Can population-level variation in early childhood development be measured in a manner that supports service planning and intervention?

Background: The Early Development Instrument (EDI) is a population-level measure of five developmental domains at school-entry age. The overall aim of this thesis was to explore the potential of the EDI as an indicator of early development in Ireland. Methods: A cross-sectional study was conducted in 47 primary schools in 2011 using the EDI and a linked parental questionnaire. EDI (teacher completed) scores were calculated for 1,344 children in their first year of full-time education. Those scoring in the lowest 10% of the sample population in one or more domains were deemed to be 'developmentally vulnerable'. Scores were correlated with contextual data from the parental questionnaire and with indicators of area and school-level deprivation. Rasch analysis was used to determine the validity of the EDI. Results: Over one quarter (27.5%) of all children in the study were developmentally vulnerable. Individual characteristics associated with increased risk of vulnerability were being male; under 5 years old; and having English as a second language. Adjusted for these demographics, low birth weight, poor parent/child interaction and mother’s lower level of education showed the most significant odds ratios for developmental vulnerability. Vulnerability did not follow the area-level deprivation gradient as measured by a composite index of material deprivation. Children considered by the teacher to be in need of assessment also had lower scores, which were not significantly different from those of children with a clinical diagnosis of special needs. all domains showed at least reasonable fit to the Rasch model supporting the validity of the instrument. However, there was a need for further refinement of the instrument in the Irish context. Conclusion: This thesis provides a unique snapshot of early development in Ireland. The EDI and linked parental questionnaires are promising indicators of the extent, distribution and determinants of developmental vulnerability.

Diphtheria, the public health response and the origins of the childhood immunisation programme in Ireland

In common with most countries, the childhood immunisation programme in Ireland was founded on a successful public health response to diphtheria. The success of the antidiphtheria public health intervention in Ireland has meant that no case of the disease has been recorded in the state for almost fifty years. This is a significant achievement considering that diphtheria continues to appear annually in many European states, albeit in much reduced numbers on former years. For parents and children of nineteenth, and early twentieth-century Ireland, diphtheria represented the ‘most dreaded disease of childhood’, however, for their modern day counterparts diphtheria is no more than an obscure disease mentioned in leaflets promoting the benefits of childhood immunisation. In Ireland, diphtheria has been consigned to history, and so too have the horrors and mass fatalities once associated with it. But how was this achieved? Was active immunisation received with open arms by public health authorities, the wider medical community, and the general public? This study tackles these questions by undertaking the first historical examination of the issues which underpin the origins of active immunisation in Ireland. It explores the driving forces that shaped the national childhood immunisation programme, and those that opposed them. In addition, it examines the complex social implications attendant on the introduction of this mass public health intervention in an Irish context.

States of play: Irish childhoods, race and belonging

This thesis explores the meaning-making practices of migrant and non-migrant children in relation to identities, race, belonging and childhood itself in their everyday lives and in the context of ‘normalizing’ discourses and spaces in Ireland. The relational, spatial and institutional contexts of children’s worlds are examined in the arenas of school, home, family, peer groups and consumer culture. The research develops a situated account of children’s complex subject positions, belongings and exclusions, as negotiated within discursive constructs, emerging in the ‘in-between’ spaces explored with other children and with adults. As a peripheral EU area both geographically and economically, Ireland has traditionally been a country of net emigration. This situation changed briefly in the late 1990s to early 2000s, sparking broad debate on Ireland’s perceived ‘new’ ethnic, cultural and linguistic diversity arising from the arrival of migrant people both from within and beyond the EU as workers and as asylum seekers, and drawing attention to issues of race, identity, equality and integration in Irish society. Based in a West of Ireland town where migrant children and children of migrants comprise very small minorities in classroom settings, this research engages with a particular demographic of children who have started primary school since these changes have occurred. It seeks to represent the complexities of the processes which constitute children’s subjectivities, and which also produce and reproduce race and childhood itself in this context. The role of local, national and global spaces, relational networks and discursive currents as they are experienced and negotiated by children are explored, and the significance of embodied, sensory and affective processes are integrated into the analysis. Notions of the functions and rhetorics of play and playfulness (Sutton-Smith 1997) form a central thread that runs throughout the thesis, where play is both a feature of children’s cultural worlds and a site of resistance or ‘thinking otherwise’. The study seeks to examine how children actively participate in (re)producing definitions of both childhood and race arising in local, national and global spaces, demonstrating that while contestations of the boundaries of childhood discourses are contingently successful, race tends to be strongly reiterated, clinging to bodies and places and compromising belonging. In addition, it explores how children access belongings through agentic and imaginative practices with regard to peer and family relationships, particularly highlighting constructions of home, while also illustrating practices of excluding children positioned as unintelligible, including the role of silences in such situations. Finally, drawing on teachers’ understandings and on children’s playful micro-level negotiations of race, the study argues that assumptions of childhood innocence contribute to justifying depoliticised discourses of race in the early primary school years, and also tend to silence children’s own dialogues with this issue. Central throughout the thesis is an emphasis on the productive potentials of children’s marginal positioning in processes of transgressing definitional boundaries, including the generation of post-race conceptualisations that revealed the borders of race as performative and fluid. It suggests that interrupting exclusionary raced identities in Irish primary schools requires engagement with children’s world-making practices and the multiple resources that inform their lives.

An EORTC phase I study of epirubicin in combination with fixed doses of cyclophosphamide and infusional 5-fu (CEF-infu) as primary treatment of large operable or locally advanced/inflammatory breast cancer.

PURPOSE: The association of continuous infusion 5-fluorouracil, epirubicin (50 mg/m2 q 3 weeks) and a platinum compound (cisplatin or carboplatin) was found to be very active in patients with either locally advanced/inflammatory (LA/I) [1, 2] or large operable (LO) breast cancer (BC) [3]. The same rate of activity in terms of response rate (RR) and response duration was observed in LA/I BC patients when cisplatin was replaced by cyclophosphamide [4]. The dose of epirubicin was either 50 mg/m2 [ 1, 2, 3] or 60 mg/m2/cycle [4]. The main objective of this study was to determine the maximum tolerated dose (MTD) of epirubicin when given in combination with fixed doses of cyclophosphamide and infusional 5-fluorouracil (CEF-infu) as neoadjuvant therapy in patients with LO or LA/I BC for a maximum of 6 cycles. PATIENTS AND METHODS: Eligible patients had LO or LA/I BC, a performance status 0-1, adequate organ function and were <65 years old. Cyclophosphamide was administered at the dose of 400 mg/m2 day 1 and 8, q 4 weeks and infusional 5-fluorouracil 200 mg/m2/day was given day 1-28, q 4 weeks. Epirubicin was escalated from 30 to 45 and to 60 mg/m2 day 1 and 8; dose escalation was permitted if 0/3 or 1/6 patients experienced dose limiting toxicity (DLT) during the first 2 cycles of therapy. DLT for epirubicin was defined as febrile neutropenia, grade 4 neutropenia lasting for >7 days, grade 4 thrombocytopenia, or any non-haematological toxicity of CTC grade > or =3, excluding alopecia and plantar-palmar erythrodysesthesia (this toxicity was attributable to infusional 5-fluorouracil and was not considered a DLT of epirubicin). RESULTS: A total of 21 patients, median age 44 years (range 29-63) have been treated. 107 courses have been delivered, with a median number of 5 cycles per patient (range 4-6). DLTs on cycles I and 2 on level 1, 2, 3: grade 3 (G3) mucositis occurred in 1/10 patients treated at the third dose level. An interim analysis showed that G3 PPE occurred in 5/16 pts treated with the 28-day infusional 5-FU schedule at the 3 dose levels. The protocol was subsequently amended to limit the duration of infusional 5-fluorouracil infusion from 4 to 3 weeks. No G3 PPE was detected in 5 patients treated with this new schedule. CONCLUSIONS: This study establishes that epirubicin 60mg/m2 day 1 and 8, cyclophosphamide 400mg/m2 day 1 and 8 and infusional 5-fluorouracil 200 mg/m2/day day 1-21. q 4 weeks is the recommended dose level. Given the encouraging activity of this regimen (15/21 clinical responses) we have replaced infusional 5-fluorouracil by oral capecitabine in a recently activated study.

Caring for Alaska Native prostate cancer survivors in primary care: a survey of Alaska Tribal Health System providers.

BACKGROUND: Little is known about the constraints of optimizing health care for prostate cancer survivors in Alaska primary care. OBJECTIVE: To describe the experiences and attitudes of primary care providers within the Alaska Tribal Health System (ATHS) regarding the care of prostate cancer survivors. DESIGN: In late October 2011, we emailed a 22-item electronic survey to 268 ATHS primary care providers regarding the frequency of Prostate Specific Antigen (PSA) monitoring for a hypothetical prostate cancer survivor; who should be responsible for the patient's life-long prostate cancer surveillance; who should support the patient's emotional and medical needs as a survivor; and providers' level of comfort addressing recurrence monitoring, erectile dysfunction, urinary incontinence, androgen deprivation therapy, and emotional needs. We used simple logistic regression to examine the association between provider characteristics and their responses to the survivorship survey items. RESULTS: Of 221 individuals who were successfully contacted, a total of 114 responded (52% response rate). Most ATHS providers indicated they would order a PSA test every 12 months (69%) and believed that, ideally, the hypothetical patient's primary care provider should be responsible for his life-long prostate cancer surveillance (60%). Most providers reported feeling either "moderately" or "very" comfortable addressing topics such as prostate cancer recurrence (59%), erectile dysfunction (64%), urinary incontinence (63%), and emotional needs (61%) with prostate cancer survivors. These results varied somewhat by provider characteristics including female sex, years in practice, and the number of prostate cancer survivors seen in their practice. CONCLUSIONS: These data suggest that most primary care providers in Alaska are poised to assume the care of prostate cancer survivors locally. However, we also found that large minorities of providers do not feel confident in their ability to manage common issues in prostate cancer survivorship, implying that continued access to specialists with more expert knowledge would be beneficial.

Humoral and B-cell memory responses in children five years after pertussis acellular vaccine priming.

The resurgence of pertussis suggests the need for greater efforts in understanding the long-lasting protective responses induced by vaccination. In this paper we dissect the persistence of humoral and B-cell memory responses induced by primary vaccination with two different acellular pertussis (aP) vaccines, hexavalent Hexavac(®) vaccine (Hexavac) (Sanofi Pasteur MSD) and Infanrix hexa(®) (Infanrix) (GlaxoSmithKline Biologicals). We evaluated the specific immune responses in the two groups of children, 5 years after primary vaccination by measuring the persistence of IgG and antibody secreting cells (ASC) specific for vaccine antigens. Part of the enrolled children received only primary vaccination, while others had the pre-school boost dose. A similar level of antigen-specific IgG and ASC was found in Infanrix and Hexavac vaccinated children. The mean IgG levels were significantly higher in children that received the pre-school boost as compared with children that did not receive the boost dose. A longer persistence after the pre-school boost of IgG-Pertussis Toxin (PT) and IgG-pertactin levels was observed in Infanrix primed children, but it was not statistically significant. More than 80% of children presented a positive ASC B memory response. Around 50% of children still presented protective IgG-PT levels which are reduced to 36% in no-boosted children. The pre-school booster dose restores the percentage of protected children above 50%. In conclusion our data underline the importance of giving a booster dose 5 years after primary vaccination and suggest the need for a new vaccine able to induce a long lasting protective response.

Primary Production In A Turbid Estuary

The primary production in the Bristol Channel, U.K., was studied from 1973 to 1977: in this estuary, the euphotic zone extends from less than 0.5 m to greater than 10m and there is a large riverine input of inorganic nutrients. The standing stock of phytoplankton chlorophyll a was measured in 1973 and 1974 and was similar throughout the Bristol Channel but the rate of primary production was much greater where the water was less turbid. The estimated primary production was 6.8g C m−2 for the most turbid region and 164.9g C m−2 for the Outer Bristol Channel. A larger proportion of the annual primary production occurred in the spring in the Outer Channel than in the most turbid regions. Phaeocystis developed into blooms in some, but not all, years and exhibited a different light saturation curve to other phytoplankton populations. Serial incubations of short duration gave higher fixation rates than day-long incubations and it is argued that photoinhibition is probably insignificant in a mixed water column. Excretion rates of dissolved organic carbon by phytoplankton were always low.

Coccolithophore surface distributions in the North Atlantic and their modulation of the air-sea flux of CO2 from 10 years of satellite Earth observation data

Coccolithophores are the primary oceanic phytoplankton responsible for the production of calcium carbonate (CaCO3). These climatically important plankton play a key role in the oceanic carbon cycle as a major contributor of carbon to the open ocean carbonate pump (similar to 50 %) and their calcification can affect the atmosphere-to-ocean (air-sea) uptake of carbon dioxide (CO2) through increasing the seawater partial pressure of CO2 (pCO(2)). Here we document variations in the areal extent of surface blooms of the globally important coccolithophore, Emiliania huxleyi, in the North Atlantic over a 10-year period (1998-2007), using Earth observation data from the Sea-viewing Wide Field-of-view Sensor (SeaWiFS). We calculate the annual mean sea surface areal coverage of E. huxleyi in the North Atlantic to be 474 000 +/- 104 000 km(2), which results in a net CaCO3 carbon (CaCO3-C) production of 0.14-1.71 Tg CaCO3-C per year. However, this surface coverage (and, thus, net production) can fluctuate inter-annually by -54/+81% about the mean value and is strongly correlated with the El Nino/Southern Oscillation (ENSO) climate oscillation index (r = 0.75, p < 0.02). Our analysis evaluates the spatial extent over which the E. huxleyi blooms in the North Atlantic can increase the pCO(2) and, thus, decrease the localised air-sea flux of atmospheric CO2. In regions where the blooms are prevalent, the average reduction in the monthly air-sea CO2 flux can reach 55%. The maximum reduction of the monthly air-sea CO2 flux in the time series is 155 %. This work suggests that the high variability, frequency and distribution of these calcifying plankton and their impact on pCO(2) should be considered if we are to fully understand the variability of the North Atlantic air-to-sea flux of CO2. We estimate that these blooms can reduce the annual N. Atlantic net sink atmospheric CO2 by between 3-28 %.

Coccolithophore surface distributions in the North Atlantic and their modulation of the air-sea flux of CO2 from 10 years of satellite Earth observation data

Coccolithophores are the primary oceanic phytoplankton responsible for the production of calcium carbonate (CaCO3). These climatically important plankton play a key role in the oceanic carbon cycle as a major contributor of carbon to the open ocean 5 carbonate pump (�50%) and their formation can affect the atmosphere-to-ocean (airsea) uptake of carbon dioxide (CO2) through increasing the seawater partial pressure of CO2 (pCO2). Here we document variations in the areal extent of surface blooms of the globally important coccolithophore, Emiliania huxleyi, in the North Atlantic over a 10-year period (1998–2007), using Earth observation data from the Sea-viewing Wide 10 Field of view Sensor (SeaWiFS).We calculate the annual mean surface areal coverage of E. huxleyi in the North Atlantic to be 474 000±119 000km2 yr−1, which results in a net CaCO3 production of 0.62±0.15 Tg CaCO3 carbon per year. However, this surface coverage and net production can fluctuate by −54/+81% about these mean values and are strongly correlated with the El Ni˜no/Southern Oscillation (ENSO) climate os15 cillation index (r =0.75, p<0.02). Our analysis evaluates the spatial extent over which the E. huxleyi blooms in the North Atlantic can increase the pCO2 and thus decrease the localised sink of atmospheric CO2. In regions where the blooms are prevalent, the average reduction in the monthly CO2 sink can reach 12 %. The maximum reduction of the monthly CO2 sink in the time series is 32 %. This work suggests that the high 20 variability, frequency and distribution of these calcifying plankton and their impact on pCO2 should be considered within modelling studies of the North Atlantic if we are to fully understand the variability of its air-to-sea CO2 flux.

Going Global: planning the next 80 years of the Continuous Plankton Recorder Survey

Going Global: planning the next 80 years of the Continuous Plankton Recorder Survey. Operated by the Sir Alister Hardy Foundation for Ocean Science (SAHFOS), the Continuous Plankton Recorder (CPR) survey is the world’s largest, sampling 4 ocean basins, and longest running (since 1931) plankton biodiversity monitoring programme. Having sampled enough miles to circumnavigate the globe over 200 times, the CPR database houses over 2.5 million entries, describing the distribution of 500 phytoplankton and zooplankton taxa. Routinely sampling in the Arctic, Atlantic, Pacific and Southern Oceans, the survey analyses 4000 samples yearly. Data collected from these samples are made freely available for bona fide scientific purposes. The CPR survey data is used to generate a better understanding of changes in the plankton and to date some 1000 papers have been published on plankton biodiversity. This year sees the 80th anniversary of the CPR survey and to celebrate and build upon this unique monitoring programme, SAHFOS intends to further develop its global plankton perspective. Work will be extended into the South Atlantic and Indian Ocean and an international partnership with complementary surveys in Australia, Canada, America, Japan and South Africa will be implemented. The Digital Object will describe the CPR survey using compilations made by Plymouth Art College and BBC film footage.

Enhancement of primary production in the North Atlantic outside of the spring bloom, identified by remote sensing of ocean colour and temperature

The heterogeneity in phytoplankton production in the North Atlantic after the spring bloom is poorly understood. We analysed merged microwave and infrared satellite sea surface temperature (SST) data and ocean colour phytoplankton size class biomass, primary production (PP) and new production (ExP) derived from SeaWiFS data, to assess the spatial and temporal frequency of surface thermal fronts and areas of enhanced PP and ExP. Strong and persistent surface thermal fronts occurred at the Reykjanes Ridge (RR) and sub-polar front (SPF), which sustain high PP and ExP and, outside of the spring bloom, account for 9% and 15% of the total production in the North Atlantic. When normalised by area, PP at the SPF is four times higher than the RR. Analysis of 13 years of satellite ocean colour data from SeaWiFS, and compared with MODIS-Aqua and MERIS, showed that there was no increase in Chla from 1998 to 2002, which then decreased in all areas from 2002 to 2007 and was most pronounced in the RR. These time series also illustrated that the SPF exhibited the highest PP and the lowest variation in Chla over the ocean colour record. This implies that the SPF provides a high and consistent supply of carbon to the benthos irrespective of fluctuations in the North Atlantic Oscillation.

20 Years of the Atlantic Meridional Transect — AMT

The AMT (www.amt-uk.org) is a multidisciplinary programme which undertakes biological, chemical, and physical oceanographic research during an annual voyage between the UK and a destination in the South Atlantic such as the Falkland Islands,South Africa, or Chile. This transect of >12,000 km crosses a range of ecosystems from subpolar to tropical, from euphotic shelf seas and upwelling systems, to oligotrophic mid-ocean gyres. The year 2015 has seen two milestones in the history of the AMT: the achievement of 20 years of this unique ocean going programme and the departure of the 25th cruise on the 15th of September. Both of these events were celebrated in June this year with an open science conference hosted by the Plymouth Marine Laboratory (PML) and will be further documented in a special issue of Progress in Oceanography which is planned for publication in 2016. Since 1995, the 25 research cruises have involved 242 sea-going scientists from 66 institutes representing 22 countries.

The Masculine Habitus as 'Distributed Cognition': A Case Study of 5- to 6-Year-Old Boys in an English Inner-City, Multi-Ethnic Primary School

This article provides a case study demonstrating the active role that 5- to 6-year-old boys in an English inner-city, multi-ethnic primary school play in the appropriation and reproduction of their masculine identities. It is argued that the emphasis on physicality, violence and racism found among the boys cannot be understood without reference to the immediate contexts of the local community and the school within which they are located. In making this argument the article draws upon and applies the concept of the habitus and develops this with the notion of 'distributed cognition' as proposed in sociocultural theory. Some of the implications of this analysis for working with boys in early years settings are discussed in the conclusion.

Qutting and restarting smoking: cohort study of patients with angina in primary care

Objective To examine variations in self-reported smoking habit among a cohort of individuals with chronic coronary heart disease over a five year period. Design Cross-sectional cohort; interviews at baseline, 2 years and 5 years. Setting Primary care. Participants A cross-sectional sample of 688 patients previously diagnosed as having angina, identified from 18 general practices in the Greater Belfast Area; a cohort of 487 were followed for five years. Outcome measures Changes in self-reported smoking habits; breath carbon monoxide measurement. Results Initially 92 of the 487 participants (19%) reported smoking, 34 (27%) subsequently reported non-smoking. Of the 395 self-reported non-smokers at baseline, 21 (5%) subsequently reported smoking. The prevalence of self-reported smoking amongst the cohort was 19% and 15% at two and five years respectively. However, changes in reported smoking habits indicating periods of abstinence and resumption were reported by 55/487 (11%) participants. Of the 21 non-smokers who changed their report, 20 had smoked previously, five reported having stopped for less than one year but nine for more than five years. Of the initial sample twice as many smokers as non-smokers had died by 2 years (10% v 5%; p

The SPHERE Study: Secondary prevention of heart disease in general practice: protocol of a randomised controlled trial of tailored practice and patient care plans with parallel qualitative, economic and policy analyses. [ISRCTN24081411]

Background: The aim of the SPHERE study is to design, implement and evaluate tailored practice and personal care plans to improve the process of care and objective clinical outcomes for patients with established coronary heart disease (CHD) in general practice across two different health systems on the island of Ireland.CHD is a common cause of death and a significant cause of morbidity in Ireland. Secondary prevention has been recommended as a key strategy for reducing levels of CHD mortality and general practice has been highlighted as an ideal setting for secondary prevention initiatives. Current indications suggest that there is considerable room for improvement in the provision of secondary prevention for patients with established heart disease on the island of Ireland. The review literature recommends structured programmes with continued support and follow-up of patients; the provision of training, tailored to practice needs of access to evidence of effectiveness of secondary prevention; structured recall programmes that also take account of individual practice needs; and patient-centred consultations accompanied by attention to disease management guidelines.

Methods: SPHERE is a cluster randomised controlled trial, with practice-level randomisation to intervention and control groups, recruiting 960 patients from 48 practices in three study centres (Belfast, Dublin and Galway). Primary outcomes are blood pressure, total cholesterol, physical and mental health status (SF-12) and hospital re-admissions. The intervention takes place over two years and data is collected at baseline, one-year and two-year follow-up. Data is obtained from medical charts, consultations with practitioners, and patient postal questionnaires. The SPHERE intervention involves the implementation of a structured systematic programme of care for patients with CHD attending general practice. It is a multi-faceted intervention that has been developed to respond to barriers and solutions to optimal secondary prevention identified in preliminary qualitative research with practitioners and patients. General practitioners and practice nurses attend training sessions in facilitating behaviour change and medication prescribing guidelines for secondary prevention of CHD. Patients are invited to attend regular four-monthly consultations over two years, during which targets and goals for secondary prevention are set and reviewed. The analysis will be strengthened by economic, policy and qualitative components.