[The transformation to environmentally sustainable health systems: The National Health Service example in England]. / En nationell, miljömässigt hållbar hälso- och sjukvård i sikte - Process som drivs från högsta förvaltningsnivå kan ge resultat, visar erfarenheter från England.

This article provides insight from the Sustainable Development Unit, a top down policy, monitoring and delivery unit to support a large complex health system, the National Health Service, to embed sustainable development. The dedicated unit nurtured and supported bottom up action through top down change, it translated legal requirements, embedded good governance and engaged with stakeholders.By identifying a specific and manageable topic area the unit created an entry point to broader change and enabled action, in this case the unit started with carbon footprinting and reduction. Engagement of stakeholders was a mandate for strong governance and provided feedback of successes and future challenges. Progress was monitored through carbon reduction (18.5% over ten years), with over £1.8bn energy related savings, board approved Sustainable Development Measurement Plans (71% of trusts), and public annual sustainability reporting (85% of Clinical Commissioning Groups and trusts).

Environmental sustainability and travel within the dental practice.

A significant amount of dentistry's carbon emissions originate from travel (64.5%). Dental-associated travel affects air quality, releasing over 443 tonnes of nitrogen oxides (NOx) and 22 tonnes of particulate matter (PM2.5) annually. This reduction in air quality reduces over 325 quality-adjusted life years (QALY) per year. Wider health impacts associated with noise and traffic incidents doubles the impact on health in QALYs. Dental procedures that require shorter appointment times have disproportionately higher emissions due to patient travel. The dental team can reduce appointment times by combining visits for family members or combining operative procedures, or reducing appointment frequency based on patient risk. Community oral health programmes and preventive programmes reduce travel emissions. The number of physical dental appointments can be reduced using information technology such as global positioning systems (GPS), telemedicine and teleconferencing. The mode of travel is important, with the air and carbon emissions generated by active travel negligent compared to a private car. Travel plans can help encourage active travel, as can flexible working hours, cycle to work schemes, cycle racks and shower facilities. Practices should consider purchasing locally sourced or sustainably transported goods and, ideally, use local dental laboratories.

Environmentally sustainable dentistry: energy use within the dental practice.

This paper forms part of a series of papers, seven in total, which have been requested by a number of colleagues to help them understand sustainability as it relates to dentistry. This paper focuses on energy and how the dental team can influence the amount and type of energy it uses, in order to become more sustainable. It is the authors' hope that this series of papers stimulates interest, debate and discussion and that, as well as being economically responsible, ultimately motivates and inspires dental practices to be more socially and environmentally sustainable; which will in turn help promote health and illness prevention.

Environmentally sustainable dentistry: a brief introduction to sustainable concepts within the dental practice.

This paper introduces clinicians to sustainability as it relates to dentistry. There are seven papers in the series. These include this introduction, followed by papers on energy, procurement, travel, waste, biodiversity and engagement and embedding sustainability into current dental practice. A sustainable world aims to ensure the basic needs and quality of life of everyone are met, now and for future generations. The current delivery of healthcare in the modern world is not sustainable due to rising financial costs, increasing demands and a high environmental burden. Dentists, like their medical counterparts, need to consider the General Dental Council (GDC) standards and the relationship between planetary health and human health within their practice. There is increasing awareness of the problems associated with global warming but a lack of knowledge on how to become more environmentally sustainable. There are also financial and reputational benefits to becoming more sustainable for practices. The carbon footprint is one proxy of sustainability and is closely related to expenditure. In 2014-2015, the carbon footprint of dentistry was calculated to be 675 kilotonnes carbon dioxide equivalents (CO2e) with 64.5% related to travel, 15.3% from energy and 19% from procurement. The GDC should consider incorporating sustainability education into the undergraduate framework in line with student demands and similar moves by the General Medical Council.

Supporting the UN's Sustainable Development Goals: reconceptualising a 'sustainable development assessment tool' for the health and care system in England.

AIM:: As one of the biggest organisations in the world, the National Health Service (NHS) in England can contribute considerably to the United Nations' Sustainable Development Goals (UN's SDGs). In order to optimise this, this study evaluated and reconceptualised a sustainable development assessment tool for health and care settings in England. METHODS:: A quantitative survey and user/expert discussion panels were conducted to evaluate and reconceptualise the existing sustainable development assessment tool used by the NHS in England, the so-called 'Good Corporate Citizenship Assessment Tool', including potential improvements such as the integration of the UN's SDGs. RESULTS:: A reconceptualised self-assessment tool integrating the UN's SDGs was developed and implemented online as the 'Sustainable Development Assessment Tool' (SDAT). Further improvements included a process-oriented redesign and the creation of new modules and cross-sections aligning them with the leads responsible for the implementation of key initiatives in NHS organisations, which would contribute to achieving the targets of the SDGs. CONCLUSION:: User/expert involvement has enabled an informed approach to a reconceptualisation of a sustainable assessment tool for health and care settings. The tool will support organisations to build their mandatory Sustainable Development Management Plans, as part of the National Public Health Outcomes Framework. Alignment of the tool to the UN's SDGs provides an opportunity for health and care organisations to demonstrate accountability and progress against the UN's set of transformational goals. Furthermore, the tool could be adapted to other public service providers.

Risk Factors for Smoking in Rural Women: The Role of Gender-Based Sexual and Intimate Partner Violence.

BACKGROUND: Women living in Ohio Appalachia experience cervical cancer at disproportionately high rates. Intimate partner and sexual gender-based violence (GBV) and smoking are independent risk factors for cervical cancer and interact to heighten risk. Appalachian women smoke at higher rates than other Ohio women, but little is known about GBV exposure in the region. The purpose of this study was to establish prevalence of women's exposure to GBV in Ohio Appalachia and examine the association between GBV and smoking among women in the region. METHODS: A two-phase address-based random sampling approach was used in three purposefully selected Ohio Appalachian counties to identify women to complete an interviewer administered cross-sectional survey (n = 398). The primary exposure variable was GBV Index Score, a 4 level indices representing increasing exposure to eight abuse types. Correlation analysis and logistic regression were used to examine smoking correlations and risk. RESULTS: Almost 57% of women in the three selected Ohio Appalachian counties experienced GBV, with rate increasing to 77.5% among current smokers. The distribution of the GBV Exposure Index Score was significantly different across smoking status (p < = 0.0001), with exposure of GBV increasing when moving from never, to former, to current smokers. When controlling for depression, age, and adult socioeconomic position, GBV Exposure Index was significantly associated with current smoking behavior (OR:1.62, 95% CI [1.21-2.17]). DISCUSSION: Professionals working to reduce disparate disease burden among women in Ohio Appalachia should consider the role GBV plays in health behavior and behavioral change interventions, including smoking and smoking cessation.

Emergent literacy profiles of preschool-age children with specific language impairment.

The primary aim of the present study was to explore the heterogeneity of emergent literacy skills among preschool-age children with specific language impairment (SLI) through examination of profiles of performance. Fifty-nine children with SLI were assessed on a battery of emergent literacy skills (i.e., alphabet knowledge, print concepts, emergent writing, rhyme awareness) and oral language skills (i.e., receptive/expressive vocabulary and grammar). Cluster analysis techniques identified three emergent literacy profiles: (1) Highest Emergent Literacy, Strength in Alphabet Knowledge; (2) Average Emergent Literacy, Strength in Print Concepts; and (3) Lowest Emergent Literacy across Skills. After taking into account the contribution of child age, receptive and expressive language skills made a small contribution to the prediction of profile membership. The present findings, which may be characterized as exploratory given the relatively modest sample size, suggest that preschool-age children with SLI display substantial individual differences with regard to their emergent literacy skills and that these differences cannot be fully determined by children's age or oral language performance. Replication of the present findings with a larger sample of children is needed.

RPE association with lactate and heart rate during high-intensity interval cycling.

PURPOSE: Physiological and perceptual measures during interval exercise are not well understood. The current study therefore examined the correspondence between RPE, HR, and blood lactate concentration ([La]) during interval cycling. METHODS: VO2peak and the 4.0 mmol x L(-1) lactate threshold were determined. In session 2, subjects (N = 12) warmed up (10 min, 0 W) and completed five 2-min intervals (INT) at >4 mmol x L(-1) workload, each separated by 3 min of recovery (REC) (60 rpm, 0 W). HR, RPE, and [La] were recorded at 10 min, at the conclusion of each INT, and each REC and 5- and 10-min recovery. RESULTS: Repeated-measures ANOVA showed [La], HR, and RPE increased significantly across time (INT and REC). At each time point, repeated-measures ANOVA was used to compare standardized data (alpha = 0.05). RPE (at INT) intensified concurrently with HR and [La] at INT. Correlations were significant for INT (P < or = 0.05) (HR-RPE: r = 0.63, [La]-RPE: r = 0.43). Similarly, RPE and HR for REC systematically increased with [La]. Correlations for REC were also significant (HR-RPE: r = 0.44, [La]-RPE: r = 0.34). Correlations were also significant for INT and REC combined (HR-RPE: r = 0.70, [La]-RPE: r = 0.22). CONCLUSIONS: INT and REC independently showed moderate correspondence for RPE-[La] and RPE-HR. However, tighter overall coupling of HR with RPE (vs [La] with RPE) and a dissociation between RPE-[La] suggest RPE during intervals of intense cycling were more sensitive to acute metabolic demand (evidenced by HR) versus [La].

Does occupational exposure to organic solvents affect colour discrimination?

This review assesses the evidence regarding the effects of occupational exposure to organic solvents on colour discrimination and investigates exposure-response relationships and reversibility. This review also considers the current state of knowledge of the possible mechanisms underlying changes in colour vision, and the human health significance of any reported changes. Among the commonly used organic solvents, styrene has been investigated the most thoroughly. Studies of styrene-exposed workers in Germany, Italy and Japan provide a sufficiently consistent body of evidence to support a robust conclusion that styrene does cause an impairment of colour discrimination relative to age-matched controls. Generally, the impairment of colour discrimination observed in styrene-exposed workers tends to be of the tritan (blue-yellow) type, although some cases of red-green impairment have also been found. The limited information available on exposure-response relationships indicates that the effects on colour discrimination would not be expected at 8-hour time weighted average (8 h TWA) exposures <20 ppm, although a precise threshold cannot be determined. The data on reversibility are limited and inconclusive. The results from the most rigorous study in which this aspect was investigated point to a reversibility of effects after a 4-week exposure-free period, whereas results from a study with limitations suggest a persistence of effect. The effects of toluene, tetrachloroethylene or mixed solvent exposure have also been investigated, although the information available is generally less reliable than for styrene. For toluene, it can be confidently concluded that this solvent does not have an acute effect on colour discrimination, even when exposures are relatively high (50-150 ppm 8 h TWA, and 290-360 ppm 30 minutes TWA). However, studies are inconclusive on whether long-term or repeated exposure to toluene can cause a persistent impairment of colour discrimination. There are few studies that have specifically investigated the effects of tetrachloroethylene on colour discrimination. Among these studies, none has examined the potential for any acute effects of this solvent vapour. A large-scale study in Japanese workers showed no effects of long-term exposure to tetrachloroethylene concentrations in the region of 12-13 ppm. However, the test methodology used was relatively insensitive to changes in colour discrimination, hence the results do not provide reassurance for an absence of subtle effects. A study in Italian dry-cleaners suggested a slight impairment of colour discrimination relative to controls, associated with relatively low exposures to tetrachloroethylene (mean 8 h TWA exposure approximately 6 ppm). The studies concerning the effects of mixed solvent exposure on colour discrimination are based on workers exposed to solvents in paints and lacquers, workers from the printing and petrochemical industries, people working in or living near to microelectronics factories and children exposed to solvents prenatally. However, these studies are subject to design limitations or methodological irregularities, such that no conclusions regarding the effects of mixed solvent exposure on colour discrimination can be drawn. Overall, the only credible evidence for an effect of solvents on colour discrimination derives from the studies on styrene. Because of limitations in the data for other solvents it is not possible to determine whether the evidence for styrene reflects a generic property of solvents. The mechanisms of styrene-induced effects on colour discrimination have not been properly investigated and can only be the subject of speculation. One conclusion that can be drawn is that pathological changes to the ocular system, such as changes to the lens, are unlikely to be involved. This is because there is an absence of convincing evidence for such changes from medical examinations conducted in epidemiological studies of solvent-exposed workers. Also, it seems unlikely that effects on colour discrimination are a nonspecific consequence of more generalised CNS depression, given that styrene-induced effects on colour discrimination appear to occur below the threshold for narcotic effects. The effects of styrene on colour discrimination are subtle and involve an impairment of the ability to discriminate accurately between closely related shades of the same colour rather than 'colour blindness'. There is no valid basis for using colour discrimination as a marker for other forms of solvent-induced neurotoxicity.

A series of studies--a practical protocol for testing muscular endurance recovery.

The purpose of this series of studies was to use a practical measure to examine the course of muscular endurance recovery after 3 sets to failure in 10 men (ages 18 to 30 years) and then compare those results with 10 men (ages 18 to 30 years) who performed 7 sets and 10 older men (ages 50 to 65 years) who performed 3 sets. Recovery as indicated by number of repetitions performed was observed at 24, 48, 72, and 96 hours. Repeated-measures ANOVA was used to investigate differences in recovery over time. For group means, performance was significantly lower in all 3 groups after 24 hours (p < 0.05). At 48 hours, performance of the groups was not significantly different from baseline (p > 0.05). Number of repetitions performed at 72 hours was significantly higher than that in session 1 (10.2 +/- 1.4 reps in session 1 vs. 11.2 +/- 2.3 at 72 hours, p = 0.022) in the young 3-sets group, but not in the other groups. After 96 hours, only the young 7-sets group was found to be performing at a level approaching significance (10.3 +/- 1.2 reps in session 1 vs. 11.1 +/- 2.0 at 96 hours, p = 0.051). No significant difference was found between the young 3-sets and 7-sets groups at any time (p > 0.05). The young 3-sets group was found to be performing at a significantly higher level than the older group at 72 hours (11.2 +/- 2.3 reps in the younger vs. 9.9 +/- 1.7 in the older group, p = 0.008), a difference that also approached significance at 96 hours (p = 0.06). Large intersubject variability was observed at all time points. The results suggest that individual recovery testing before exercise prescription is practical, and this protocol may be sensitive to differences in training volume and subject age.

Basal and physiological Ca(2+) leak from the endoplasmic reticulum of pancreatic acinar cells. Second messenger-activated channels and translocons.

We have studied the Ca(2+) leak pathways in the endoplasmic reticulum of pancreatic acinar cells by directly measuring Ca(2+) in the endoplasmic reticulum ([Ca(2+)](ER)). Cytosolic Ca(2+) ([Ca(2+)](C)) was clamped to the resting level by a BAPTA-Ca(2+) mixture. Administration of cholecystokinin within the physiological concentration range caused a graded decrease of [Ca(2+)](ER), and the rate of Ca(2+) release generated by 10 pm cholecystokinin is at least 3x as fast as the basal Ca(2+) leak revealed by inhibition of the endoplasmic reticulum Ca(2+)-ATPase. Acetylcholine also evokes a dose-dependent decrease of [Ca(2+)](ER), with an EC(50) of 0.98 +/- 0.06 microm. Inhibition of receptors for inositol 1,4,5-trisphosphate (IP(3)) by heparin or flunarizine blocks the effect of acetylcholine but only partly blocks the effect of cholecystokinin. 8-NH(2) cyclic ADP-ribose (20 microm) inhibits the action of cholecystokinin, but not of acetylcholine(.) The basal Ca(2+) leak from the endoplasmic reticulum is not blocked by antagonists of the IP(3) receptor, the ryanodine receptor, or the receptor for nicotinic acid adenine dinucleotide phosphate. However, treatment with puromycin (0.1-1 mm) to remove nascent polypeptides from ribosomes increases Ca(2+) leak from the endoplasmic reticulum by a mechanism independent of the endoplasmic reticulum Ca(2+) pumps and of the receptors for IP(3) or ryanodine.