NHS Highland

1. While teaching statistics to ecologists, the lead authors of this paper have noticed common statistical problems. If a random sample of their work (including scientific papers) produced before doing these courses were selected, half would probably contain violations of the underlying assumptions of the statistical techniques employed. 2. Some violations have little impact on the results or ecological conclusions; yet others increase type I or type II errors, potentially resulting in wrong ecological conclusions. Most of these violations can be avoided by applying better data exploration. These problems are especially troublesome in applied ecology, where management and policy decisions are often at stake. 3. Here, we provide a protocol for data exploration; discuss current tools to detect outliers, heterogeneity of variance, collinearity, dependence of observations, problems with interactions, double zeros in multivariate analysis, zero inflation in generalized linear modelling, and the correct type of relationships between dependent and independent variables; and provide advice on how to address these problems when they arise. We also address misconceptions about normality, and provide advice on data transformations. 4. Data exploration avoids type I and type II errors, among other problems, thereby reducing the chance of making wrong ecological conclusions and poor recommendations. It is therefore essential for good quality management and policy based on statistical analyses.

BACKGROUND: Abiraterone acetate plus prednisolone improves survival in men with relapsed prostate cancer. We assessed the effect of this combination in men starting long-term androgen-deprivation therapy (ADT), using a multigroup, multistage trial design. METHODS: We randomly assigned patients in a 1:1 ratio to receive ADT alone or ADT plus abiraterone acetate (1000 mg daily) and prednisolone (5 mg daily) (combination therapy). Local radiotherapy was mandated for patients with node-negative, nonmetastatic disease and encouraged for those with positive nodes. For patients with nonmetastatic disease with no radiotherapy planned and for patients with metastatic disease, treatment continued until radiologic, clinical, or prostate-specific antigen (PSA) progression; otherwise, treatment was to continue for 2 years or until any type of progression, whichever came first. The primary outcome measure was overall survival. The intermediate primary outcome was failure-free survival (treatment failure was defined as radiologic, clinical, or PSA progression or death from prostate cancer). RESULTS: A total of 1917 patients underwent randomization from November 2011 through January 2014. The median age was 67 years, and the median PSA level was 53 ng per milliliter. A total of 52% of the patients had metastatic disease, 20% had node-positive or node-indeterminate nonmetastatic disease, and 28% had node-negative, nonmetastatic disease; 95% had newly diagnosed disease. The median follow-up was 40 months. There were 184 deaths in the combination group as compared with 262 in the ADT-alone group (hazard ratio, 0.63; 95% confidence interval [CI], 0.52 to 0.76; P<0.001); the hazard ratio was 0.75 in patients with nonmetastatic disease and 0.61 in those with metastatic disease. There were 248 treatment-failure events in the combination group as compared with 535 in the ADT-alone group (hazard ratio, 0.29; 95% CI, 0.25 to 0.34; P<0.001); the hazard ratio was 0.21 in patients with nonmetastatic disease and 0.31 in those with metastatic disease. Grade 3 to 5 adverse events occurred in 47% of the patients in the combination group (with nine grade 5 events) and in 33% of the patients in the ADT-alone group (with three grade 5 events). CONCLUSIONS: Among men with locally advanced or metastatic prostate cancer, ADT plus abiraterone and prednisolone was associated with significantly higher rates of overall and failure-free survival than ADT alone. (Funded by Cancer Research U.K. and others; STAMPEDE ClinicalTrials.gov number, NCT00268476 , and Current Controlled Trials number, ISRCTN78818544 .).

BACKGROUND: Health and social care workers (HSCWs) have carried a heavy burden during the COVID-19 crisis and, in the challenge to control the virus, have directly faced its consequences. Supporting their psychological wellbeing continues, therefore, to be a priority. This rapid review was carried out to establish whether there are any identifiable risk factors for adverse mental health outcomes amongst HSCWs during the COVID-19 crisis. METHODS: We undertook a rapid review of the literature following guidelines by the WHO and the Cochrane Collaboration's recommendations. We searched across 14 databases, executing the search at two different time points. We included published, observational and experimental studies that reported the psychological effects on HSCWs during the COVID-19 pandemic. RESULTS: The 24 studies included in this review reported data predominantly from China (18 out of 24 included studies) and most sampled urban hospital staff. Our study indicates that COVID-19 has a considerable impact on the psychological wellbeing of front-line hospital staff. Results suggest that nurses may be at higher risk of adverse mental health outcomes during this pandemic, but no studies compare this group with the primary care workforce. Furthermore, no studies investigated the psychological impact of the COVID-19 pandemic on social care staff. Other risk factors identified were underlying organic illness, gender (female), concern about family, fear of infection, lack of personal protective equipment (PPE) and close contact with COVID-19. Systemic support, adequate knowledge and resilience were identified as factors protecting against adverse mental health outcomes. CONCLUSIONS: The evidence to date suggests that female nurses with close contact with COVID-19 patients may have the most to gain from efforts aimed at supporting psychological well-being. However, inconsistencies in findings and a lack of data collected outside of hospital settings, suggest that we should not exclude any groups when addressing psychological well-being in health and social care workers. Whilst psychological interventions aimed at enhancing resilience in the individual may be of benefit, it is evident that to build a resilient workforce, occupational and environmental factors must be addressed. Further research including social care workers and analysis of wider societal structural factors is recommended.

Summary Scientific investigation is of value only insofar as relevant results are obtained and communicated, a task that requires organizing, evaluating, analysing and unambiguously communicating the significance of data. In this context, working with ecological data, reflecting the complexities and interactions of the natural world, can be a challenge. Recent innovations for statistical analysis of multifaceted interrelated data make obtaining more accurate and meaningful results possible, but key decisions of the analyses to use, and which components to present in a scientific paper or report, may be overwhelming. We offer a 10‐step protocol to streamline analysis of data that will enhance understanding of the data, the statistical models and the results, and optimize communication with the reader with respect to both the procedure and the outcomes. The protocol takes the investigator from study design and organization of data (formulating relevant questions, visualizing data collection, data exploration, identifying dependency), through conducting analysis (presenting, fitting and validating the model) and presenting output (numerically and visually), to extending the model via simulation. Each step includes procedures to clarify aspects of the data that affect statistical analysis, as well as guidelines for written presentation. Steps are illustrated with examples using data from the literature. Following this protocol will reduce the organization, analysis and presentation of what may be an overwhelming information avalanche into sequential and, more to the point, manageable, steps. It provides guidelines for selecting optimal statistical tools to assess data relevance and significance, for choosing aspects of the analysis to include in a published report and for clearly communicating information.

The still poorly explored world of microbial functioning is about to be uncovered by a combined application of old and new technologies. Bacteria, especially, are still in the dark with respect to their phylogenetic affiliations as well as their metabolic capabilities and functions. However, with the advent of sophisticated flow cytometric and cell sorting technologies in microbiological labs, there is now the possibility to gain this knowledge at the single-cell level without cumbersome cultivation approaches. Cytometry also facilitates the understanding of physiological diversity in seemingly likewise acting populations. Both individuality and diversity lead to the complex and concerted actions of microbial consortia. This review provides an overview of the state of the art in the field. It deals with the handling of microorganisms from the very beginning (i.e. sampling, and detachment and fixation procedures) and goes on to discuss the pitfalls and problems in analysing cells without any further treatment. If information cannot be gained by specific staining procedures, phylogenetic technologies, transcriptomic and proteomic approaches may be options for achieving advanced insights. All in all, flow cytometry will be a mediator technology to gain a deeper insight into the heterogeneity of populations and the functioning of microbial communities.

Primary biliary cirrhosis (PBC) is a classical autoimmune liver disease for which effective immunomodulatory therapy is lacking. Here we perform meta-analyses of discovery data sets from genome-wide association studies of European subjects (n=2,764 cases and 10,475 controls) followed by validation genotyping in an independent cohort (n=3,716 cases and 4,261 controls). We discover and validate six previously unknown risk loci for PBC (Pcombined<5 × 10(-8)) and used pathway analysis to identify JAK-STAT/IL12/IL27 signalling and cytokine-cytokine pathways, for which relevant therapies exist.

Objective: To investigate variations in the prevalence of self reported symptoms, diagnosis, and treatment of asthma in 12–14 year old children. Design: Self completion questionnaire. Setting: Great Britain. Subjects: All pupils aged 12–14 years in a stratified cluster sample of 93 large mixed secondary schools in 1995. Main outcome measures: Self reported prevalence of symptoms, diagnosis, and treatment of asthma at four geographical levels. Results: 27 507 questionnaires were completed (85.9% response rate). The national 12 month prevalence of any wheezing, speech limiting wheeze, four or more attacks of wheeze, and frequent night waking with wheeze was 33.3% (n=9155), 8.8% (2427), 9.6% (2634), and 3.7% (1023) respectively. The prevalence of ever having had a diagnosis of asthma was 20.9% (5736). In total, 19.8% (5438/27 507) of pupils reported treatment with anti-asthma drugs in the past year, but, of pupils reporting frequent nocturnal wheeze in the past year, 33.8% (342/1012) had no diagnosis of asthma and 38.6% (395/1023) denied receiving inhaler therapy. The 12 month prevalence of wheeze was highest in Scotland (36.7%, 1633/4444), but in England and Wales there was no discernible north-south or east-west gradient. Wheeze prevalence was slightly higher in non-metropolitan areas (35.0%, 6155/17 605) than in metropolitan areas (30.3%, 3000/9902). The prevalence of self reported asthma diagnosis and inhaler use showed no discernible national, regional, north-south, or east-west geographical pattern but was higher in non-metropolitan areas. Conclusion: Prevalence of self reported symptoms, diagnosis, and treatment of asthma was high among 12–14 year olds throughout Great Britain with little geographical or urban-rural variation. Underdiagnosis and undertreatment were substantial. Key messages We investigated the prevalence of self reported symptoms, diagnosis, and treatment of asthma in 12–14 year old children in Great Britain A third of subjects reported wheezing in the past year, and a fifth reported ever having had a diagnosis of asthma—higher prevalences than reported previously Prevalences of symptoms generally varied by a factor of 1.3 or less across Great Britain but, in contrast to previous reports, were significantly higher in Scotland than England and in non-metropolitan areas than metropolitan ones Asthma may still be undiagnosed and undertreated—4% of pupils reported having had a diagnosis of asthma but were still experiencing moderate or greater disruption of their lives, while 1-3.4% reported moderate to severe symptoms but were undiagnosed and untreated The limited geographical variation in prevalences of symptoms and diagnosis of asthma suggests that the causes of asthma are widely distributed in Great Britain and that factors which do vary geographically—such as climate, diet, and outdoor environment—are not the main determinants of prevalence.

Wide-scale and sudden shifts in several biological and environmental systems of NW Europe have been reported in recent years, and attributed to a range of factors, both climatic and anthropogenic. To examine whether there is any evidence of coinciding region-wide environmental shifts, we gathered existing long-term data series on a wide range of physical and biological parameters from the 1960s to the present and, following the methods of a similar recent study on North Pacific regime shifts, we analysed the data using principal component analysis and regime shift analysis to identify the extent and timing of regime shifts in NW Europe. The end-point of a regime (i.e. the year) was determined using a sliding window in regime shift analysis. Additionally we applied chronological clustering to the (1) combined data, (2) biological data and (3) environmental data. In all 3 cases, the same regimes were identified. Our results indicate that substantial regime shifts occurred in the marine ecosystem in 1979 and 1988 and perhaps also in 1998, although results were less clear-cut in the latter case. These regime shifts were most evident among the biological data series, but they appeared to have been triggered by earlier shifts in a number of environmental factors. Salinity and weather conditions played an important role in the 1979 shift, while in the 1988 shift, temperature and weather conditions were the predominant factors. Our results confirm those of the North Pacific study, with concomitant changes in physical and biological indices. This indicates a shift in climate-ocean interactions throughout the entire temperate zone of the Northern Hemisphere.

OBJECTIVES: To explore how general practitioners operate the sickness certification system, their views on the system, and suggestions for change. DESIGN: Qualitative focus group study consisting of 11 focus groups with 67 participants. SETTING: General practitioners in practices in Glasgow, Tayside, and Highland regions, Scotland. SAMPLE: Purposive sample of general practitioners, with further theoretical sampling of key informant general practitioners to examine emerging themes. RESULTS: General practitioners believed that the sickness certification system failed to address complex, chronic, or doubtful cases. They seemed to develop various operational strategies for its implementation. There appeared to be important deliberate misuse of the system by general practitioners, possibly related to conflicts about roles and incongruities in the system. The doctor-patient relationship was perceived to conflict with the current role of general practitioners in sickness certification. When making decisions about certification, the general practitioners considered a wide variety of factors. They experienced contradictory demands from other system stakeholders and felt blamed for failing to make impossible reconciliations. They clearly identified the difficulties of operating the system when there was no continuity of patient care. Many wished either to relinquish their gatekeeper role or to continue only with major changes. CONCLUSIONS: Policy makers need to recognise and accommodate the range and complexity of factors that influence the behaviour of general practitioners operating as gatekeepers to the sickness certification system, before making changes. Such changes are otherwise unlikely to result in improvement. Models other than the primary care gatekeeper model should be considered.

BACKGROUND: eHealth interventions are becoming increasingly used in public health, with virtual reality (VR) being one of the most exciting recent developments. VR consists of a three-dimensional, computer-generated environment viewed through a head-mounted display. This medium has provided new possibilities to adapt problematic behaviors that affect mental health. VR is no longer unaffordable for individuals, and with mobile phone technology being able to track movements and project images through mobile head-mounted devices, VR is now a mobile tool that can be used at work, home, or on the move. OBJECTIVE: In line with recent advances in technology, in this review, we aimed to critically assess the current state of research surrounding mental health. METHODS: We compiled a table of 82 studies that made use of head-mounted devices in their interventions. RESULTS: Our review demonstrated that VR is effective in provoking realistic reactions to feared stimuli, particularly for anxiety; moreover, it proved that the immersive nature of VR is an ideal fit for the management of pain. However, the lack of studies surrounding depression and stress highlight the literature gaps that still exist. CONCLUSIONS: Virtual environments that promote positive stimuli combined with health knowledge could prove to be a valuable tool for public health and mental health. The current state of research highlights the importance of the nature and content of VR interventions for improved mental health. While future research should look to incorporate more mobile forms of VR, a more rigorous reporting of VR and computer hardware and software may help us understand the relationship (if any) between increased specifications and the efficacy of treatment.

BACKGROUND: Adherence to effective Web-based interventions for common mental disorders (CMDs) and well-being remains a critical issue, with clear potential to increase effectiveness. Continued identification and examination of "active" technological components within Web-based interventions has been called for. Gamification is the use of game design elements and features in nongame contexts. Health and lifestyle interventions have implemented a variety of game features in their design in an effort to encourage engagement and increase program adherence. The potential influence of gamification on program adherence has not been examined in the context of Web-based interventions designed to manage CMDs and well-being. OBJECTIVE: This study seeks to review the literature to examine whether gaming features predict or influence reported rates of program adherence in Web-based interventions designed to manage CMDs and well-being. METHODS: A systematic review was conducted of peer-reviewed randomized controlled trials (RCTs) designed to manage CMDs or well-being and incorporated gamification features. Seven electronic databases were searched. RESULTS: A total of 61 RCTs met the inclusion criteria and 47 different intervention programs were identified. The majority were designed to manage depression using cognitive behavioral therapy. Eight of 10 popular gamification features reviewed were in use. The majority of studies utilized only one gamification feature (n=58) with a maximum of three features. The most commonly used feature was story/theme. Levels and game leaders were not used in this context. No studies explicitly examined the role of gamification features on program adherence. Usage data were not commonly reported. Interventions intended to be 10 weeks in duration had higher mean adherence than those intended to be 6 or 8 weeks in duration. CONCLUSIONS: Gamification features have been incorporated into the design of interventions designed to treat CMD and well-being. Further research is needed to improve understanding of gamification features on adherence and engagement in order to inform the design of future Web-based health interventions in which adherence to treatment is of concern. Conclusions were limited by varied reporting of adherence and usage data.

OBJECTIVES: Evaluate the effectiveness of an online self-management programme (EPP Online) for England residents with long-term conditions. METHODS: A prospective longitudinal study. Data were collected online at baseline, 6 and 12 months. The intervention was an asynchronous 6-week chronic-disease self-management programme offered online. We measured seven health status measures (health distress, self-rated health, illness intrusiveness, disability, fatigue, pain and shortness of breath), four behaviours (aerobic exercise, stretching exercise, stress management and communications with physician), and five utilization measures (GP visits, pharmacy visits, PT/OT visits, emergency visits and hospitalizations). We also measured self-efficacy and satisfaction with the health care system. RESULTS: A total of 568 completed baseline data: 546 (81%) completed 6 months and 443 (78%) completed 1 year. Significant improvements (p < 0.01) were found at 6 months for all variables except self-rated health, disability, stretching, hospitalizations and nights in hospital. At 12 months only decrease in disability, nights in hospital and hospitalizations were not significant with reduction in visits to emergency departments being marginally significant (p = 0.012). Both self-efficacy and satisfaction with the health care system improved significantly. DISCUSSION: The peer-led online programme conditions appears to decrease symptoms, improve health behaviours, self-efficacy and satisfaction with the health care system and reducing health care utilization up to 1 year.

Background Approximately 50% of cardiovascular disease (CVD) cases are attributable to lifestyle risk factors. Despite widespread education, personal knowledge, and efficacy, many individuals fail to adequately modify these risk factors, even after a cardiovascular event. Digital technology interventions have been suggested as a viable equivalent and potential alternative to conventional cardiac rehabilitation care centers. However, little is known about the clinical effectiveness of these technologies in bringing about behavioral changes in patients with CVD at an individual level. Objective The aim of this study is to identify and measure the effectiveness of digital technology (eg, mobile phones, the internet, software applications, wearables, etc) interventions in randomized controlled trials (RCTs) and determine which behavior change constructs are effective at achieving risk factor modification in patients with CVD. Methods This study is a systematic review and meta-analysis of RCTs designed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) statement standard. Mixed data from studies extracted from selected research databases and filtered for RCTs only were analyzed using quantitative methods. Outcome hypothesis testing was set at 95% CI and P=.05 for statistical significance. Results Digital interventions were delivered using devices such as cell phones, smartphones, personal computers, and wearables coupled with technologies such as the internet, SMS, software applications, and mobile sensors. Behavioral change constructs such as cognition, follow-up, goal setting, record keeping, perceived benefit, persuasion, socialization, personalization, rewards and incentives, support, and self-management were used. The meta-analyzed effect estimates (mean difference [MD]; standard mean difference [SMD]; and risk ratio [RR]) calculated for outcomes showed benefits in total cholesterol SMD at −0.29 [−0.44, −0.15], P&lt;.001; high-density lipoprotein SMD at –0.09 [–0.19, 0.00], P=.05; low-density lipoprotein SMD at −0.18 [−0.33, −0.04], P=.01; physical activity (PA) SMD at 0.23 [0.11, 0.36], P&lt;.001; physical inactivity (sedentary) RR at 0.54 [0.39, 0.75], P&lt;.001; and diet (food intake) RR at 0.79 [0.66, 0.94], P=.007. Initial effect estimates showed no significant benefit in body mass index (BMI) MD at −0.37 [−1.20, 0.46], P=.38; diastolic blood pressure (BP) SMD at −0.06 [−0.20, 0.08], P=.43; systolic BP SMD at −0.03 [−0.18, 0.13], P=.74; Hemoglobin A1C blood sugar (HbA1c) RR at 1.04 [0.40, 2.70], P=.94; alcohol intake SMD at −0.16 [−1.43, 1.10], P=.80; smoking RR at 0.87 [0.67, 1.13], P=.30; and medication adherence RR at 1.10 [1.00, 1.22], P=.06. Conclusions Digital interventions may improve healthy behavioral factors (PA, healthy diet, and medication adherence) and are even more potent when used to treat multiple behavioral outcomes (eg, medication adherence plus). However, they did not appear to reduce unhealthy behavioral factors (smoking, alcohol intake, and unhealthy diet) and clinical outcomes (BMI, triglycerides, diastolic and systolic BP, and HbA1c).

Bottle incubations were conducted to examine how exposure to seawater containing 8000 ppm carbon dioxide (CO 2 ; pH 6.95) influenced the growth and reproduction of the keystone copepod Calanus finmarchicus. The chosen concentration of CO 2 is expected to occur over 100s of cubic kilometres of seawater as a result of marine CO 2 storage/disposal, and is also representative of the predicted 'worst-case' atmospheric CO 2 scenario in the year 2300. Growth (egg production and biomass loss) in adult female copepods was not affected by the simulated ocean acidification. In contrast, a maximum of only 4% of the eggs successfully yielded nauplii after 72 h in the experimental treatment. Our results demonstrate that environmental risk assessments for marine CO 2 storage/disposal must look beyond adult mortality as an endpoint. Furthermore, if CO 2 is to be disposed of in the deep sea, the location and timing of such activities must take into consideration the overwintering populations of C. finmarchicus.

Delirium is a common problem and cause of distress among patients with palliative care needs. The focus to date has been on managing the patient with agitated, hyperactive delirium, as these patients are very noticeable within the palliative care setting. This study in two parts shows that palliative care patients with agitated delirium are a minority of the total proportion of those with delirium. Part I: 100 acute admissions to a specialist palliative care unit were assessed and while 29% were found to have delirium, 86% of these had the hypoactive subtype of delirium. We also demonstrated a positive correlation between high ratings on a depression screening tool and delirium severity ratings. Part II: 8 specialist palliative care units took part in a point prevalence study of delirium over a 48-hour period. One hundred and nine patients were assessed and while 29.4% of these inpatients had delirium, 78% of them had the hypoactive subtype. Patients with hypoactive delirium may be much less noticeable or may be misdiagnosed as having depression or fatigue and the results of this study would advocate the routine use of delirium screening tools in all palliative care settings.

Many aspects of the management of acutely disturbed behaviour have only relatively recently come under systematic scrutiny. Perhaps regrettably one of the last amongst the range of strategies that may be employed to be subjected to rigorous examination has been physical restraint. Considerable debate has recently taken place around what represents good practice in this sensitive and controversial area but the continuing dearth of research in some aspects of this area of practice has meant that this discussion has arguably been over reliant on 'expert' opinion. Questions continue regarding some fundamental issues of restraint, including the relative risks involved in alternative approaches, and anxieties have been expressed about the potential for injuries and death to result from restraint. This article outlines the results of a survey that sought to explore the incidence of deaths associated with restraint in health and social care settings in the UK. The outcome of an initial analysis of the cases identified is then discussed, with reference to the literature on restraint-related deaths, in order to identify the implications for practice.

A severe scarcity of life history and population data for deep-water fishes is a major impediment to successful fisheries management. Long-term data for non-target species and those living deeper than the fishing grounds are particularly rare. We analysed a unique dataset of scientific trawls made from 1977 to 1989 and from 1997 to 2002, at depths from 800 to 4800 m. Over this time, overall fish abundance fell significantly at all depths from 800 to 2500 m, considerably deeper than the maximum depth of commercial fishing (approx. 1600 m). Changes in abundance were significantly larger in species whose ranges fell at least partly within fished depths and did not appear to be consistent with any natural factors such as changes in fluxes from the surface or the abundance of potential prey. If the observed decreases in abundance are due to fishing, then its effects now extend into the lower bathyal zone, resulting in declines in areas that have been previously thought to be unaffected. A possible mechanism is impacts on the shallow parts of the ranges of fish species, resulting in declines in abundance in the lower parts of their ranges. This unexpected phenomenon has important consequences for fisheries and marine reserve management, as this would indicate that the impacts of fisheries can be transmitted into deep offshore areas that are neither routinely monitored nor considered as part of the managed fishery areas.

BACKGROUND: Recruiting and retaining a skilled health workforce is a common challenge for remote and rural communities worldwide, negatively impacting access to services, and in turn peoples' health. The research literature highlights different factors facilitating or hindering recruitment and retention of healthcare workers to remote and rural areas; however, there are few practical tools to guide local healthcare organizations in their recruitment and retention struggles. The purpose of this paper is to describe the development process, the contents, and the suggested use of The Framework for Remote Rural Workforce Stability. The Framework is a strategy designed for rural and remote healthcare organizations to ensure the recruitment and retention of vital healthcare personnel. METHOD: The Framework is the result of a 7-year, five-country (Sweden, Norway, Canada, Iceland, and Scotland) international collaboration combining literature reviews, practical experience, and national case studies in two different projects. RESULT: The Framework consists of nine key strategic elements, grouped into three main tasks (plan, recruit, retain). Plan: activities to ensure that the population's needs are periodically assessed, that the right service model is in place, and that the right recruits are targeted. Recruit: activities to ensure that the right recruits and their families have the information and support needed to relocate and integrate in the local community. Retain: activities to support team cohesion, train current and future professionals for rural and remote health careers, and assure the attractiveness of these careers. Five conditions for success are recognition of unique issues; targeted investment; a regular cycle of activities involving key agencies; monitoring, evaluating, and adjusting; and active community participation. CONCLUSION: The Framework can be implemented in any local context as a holistic, integrated set of interventions. It is also possible to implement selected components among the nine strategic elements in order to gain recruitment and/or retention improvements.

OBJECTIVES: To describe the prevalence of atopic symptoms in children throughout the UK. METHOD: A questionnaire survey of 12-14 year olds throughout England, Wales, Scotland, and the Scottish Islands using the international study of asthma and allergies in childhood (ISAAC) protocol. RESULTS: A total of 27 507 (86%) children took part. Recent rhinoconjunctivitis was reported by 18.2%, with 6.2% reporting symptoms between March and September; 16.4% reported itchy flexural rash in the past 12 months. The prevalence of atopic symptoms was higher in girls and subjects born within the UK. The prevalence of severe wheeze was highest in subjects reporting perennial rhinoconjunctivitis, as opposed to summertime only symptoms. Winter rhinoconjunctivitis was associated with severe wheeze and severe flexural rash. One or more current symptoms were reported by 47.6% of all children and 4% reported all three symptoms. CONCLUSION: In general, geographical variations were small but the prevalence of symptoms was significantly higher in Scotland and northern England. The study demonstrates the importance of atopic diseases both in their own right and in association with asthma.

An outbreak of E. coli O157 infection occurred in the Highland Region of Scotland in the summer of 1999. The source of the outbreak was traced to an untreated private water supply. All six cases identified arose in visitors to the area, and most had very limited exposure to the contaminated water. Permanent residents on the same supply were unaffected. The E. coli O157 isolates from the water, sheep faeces collected from around the source and the human stool samples were indistinguishable using pulsed field gel electrophoresis. Previously reported outbreaks of E. coli O157 linked to potable water supplies have resulted from structural or treatment failures, which allowed faecal contamination of source water. Here, contamination of the water supply and subsequent human infection was due to the use of an untreated, unprotected private water source in a rural area where animals grazed freely.