Objective To evaluate the effectiveness and costs of a multifaceted flexible educational programme aimed at reducing antibiotic dispensing at the practice level in primary care.Design Randomised controlled trial with general practices as the unit of randomisation and analysis. Clinicians and researchers were blinded to group allocation until after randomisation.Setting 68 general practices with about 480 000 patients in Wales, United Kingdom.Participants 34 practices were randomised to receive the educational programme and 34 practices to be controls. 139 clinicians from the intervention practices and 124 from control practices had agreed to participate before randomisation. Practice level data covering all the clinicians in the 68 practices were analysed.Interventions Intervention practices followed the Stemming the Tide of Antibiotic Resistance (STAR) educational programme, which included a practice based seminar reflecting on the practices’ own dispensing and resistance data, online educational elements, and practising consulting skills in routine care. Control practices provided usual care.Main outcome measures Total numbers of oral antibiotic items dispensed for all causes per 1000 practice patients in the year after the intervention, adjusted for the previous year’s dispensing. Secondary outcomes included reconsultations, admissions to hospital for selected causes, and costs.Results The rate of oral antibiotic dispensing (items per 1000 registered patients) decreased by 14.1 in the intervention group but increased by 12.1 in the control group, a net difference of 26.1. After adjustment for baseline dispensing rate, this amounted to a 4.2% (95% confidence interval 0.6% to 7.7%) reduction in total oral antibiotic dispensing for the year in the intervention group relative to the control group (P=0.02). Reductions were found for all classes of antibiotics other than penicillinase-resistant penicillins but were largest and significant individually for phenoxymethylpenicillins (penicillin V) (7.3%, 0.4% to 13.7%) and macrolides (7.7%, 1.1% to 13.8%). There were no significant differences between intervention and control practices in the number of admissions to hospital or in reconsultations for a respiratory tract infection within seven days of an index consultation. The mean cost of the programme was £2923 (€3491, $4572) per practice (SD £1187). There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared with the control group (−0.4% to 11.4%), equivalent to a reduction of about £830 a year for an average intervention practice.Conclusion The STAR educational programme led to reductions in all cause oral antibiotic dispensing over the subsequent year with no significant change in admissions to hospital, reconsultations, or costs.Trial registration ISRCT No 63355948.

ObjectivesTo examine the prevalence of electronic(e)-cigarette use, prevalence of e-cigarette and tobacco use by age, and associations of e-cigarette use with sociodemographic characteristics, tobacco and cannabis use among young people in Wales.DesignData from two nationally-representative cross-sectional surveys undertaken in 2013–2014. Logistic regression analyses, adjusting for school-level clustering, examined sociodemographic characteristics of e-cigarette use, and associations between e-cigarette use and smoking.SettingPrimary and secondary schools in Wales.ParticipantsPrimary-school children aged 10–11 (n=1601) and secondary-school students aged 11–16 (n=9055).ResultsPrimary-school children were more likely to have used e-cigarettes (5.8%) than tobacco (1.6%). Ever use of e-cigarettes remained more prevalent than ever use of tobacco until age 14–15. Overall, 12.3% of secondary-school students (aged 11–16) reported ever using e-cigarettes, with no differences according to gender, ethnicity or family affluence. The percentage of ‘never smokers’ reporting having used e-cigarettes was 5.3% at age 10–11 to 8.0% at age 15–16. The proportion of children who had ever used an e-cigarette and reported currently smoking increased from 6.9% among 10–11 year olds to 39.2% in 15–16 year olds. Only 1.5% (n=125) of 11–16 year-olds, including 0.3% of never smokers, reported regular e-cigarette use (use at least once a month). Current weekly smokers were 100 times more likely than non-smokers to report regular e-cigarette use (relative risk ratio (RRR=121.15; 95% CI 57.56 to 254.97). Regular e-cigarette use was also more likely among those who had smoked cannabis (RRR 53.03; 95% CI 38.87 to 80.65).ConclusionsMany young people (including never-smokers) have tried e-cigarettes. However, regular use is less common, and is associated with tobacco cigarette use. Longitudinal research is needed to understand age-related trajectories of e-cigarette use and to understand the temporal nature of relationships between e-cigarette and tobacco use.

Background Little is known about how breastfeeding rates are affected by drugs routinely administered in labour.Objective To examine a large obstetric data set to investigate potentially modifiable associations between drugs routinely administered in labour and breastfeeding in healthy women and infants.Design Retrospective cohort.Setting The Cardiff (Wales UK) Births Survey.Population A total of 48 366 healthy women delivering healthy singleton babies at term.Methods Analysis of the Cardiff Births Survey.Main outcome measure Association between intrapartum medications and breastfeeding at 48 hours postpartum.Results At 48 hours, 43.3% (20 933/48 366) women were not breastfeeding. Regression analysis confirmed previously reported associations of lower breastfeeding rates with certain demographic indicators, epidural analgesia, intramuscular opioid analgesia and ergometrine. Novel associations were detected with oxytocin alone or in combination with ergometrine administered for prevention of postpartum haemorrhage (PPH), which were associated with reductions of 6-8%, (intramuscular oxytocin OR 0.75, 95% CI 0.61-0.91, intravenous oxytocin OR 0.68, 95% CI 0.57-0.82, oxytocin/ergometrine OR 0.77, 95% CI 0.65-0.91), and prostaglandins administered for induction of labour. The associations were maintained when subgroups, such as primiparous women, women whose labours were neither induced nor augmented, and women not receiving epidural analgesia were considered.Conclusion Prospective studies on drugs in labour are needed to investigate potential causative associations between intrapartum medications and breastfeeding. Such studies will delineate the optimum balance between breastfeeding and maternal health, most importantly the risk of PPH.

BackgroundThe Stemming the Tide of Antibiotic Resistance (STAR) Educational Program aims to enhance the quality of antibiotic prescribing and raise awareness about antibiotic resistance among general medical practitioners. It consists of a seven part, theory-based blended learning program that includes online reflection on clinicians' own practice, presentation of research evidence and guidelines, a practice-based seminar focusing on participants' own antibiotic prescribing and resistance rates in urine samples sent from their practice, communication skills training using videos of simulated patients in routine surgeries, and participation in a web forum. Effectiveness was evaluated in a randomised controlled trial in which 244 GPs and Nurse Practitioners and 68 general practices participated. This paper reports part of the process evaluation of that trial.MethodsSemi-structured, digitally recorded, and transcribed telephone interviews with 31 purposively sampled trial participants analysed using thematic content analysis.ResultsThe majority of participants reported increased awareness of antibiotic resistance, greater self-confidence in reducing antibiotic prescribing and at least some change in consultation style and antibiotic prescribing behaviour. Reported practical changes included adopting a practice-wide policy of antibiotic prescription reduction. Many GPs also reported increased insight into patients' expectations, ultimately contributing to improved doctor-patient rapport. The components of the intervention put forward as having the greatest influence on changing clinician behaviour were the up-to-date research evidence resources, simple and effective communication skills presented in on-line videos, and presentation of the practice's own antibiotic prescribing levels combined with an overview of local resistance data.ConclusionParticipants regarded this complex blended learning intervention acceptable and feasible, and reported wide-ranging, positive changes in attitudes and clinical practice as a result of participating in the STAR Educational Program.Trial registrationCurrent Controlled Trials ISRCTN63355948

Delivering better care to whole populations across organisational and professional boundaries required sustained work over long periods, and at all levels of the system of care. Past network focus on clinical collaboration has been effective at improving clinical process and outcome, and the network is now prioritising work with managers and patients to support future redesign.

A simple method for analyzing cylindrical Langmuir probe curves in a cold-ion plasma is described which yields the ion density in weakly collisional plasmas for which purely collisionless theories give erroneous results. The method is based on an extrapolation to the floating potential of the saturation ion current raised to the 4/3 power. This procedure is not supported by theory but apparently works because effects neglected in the theory tend to cancel.

Abstract. Operation of helicon discharges at magnetic fields B 0 below 100 G is of interest for plasma etching and deposition reactors if high ion flux can be maintained with reduced field requirements. The theory of coupled helicon and Trivelpiece-Gould modes is summarized for uniform B 0 . Initial results from two experiments are reported. The first has a single 5 cm diameter tube with B 0 = 0-100 G injecting plasma into a field-free region. The second contains a two-dimensional array of seven such tubes covering a large area. Densities and density profiles are measured for various fields, RF powers and gas pressures. The highest density generally occurs at zero field. Because of the non-uniformity in B 0 , direct comparison with theory cannot yet be made.

The use of Langmuir probes for measuring plasma density is subject to uncertainty because the theories commonly used to interpret the data give widely differing results. This is especially troublesome in partially ionized plasmas used, for instance, in the semiconductor industry, since no existing theory adequately treats the case when there are a few collisions between ions and neutral atoms. In this work, plasma densities measured by microwave interferometry and plasma-oscillation probes are compared with those from probe data analyzed with Langmuir's orbital motion limited (OML) theory, the Allen-Boyd-Reynolds (ABR) theory and the Bernstein-Rabinowitz-Laframboise (BRL) theory. It is found that ABR underestimates and BRL overestimates the density, the problems being the neglect of ion orbiting in ABR and the effect of ion-neutral collisions in BRL. The best theory is either OML or the geometric mean between the ABR and BRL results. For thicker probes, other methods are suggested.