which commonly must be taken when caring for individuals who are dying. All consultants (N = 119), nurse key workers (N = 36) and specialist registrars (N = 44) working in an acute hospital in the north-east of England were asked to complete a postal questionnaire. In all, 65% of consultants, 67% of nurse key workers and 41% of specialist registrars responded. Results showed that consultants' religion and belief systems differed from those of nurses and the population they served. Consultants and nurses had statistically significant differences in their attitudes to common end of life decisions with consultants more likely to continue hydration and not withdraw treatment. Nurses were more sympathetic to the idea of physician-assisted suicide for unbearable suffering. This study shows the variability in belief system and attitudes to end of life decision making both within and between clinical groups. This may have practical implications for the clinical care given and the place of care. The personal belief system of consultants was not shown to affect their overall attitudes to withdrawing life-sustaining treatment or physician-assisted suicide.

Dietary advice for treatment of type 2 diabetes mellitus in adults.

BACKGROUND: While initial dietary management immediately after formal diagnosis is an 'accepted' cornerstone of treatment of type 2 diabetes mellitus, a formal and systematic overview of its efficacy and method of delivery is not currently available. OBJECTIVES: To assess the effects of type and frequency of different types of dietary advice for adults with type 2 diabetes. SEARCH STRATEGY: We carried out a comprehensive search of The Cochrane Library, MEDLINE, EMBASE, CINAHL, AMED, bibliographies and contacted relevant experts. SELECTION CRITERIA: All randomised controlled trials, of six months or longer, in which dietary advice was the main intervention. DATA COLLECTION AND ANALYSIS: The lead investigator performed all data extraction and quality scoring with duplication being carried out by one of the other six investigators independently with discrepancies resolved by discussion and consensus. Authors were contacted for missing data. MAIN RESULTS: Thirty-six articles reporting a total of eighteen trials following 1467 participants were included. Dietary approaches assessed in this review were low-fat/high-carbohydrate diets, high-fat/low-carbohydrate diets, low-calorie (1000 kcal per day) and very-low-calorie (500 kcal per day) diets and modified fat diets. Two trials compared the American Diabetes Association exchange diet with a standard reduced fat diet and five studies assessed low-fat diets versus moderate fat or low-carbohydrate diets. Two studies assessed the effect of a very-low-calorie diet versus a low-calorie diet. Six studies compared dietary advice with dietary advice plus exercise and three other studies assessed dietary advice versus dietary advice plus behavioural approaches. The studies all measured weight and measures of glycaemic control although not all studies reported these in the articles published. Other outcomes which were measured in these studies included mortality, blood pressure, serum cholesterol (including LDL and HDL cholesterol), serum triglycerides, maximal exercise capacity and compliance. The results suggest that adoption of regular exercise is a good way to promote better glycaemic control in type 2 diabetic patients, however all of these studies were at high risk of bias. AUTHORS' CONCLUSIONS: There are no high quality data on the efficacy of the dietary treatment of type 2 diabetes, however the data available indicate that the adoption of exercise appears to improve glycated haemoglobin at six and twelve months in people with type 2 diabetes. There is an urgent need for well-designed studies which examine a range of interventions, at various points during follow-up, although there is a promising study currently underway.

Wholegrain cereals for coronary heart disease.

BACKGROUND: There is increasing evidence from observational studies that wholegrains can have a beneficial effect on risk factors for coronary heart disease (CHD). OBJECTIVES: The primary objective is to review the current evidence from randomised controlled trials (RCTs) that assess the relationship between the consumption of wholegrain foods and the effects on CHD mortality, morbidity and on risk factors for CHD, in participants previously diagnosed with CHD or with existing risk factors for CHD. SEARCH STRATEGY: We searched CENTRAL (Issue 4, 2005), MEDLINE (1966 to 2005), EMBASE (1980 to 2005), CINAHL (1982 to 2005), ProQuest Digital Dissertations (2004 to 2005). No language restrictions were applied. SELECTION CRITERIA: We selected randomised controlled trials that assessed the effects of wholegrain foods or diets containing wholegrains, over a minimum of 4 weeks, on CHD and risk factors. Participants included were adults with existing CHD or who had at least one risk factor for CHD, such as abnormal lipids, raised blood pressure or being overweight. DATA COLLECTION AND ANALYSIS: Two of our research team independently assessed trial quality and extracted data. Authors of the included studies were contacted for additional information where this was appropriate. MAIN RESULTS: Ten trials met the inclusion criteria. None of the studies found reported the effect of wholegrain diets on CHD mortality or CHD events or morbidity. All 10 included studies reported the effect of wholegrain foods or diets on risk factors for CHD. Studies ranged in duration from 4 to 8 weeks. In eight of the included studies, the wholegrain component was oats. Seven of the eight studies reported lower total and low density lipoproteins (LDL) cholesterol with oatmeal foods than control foods. When the studies were combined in a meta-analysis lower total cholesterol (-0.20 mmol/L, 95% confidence interval (CI) -0.31 to -0.10, P = 0.0001 ) and LDL cholesterol (0.18 mmol/L, 95% CI -0.28 to -0.09, P < 0.0001) were found with oatmeal foods. However, there is a lack of studies on other wholegrains or wholegrain diets. AUTHORS' CONCLUSIONS: Despite the consistency of effects seen in trials of wholegrain oats, the positive findings should be interpreted cautiously. Many of the trials identified were short term, of poor quality and had insufficient power. Most of the trials were funded by companies with commercial interests in wholegrains. There is a need for well-designed, adequately powered, longer term randomised controlled studies in this area. In particular there is a need for randomised controlled trials on wholegrain foods and diets other than oats.

Independent associations between weight status and disability in adults: results from the Health Survey for England.

OBJECTIVES: While direct links between obesity and some illnesses are well-established, there is a relative paucity of research on associations between obesity and disabilities. The aim of this study was to test for significant associations between overweight and obesity and the presence of a wide range of disabling conditions in adults, controlling for sex, age, education, social class, income, cigarette smoking status and alcohol consumption. STUDY DESIGN: Data were extracted from the Health Survey for England (2001); a cross-sectional survey of the community-dwelling population. In total, 8613 adult participants were included in the analysis. METHODS: Multivariate logistic regression was employed to test whether the odds of having a range of disabling conditions are higher in the overweight and obese populations compared with those in the ideal weight range. RESULTS: The risk of nearly all disabling conditions tested was elevated in the obese and morbidly obese groups. Of great importance for public health, the risks of musculoskeletal illness, arthritis and rheumatism, and personal care disability were significantly elevated, even in those in the overweight category (currently about half of the adult population living in the UK). CONCLUSIONS: Obesity is independently associated with a range of disabling conditions in adults. The present study highlights the need for further research into the mechanisms by which these associations occur.

Prospective, randomised, controlled trial to study the effect of intracoronary injection of verapamil and adenosine on coronary blood flow during percutaneous coronary intervention in patients with acute coronary syndromes.

OBJECTIVES: To study the impact of injection of verapamil and adenosine in the coronary arteries on TIMI (Thrombolysis in Myocardial Infarction) frame count (TFC) after percutaneous coronary intervention (PCI) in patients with an acute coronary syndrome (ACS). METHODS: Prospective, randomised, controlled study of the intracoronary administration of normal saline versus verapamil versus adenosine in patients undergoing PCI in the setting of an ACS, even when flow is visually established to be normal or near normal. Patients were randomised to receive verapamil (n = 49), adenosine (n = 51) or normal saline (n = 50) after PCI. Quantitative angiography, TIMI flow grade (TFG), TFC and myocardial blush grade were assessed before PCI, after PCI and after drugs were given. Wall motion index (WMI) was measured at days 1 and 30. RESULTS: 9 patients in the verapamil group developed transient heart block, not seen with adenosine (p

Low glycaemic index diets for coronary heart disease.

BACKGROUND: The glycaemic index (GI) is a physiological measure of the ability of a carbohydrate to affect blood glucose. Interest is growing in the low GI carbohydrate concept for the clinical management of people at risk of, or with established coronary heart disease. There is a need to review the current evidence from controlled trials in this area. OBJECTIVES: The primary objective is to review the current evidence from RCTs that assess the relationship between the consumption of low glycaemic index diets and the effects on coronary heart disease and on risk factors for coronary heart disease. SEARCH STRATEGY: We searched CENTRAL (Issue 4, 2003), MEDLINE (1966 to 2003), EMBASE (1980 to 2003) and CINAHL (1982 to 2003). We also contacted experts in the field. SELECTION CRITERIA: We selected randomised controlled trials that assessed the effects of low glycaemic index diets, over a minimum of 4 weeks, on coronary heart disease (CHD) and risk factors. Participants included were adults who carry at least one major risk factor for coronary heart disease such as abnormal lipids, diabetes or being overweight. DATA COLLECTION AND ANALYSIS: Two of our research team independently assessed trial quality and extracted data. Authors of the included studies were contacted for additional information when this was appropriate. MAIN RESULTS: Fifteen randomised controlled trials met the inclusion criteria. No studies found reported the effect of low glycaemic index diets on CHD mortality or CHD events and morbidity. All fifteen included studies report the effect of low glycaemic index diets on major risk factors for CHD. Meta-analysis detected limited and weak evidence of a relationship between low glycaemic index diets and slightly lower total cholesterol, compared with higher glycaemic index diets. There is also limited and weak evidence of a small reduction in HbA1c after 12 weeks on low glycaemic index diets but not at 4 to 5 weeks. There is no evidence that low glycaemic index diets have an effect on LDL cholesterol or HDL cholesterol, triglycerides, fasting glucose or fasting insulin levels. REVIEWERS' CONCLUSIONS: The evidence from randomised controlled trials showing that low glycaemic index diets reduces coronary heart disease and CHD risk factors is weak. Many of the trials identified were short-term, of poor quality and conducted on small sample sizes. There is a need for well designed, adequately powered, randomised controlled studies, of greater than 12 weeks duration to assess the effects of low glycaemic index diets for CHD.

Preconceptions versus experience of transvaginal ultrasonography in older women.

OBJECTIVE: To determine whether women find that having a transvaginal ultrasound scan is better or worse than they had expected. METHODS: Fifty-four consecutive women in an ovarian cancer screening trial filled in linked questionnaires before and after having a transvaginal ultrasound scan. RESULTS: The women found that having a transvaginal scan was less painful (P = 0.003) and less embarrassing (P = 0.001) than they had expected. They found it less uncomfortable than expected in comparison to having mammography (P = 0.013) or a cervical smear (P = 0.004). CONCLUSIONS: Women attending for a transvaginal scan can be reassured that it will not be as painful or embarrassing as they fear, and that it is not as uncomfortable as having mammography or a cervical smear.

Arcachon and cholinergic transmission.

The cholinergic nature of transmission at the electromotor synapse of Torpedo marmorata was established at Arcachon in 1939 by Feldberg, Fessard and Nachmansohn (J. Physiol. (Lond.) 97 (1939/1940) 3P-4P) soon after transmission at the neuromuscular junction had been shown to be cholinergic. In 1964, after a quarter of a century of neglect, workers in Cambridge, then in Paris, Göttingen and elsewhere, began to use this system, 500-1000 times richer in cholinergic synapses than muscle, for intensive studies of cholinergic transmission at the cellular and molecular level.

Interferon-gamma alters nerve-induced redistribution of acetylcholine receptors in cultured rat skeletal muscle cells.

The influence of recombinant interferon-gamma (rIFN-gamma) on the development of acetylcholine receptor (AChR) aggregates in cocultures of rat embryonic muscle cells and spinal cord neurons was studied by counting the number of AChR aggregates in relation to cholinergic nerve fibers coming to the muscle fibers. rIFN-gamma caused no decrease in the number of cholinergic nerve fibers, but inhibited the increase in the number of AChR aggregates that occurs early during cocultivation and is an early sign in the development of neuromuscular junctions. rIFN-gamma stimulated release of nitric oxide, but no effects on aggregation of AChRs occurred after exposure to a nitric oxide synthase inhibitor, L-NG-monomethylarginine, or by the addition of nitroprusside, a generator of nitric oxide. No effect was seen on the number of AChR aggregates when the cultures were exposed to rIFN-gamma at later time points of cocultivation, when the increase in number of AChRs had already occurred. These studies indicate that the key immunoregulatory cytokine IFN-gamma can cause alterations in the early process of synapse formation and that these effects are independent of the nitric oxide release caused by the cytokine.

Cholinergic-specific glycoconjugates.

Cholinergic nerve terminals utilize glycoconjugates in several ways, as surface markers and as structural components of the synaptic vesicles present within them. The surface markers have been discovered immunochemically: antibodies raised against them are able specifically to sensitize the cholinergic subpopulation of mammalian brain synaptosomes to complement-mediated lysis. One such group of antigens (Chol-1) have been identified as a novel series of minor gangliosides having in common a sialylated N-acetylgalactosamine residue. These gangliosides may constitute the major gangliosides at cholinergic terminals. A second surface antigen (Chol-2) is thought to be a protein with an epitope in common with a Torpedo electric organ ganglioside. Cholinergic synaptic vesicles are rich in a proteoglycan which appears to assist in the sequestration of acetylcholine within the vesicle and to stabilize the vesicle membrane during cycles of exocytosis and recovery. It may be the cholinergic equivalent of the chromogranins.

Thirty years of synaptosome research.

Detached synapses (synaptosomes), first isolated by the author in 1958 and identified as such in 1960, are sealed presynaptic nerve terminals often with a portion of the target cell--sometimes amounting to a complete dendritic spine--adhering to their external surface. They can be prepared in high yield from brain tissue and also in decreasing yield from spinal cord, retina, sympathetic ganglia, myenteric plexus and electric organs. They are sealed structures which, under metabolizing conditions, respire, take up oxygen and glucose, extrude Na+, accumulate K+, maintain a normal membrane potential and, on depolarization, release transmitter in a Ca(2+)-dependent manner. They thus provide an excellent preparation with which to investigate synaptic function without the complications encountered with synapses in situ. They also serve as the parent fraction for preparations of synaptic vesicles and other synaptic components.

A novel cholinergic-specific antigen (Chol-2) in mammalian brain.

Three new antisera have been raised in sheep against cholinergic electromotor presynaptic plasma membranes prepared from the electric organs of the electric ray, Torpedo marmorata. They all recognized one or more cholinergic-specific antigens in the mammalian nervous system by the following criteria: they sensitized the cholinergic subpopulation of rat-brain synaptosomes--and only this subpopulation--to lysis by the complement system and, in an immunocytochemical study, selectively stained choline acetyltransferase-positive cholinergic neurons in the rat spinal cord. However, two of the three antisera failed to recognize Chol-1 alpha and -beta, two closely related minor gangliosides already identified as the cholinergic-specific antigens recognized by previous anti-Torpedo presynaptic plasma membrane antisera or indeed any other ganglioside and the third recognized only Chol-1 alpha. A further investigation of the antigen(s) recognized by the most antigenic of the new antisera indicated that it is proteinaceous in nature, but has epitopes in common with electric organ gangliosides.

Vesamicol blocks the recovery, by recycling cholinergic electromotor synaptic vesicles, of the biophysical characteristics of the reserve population.

The effect of vesamicol on the ability of recycling cholinergic synaptic vesicles to recover, during a period of post-stimulation rest, the biophysical properties of the reserve pool was studied in prestimulated perfused blocks of the electric organ of the electric ray, Torpedo marmorata, a tissue rich in cholinergic synapses. The effect of the drug was analysed by high-resolution centrifugal density-gradient fractionation in a zonal rotor of the extracted vesicles. The two vesicle fractions were identified by their ATP and acetylcholine content and the recycled vesicles by their acquisition of [3H]acetylcholine derived from [3H]acetate in the perfusate. Vesamicol (10 microM) blocked the uptake of tritiated acetylcholine by recycled vesicles and also prevented them from rejoining the reserve pool. This is consistent with a previously formulated model of the recovery process, whereby the increase in the acetylcholine and ATP content of the recycled vesicles which takes place during a post-stimulus period of rest increases their osmotic load and thus their content of free water. Vesamicol, by blocking acetylcholine uptake, also blocks rehydration of the recycled vesicles and thus the accompanying decrease in their density to the value characteristic of fully charged vesicles.

The cholinergic marker Chol-1 is selectively localized in nerve terminals.

The subcellular distribution of the cholinergic-specific gangliosidic Chol-1 antigens in rat brain has been compared with that of total ganglioside as a marker for neural plasma membranes, particle-bound choline acetyltransferase (ChAT) as a synaptosomal marker, and supernatant ChAT as a marker for neuronal perikaryal cytoplasm. Over 50% of brain Chol-1 was recovered in a synaptosome fraction prepared by a standard density-gradient method. The specific concentration of Chol-1 relative to protein or major gangliosides was also highest in the synaptosome fraction and low in a supernatant fraction which contained most of the neuronal plasma membrane fragments. ChAT was likewise mainly recovered in the synaptosome fraction but its relative concentration there was significantly less than that of Chol-1 (p < 0.01).