From the National Health Service to local government: perceptions of public health transition in England.

OBJECTIVES: In England, in 2013, responsibility for some public health (PH) functions transferred from the National Health Service (NHS) to local government. This moved PH from a health-focussed into a broader and more politically oriented context. This article reports on the perceptions of those involved in this transition about how the PH function was changing as it transited to local government. STUDY DESIGN: This is a cross-sectional interview study. METHODS: The study included semi-structured interviews with 31 local government councillors, directors and deputy directors of PH, PH team members and members of clinical commissioning groups. Interviews and data analysis were informed by a theoretical framework, COM-B and an inductive and deductive approach was taken to identify relevant themes. RESULTS: There was a mixed picture of perceived gains and losses for PH. The transition from NHS to local government was seen by some as a 'homecoming', providing the opportunity for PH to have further reach through influence and collaboration with departments like housing, transport and planning. The opportunity to promote evidence-based practice across local government was also seen as a positive aspect of the transition. However, professional roles of PH and individual PH practitioners were perceived to have less influence and autonomy than in the NHS, with some uncertainty about roles within local government. PH practitioners perceived the need to develop other skills to fulfil their roles in local government. Shorter timescales for action and pressure for faster responses were reported to be the reason for less emphasis on using PH evidence to inform policy and decision-making than hitherto in the NHS. CONCLUSION: This study illustrates a variety of consequences of transitioning from NHS to local government. There were perceived benefits afforded by proximity to related local government departments but at the costs of reduction in status for PH practitioners and working to a timescale which in some cases reduced drawing on scientific evidence.

Evidence-based medicine meets democracy: the role of evidence-based public health guidelines in local government.

Background: In 2013, many public health functions transferred from the National Health Service to local government in England. From 2006 NICE had produced public health guidelines based on the principles of evidence-based medicine. This study explores how the guidelines were received in the new environment in local government and related issues raised relating to the use of evidence in local authoritites. Methods: In depth, interviews with 31 elected members and officers, including Directors of Public Health, from four very different local government organizations ('local authorities'). Results: Participants reported that (i) there were tensions between evidence-based, and political decision-making; (ii) there were differences in views about what constituted 'good' evidence and (iii) that organizational life is an important mediator in the way evidence is used. Conclusions: Democratic political decision-making does not necessarily naturally align with decision-making based on evidence from the international scientific literature, and local knowledge and local evidence are very important in the ways that public health decisions are made.

High-Quality Draft Genome Sequence of Francisella tularensis subsp. holarctica Strain OR96-0246.

The bacterial pathogen Francisella tularensis was recently renewed as a tier-one select agent. F. tularensis subsp. tularensis (type A) and holarctica (type B) are of clinical relevance. Here, we report the complete genome of a virulent F. tularensis type B strain and describe its usefulness in comparative genomics.

'Are we there yet?' - operationalizing the concept of Integrated Public Health Policies.

OBJECTIVES: Although 'integrated' public health policies are assumed to be the ideal way to optimize public health, it remains hard to determine how far removed we are from this ideal, since clear operational criteria and defining characteristics are lacking. METHODS: A literature review identified gaps in previous operationalizations of integrated public health policies. We searched for an approach that could fill these gaps. RESULTS: We propose the following defining characteristics of an integrated policy: (1) the combination of policies includes an appropriate mix of interventions that optimizes the functioning of the behavioral system, thus ensuring that motivation, capability and opportunity interact in such a way that they promote the preferred (health-promoting) behavior of the target population, and (2) the policies are implemented by the relevant policy sectors from different policy domains. CONCLUSION: Our criteria should offer added value since they describe pathways in the process towards formulating integrated policy. The aim of introducing our operationalization is to assist policy makers and researchers in identifying truly integrated cases. The Behavior Change Wheel proved to be a useful framework to develop operational criteria to assess the current state of integrated public health policies in practice.

Advantages and challenges of using physics curricula as a model for reforming an undergraduate biology course.

We report on the development of a life sciences curriculum, targeted to undergraduate students, which was modeled after a commercially available physics curriculum and based on aspects of how people learn. Our paper describes the collaborative development process and necessary modifications required to apply a physics pedagogical model in a life sciences context. While some approaches were easily adapted, others provided significant challenges. Among these challenges were: representations of energy, introducing definitions, the placement of Scientists' Ideas, and the replicability of data. In modifying the curriculum to address these challenges, we have come to see them as speaking to deeper differences between the disciplines, namely that introductory physics--for example, Newton's laws, magnetism, light--is a science of pairwise interaction, while introductory biology--for example, photosynthesis, evolution, cycling of matter in ecosystems--is a science of linked processes, and we suggest that this is how the two disciplines are presented in introductory classes. We illustrate this tension through an analysis of our adaptations of the physics curriculum for instruction on the cycling of matter and energy; we show that modifications of the physics curriculum to address the biological framework promotes strong gains in student understanding of these topics, as evidenced by analysis of student work.

Breast cancer awareness and barriers to symptomatic presentation among women from different ethnic groups in East London.

BACKGROUND: During 2001 to 2005, 1-year breast cancer survival was low in ethnically diverse East London. We hypothesised that this was due to low breast cancer awareness and barriers to symptomatic presentation, leading to late stage at diagnosis in women from ethnic minorities. We examined ethnic differences in breast cancer awareness and barriers to symptomatic presentation in East London. METHODS: We carried out a population-based survey of 1515 women aged 30+ using the Cancer Research UK Breast Cancer Awareness Measure. We analysed the data using logistic regression adjusting for age group and level of deprivation. RESULTS: South Asian and black women had lower breast cancer awareness than white women. South Asian women, but not black women, reported more emotional barriers to seeking medical help than white women. White women were more likely than non-white women to report worry about wasting the doctor's time as a barrier to symptomatic presentation. CONCLUSION: Interventions to promote early presentation of breast cancer for South Asian and black women should promote knowledge of symptoms and skills to detect changes, and tackle emotional barriers to symptomatic presentation and for white women tackle the idea that going to the doctor to discuss a breast symptom will waste the doctor's time.

A promoting early presentation intervention increases breast cancer awareness in older women after 2 years: a randomised controlled trial.

BACKGROUND: We have developed the Promoting Early Presentation (PEP) Intervention to equip older women with the knowledge, skills, confidence and motivation to present promptly with breast symptoms, and thereby improve survival from breast cancer. The PEP Intervention consists of a 10-min interaction between a radiographer and an older woman, supported by a booklet. Our previous report showed that at 1 year, the PEP intervention increased the proportion who were breast cancer aware compared with usual care. METHODS: We randomised 867 women aged 67-70 years attending for their final routine appointment on the National Health Service Breast Screening Programme to receive the PEP Intervention, a booklet alone or usual care. The primary outcome was breast cancer awareness measured using a validated questionnaire asking about knowledge of breast cancer symptoms, knowledge that the risk of breast cancer increases with age and breast checking behaviour. RESULTS: At 2 years, the PEP Intervention increased the proportion who were breast cancer aware compared with usual care (21 vs 6%; odds ratio 8.1, 95% confidence interval 2.7-25.0). CONCLUSIONS: The uniquely large and sustained effect of the PEP Intervention on breast cancer awareness increases the likelihood that a woman will present promptly should she develop breast cancer symptoms up to many years later.

Recruitment and consent of women with intellectual disabilities in a randomised control trial of a health promotion intervention.

BACKGROUND: The need for evidence-based health promotion interventions for women with intellectual and developmental disabilities is critical. However, significant barriers impede them from participating in research, including those related to recruitment and obtaining informed consent. METHODS: This study describes a procedure for the recruitment and consent of women with intellectual disabilities into a community-based, multi-site randomised controlled trial. RESULTS: Of 269 women who participated in information sessions, 203 (75%) enrolled in the study. While women with and without legal guardians consented at the same approximate rates (83% and 85%, respectively), those with legal guardians enrolled at significantly lower rates (61%) because of lower rates (74%) of guardian consent. CONCLUSIONS: It is possible to recruit community-dwelling women with intellectual disabilities into randomised controlled trials at relatively high participation rates. Recruiting women who have guardians poses additional challenges for researchers.

Interventions to promote cancer awareness and early presentation: systematic review.

BACKGROUND: Low cancer awareness contributes to delay in presentation for cancer symptoms and may lead to delay in cancer diagnosis. The aim of this study was to review the evidence for the effectiveness of interventions to raise cancer awareness and promote early presentation in cancer to inform policy and future research. METHODS: We searched bibliographic databases and reference lists for randomised controlled trials of interventions delivered to individuals, and controlled or uncontrolled studies of interventions delivered to communities. RESULTS: We found some evidence that interventions delivered to individuals modestly increase cancer awareness in the short term and insufficient evidence that they promote early presentation. We found limited evidence that public education campaigns reduce stage at presentation of breast cancer, malignant melanoma and retinoblastoma. CONCLUSIONS: Interventions delivered to individuals may increase cancer awareness. Interventions delivered to communities may promote cancer awareness and early presentation, although the evidence is limited.

Longitudinal predictors of psychological distress and self-esteem in people with ALS.

OBJECTIVE: To identify predictors of psychological distress (measured by anxiety and depression) and low self-esteem and to determine whether these change over time in people with ALS. METHOD: We interviewed 50 patients with ALS living with a spouse/partner; further interviews were held at median intervals of 6 and then 5 months. Although carers were interviewed, we report the patients' data. Patients completed measures about their social support and marital relationship; the functional impact of ALS; everyday cognitive, emotional, and behavioral changes; symptoms of anxiety and depression; and self-esteem. The ALS Severity Scale was also completed. RESULTS: From the initial sample of 50, 26 patients were interviewed on all three occasions. At the first interview, negative social support and bulbar impairment were most predictive of psychological distress; pre-illness marital intimacy was the best predictor of patients' self-esteem. Over time, negative social support and pre-illness marital intimacy retained an ability to predict patients' affective state and self-esteem. CONCLUSIONS: Social factors are important in determining longer-term psychological well-being in people with ALS who are in the relatively early stages of the disease.

Predictors of psychological distress in carers of people with amyotrophic lateral sclerosis: a longitudinal study.

BACKGROUND: The majority of people providing informal care for people with amyotrophic lateral sclerosis (ALS) are spouses. This prospective study set out to examine changes in and predictors of psychological distress in spouse carers of people with ALS. METHOD: Fifty spouse carers of people with ALS underwent an initial interview and at least 21 underwent two further interviews, at median intervals of approximately 5-6 months. They rated the functional impact of their partner's ALS on everyday activities and everyday cognitive, emotional and behavioural changes that might have occurred in the person with ALS. They also rated their own social support and marital relationship, and completed measures of mood, burden and strain. The ALS Severity Scale was also completed for their partner with ALS. RESULTS: Over time, carers' psychological distress (a global measure combining mood, burden and strain) increased significantly. Initially carers' psychological distress was best predicted by the psychosocial impact of their spouse/partners' ALS, the extent to which their partner demonstrated emotional lability and how many other people were considered as dependents of the carer. Subsequently, carer distress was best predicted by an initial measure of negative social support and by their initial satisfaction with their social relationships. CONCLUSIONS: Despite the significant physical impairment associated with ALS, psychosocial factors appear important in determining short- and longer-term psychological well-being in carers of people with ALS and may help clinicians to predict which carers are likely to experience psychological difficulties as part of their caring role.

Patients' preference for administration of endocrine treatments by injection or tablets: results from a study of women with breast cancer.

BACKGROUND: Endocrine therapies for advanced breast cancer include tablets and intramuscular injections. When treatments have similar efficacy and tolerability profiles, addressing preferences about routes of administration is important. PATIENTS AND METHODS: Two hundred and eight women>2 years post-breast cancer diagnosis were interviewed about their preferences for daily tablets or monthly intramuscular injections. Health-care professionals treating the women estimated patients' preferences. RESULTS: Sixty-three per cent of patients preferred tablets, 24.5% preferred the injection and 12.5% had no preference. The most cited reasons for tablet preference were convenience and dislike of needles; for injection preference, adherence and convenience. Variables associated with preferences were body mass index, educational level, attitudes towards injections and efficacy perceptions. Estimates about patients' preferences by health-care professionals varied widely. When asked to imagine scenarios where injections produced fewer hot flushes, or where two injections monthly improved efficacy, injection preference increased to 60.6% and 74.5%, respectively. Disturbingly, approximately 50% of patients admitted they sometimes forgot or chose not to take their current oral medication. CONCLUSIONS: The majority of breast cancer patients preferred hormone therapy via daily tablets rather than monthly injections. Information about side-effects or improved efficacy altered these preferences. Adherence to treatment cannot be assumed; patients' preferences about drug administration may influence this.

Predictors of institutionalisation in people with dementia.

OBJECTIVE: To identify what patient and carer characteristics influence transition into residential care for people with dementia. METHOD: Longitudinal study of a cohort of people with dementia and their carers in contact with old age psychiatric services in south London. RESULTS: 100 people with dementia and their main family carer were recruited. At six month follow up 22 were in residential care, 63 in the community, 8 had died, and for 7 there were missing data. Between six and 12 months, 7 of the 63 in the community went into residential care, 4 died, and 12 were lost to follow up. The most striking finding is the 20-fold protective effect of having a co-resident carer (odds ratio 0.05, 95% confidence intervals 0.01 to 0.42, p=0.006). Higher ratings of behavioural problems in the person with dementia were also statistically significantly associated with transition into residential care as was the psychological domain of quality of life of the carer. CONCLUSION: These findings powerfully illustrate the pivotal role carried out by carers of people with dementia; interventions directly targeted at helping them to maintain this role would be supported by these data. These data also suggest that strategies directed at improving carer quality of life and at the resolution of behavioural disorder in the person with dementia may also have particular value.

Health-related locus of control: does it change in motor neurone disease (MND)?

OBJECTIVES: Previous studies have attempted to describe locus of control beliefs in people with MND. This exploratory, longitudinal study set out to examine some of the possible correlations of health-related locus of control beliefs and the stability of these beliefs. METHOD: 32 people with Motor Neurone Disease completed the Multi-dimensional Health Locus of Control (MHLC) scale, initially on average 10.3 months after diagnosis, and again on average 16.4 months after diagnosis. Physical symptoms were assessed at both times. RESULTS: Initially there were no correlations between MHLC beliefs or disease duration and physical symptomatology, although longer disease duration was associated with greater beliefs in the role of powerful others in health control. At the second assessment, belief in the role of powerful others controlling health had increased, with this increase relating significantly to a worsening in physical symptoms. At this second assessment, neither duration of symptoms nor time since diagnosis correlated with MHLC beliefs. CONCLUSIONS: Whilst health locus of control beliefs do appear to change in MND, current findings suggest that this does not occur simply as a function of the passage of time. How symptoms change seems to be of particular importance when considering health locus of control beliefs in people with MND. Suggestions are made concerning other factors that might usefully be examined in future studies of this type.

Correlates of Quality of Life in people with motor neuron disease (MND).

OBJECTIVES: Previous work has not found correlations between standardized questionnaire measures of quality of life (QoL) and physical strength/functional ability in people with motor neuron disease (MND). Little is known about the relationship between ratings on an abbreviated self-generated measure of QoL, the Schedule for Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW), and measures of functional status such as the Sickness Impact Profile (SIP), although the former has been rated by people with MND as providing a more valid measure of their own QoL than the latter. The aim of this study was to examine whether self-generated ratings of QoL correlated with measures of physical impairment and self-reported functional status, psychological wellbeing and self-reported cognitive functioning, and with factors such as social support, which elsewhere has been reported to be a determinant of QoL in MND. DESIGN: The present cross-sectional study investigated between SEIQoL-DW ratings and SIP and the relationship ALS Severity Scale (ALSSS) scores, as well as with self-reported anxiety, depression, social support and everyday cognitive functioning in 31 people with MND. RESULTS: Overall QoL ratings on the SEIQoL-DW failed to correlate with any of the ALSSS or SIP subscale scores. This was despite the fact that health was nominated as an important QoL-related category by 64.5% of the sample. QoL scores were, however, found to correlate positively with the existence of confiding and emotional support; they also correlated negatively with the presence of self-rated everyday cognitive difficulties but not with affective state. CONCLUSIONS: Current findings support recent observations that individuals' ratings of their QoL cannot simply be equated with their physical impairment and functional limitations, and that support systems may be important. Cognitive functioning, known to be impaired in some people with MND, should also be considered when evaluating QoL.

Pituitary tumorigenesis and hPit-1 cells.

Despite decades of clinical data verifying the success of therapeutic approaches to human pituitary tumors, a significant number of tumors progress and can be life-threatening. The development of better therapeutic strategies for pituitary tumors is complicated by the relative scarcity of human pituitary material for basic experimentation. Human pituitary tissue was used to derive cell cultures, and a cell line, hPIT-1. Molecular and functional analyses were used to further characterize the cells as human pituitary explants in vitro. Functional analyses of the cell cultures indicated that the cells were tumorigenic and of human folliculostellate origin. hPit-1 cells revealed numerous abnormalities of ploidy. Molecular analyses indicated the absence of expression of the following pituitary hormones or hormone subunits by this culture: growth hormone, prolactin, ACTH, FSHbeta, LHbeta, THbeta, and p-glycoprotein. By contrast, the cells expressed uniformly high levels of human follistatin mRNA. Finally, the cells are moderately tumorigenic in immune-deficient mice. Although the precise molecular genetic mechanisms for tumorigenesis in the established cell culture are unknown, the cells serve as a future resource in the study of pituitary tumor initiation, progression, and response to therapy.

Amplification of AML1 in childhood acute lymphoblastic leukemias.

Amplification of AML1 has been confirmed by fluorescence in situ hybridization analysis in two cases of childhood acute lymphoblastic leukemia. It remains to be elucidated whether this amplification results in up-regulation of the normal AML1 gene product or a potentially mutant AML1 transcript.