Using realist review to inform intervention development: methodological illustration and conceptual platform for collaborative care in offender mental health

BACKGROUND

This paper reports how we used a realist review, as part of a wider project to improve collaborative mental health care for prisoners with common mental health problems, to develop a conceptual platform. The importance of offenders gaining support for their mental health, and the need for practitioners across the health service, the criminal justice system, and the third sector to work together to achieve this is recognised internationally. However, the literature does not provide coherent analyses of how these ambitions can be achieved. This paper demonstrates how a realist review can be applied to inform complex intervention development that spans different locations, organisations, professions, and care sectors.

METHODS

We applied and developed a realist review for the purposes of intervention development, using a three-stage process. (1) An iterative database search strategy (extending beyond criminal justice and offender health) and groups of academics, practitioners, and people with lived experience were used to identify explanatory accounts (n = 347). (2) From these accounts, we developed consolidated explanatory accounts (n = 75). (3) The identified interactions between practitioners and offenders (within their organisational, social, and cultural contexts) were specified in a conceptual platform. We also specify, step by step, how these explanatory accounts were documented, consolidated, and built into a conceptual platform. This addresses an important methodological gap for social scientists and intervention developers about how to develop and articulate programme and implementation theory underpinning complex interventions.

RESULTS

An integrated person-centred system is proposed to improve collaborative mental health care for offenders with common mental health problems (near to and after release) by achieving consistency between the goals of different sectors and practitioners, enabling practitioners to apply scientific and experiential knowledge in working judiciously and reflectively, and building systems and aligning resources that are centred on offenders' health and social care needs.

CONCLUSIONS

As part of a broader programme of work, a realist review can make an important contribution to the specification of theoretically informed interventions that have the potential to improve health outcomes. Our conceptual platform has potential application in related systems of health and social care where integrated, and person-centred care is a goal.

Peak systolic to end diastolic flow velocity ratio is associated with ductal patency in infants below 32 weeks of gestation

BACKGROUND

Early diagnosis and effective treatment of the patent ductus arteriosus (PDA) in infants less than 32 weeks gestation remains contentious.

OBJECTIVE

To determine which clinical and echocardiographic parameters are associated with PDA patency in preterm infants less than 32 weeks gestation.

DESIGN/METHODS

This was a prospective cohort study. An echocardiography (echo) was performed within 12-48 h of birth and a follow-up echo at 1 month of life. Parental consent was obtained.

RESULTS

55 babies were enrolled. Median (range) gestation was 28 (24-31) weeks and birth weight 1090 g (470-1800 g). ECHO 1 demonstrated that 50 babies had a PDA present within 48 h of birth, of which 19 were large (≥2 mm) (36%) and 31 were small (59%) on colour Doppler assessment of duct diameter. Three babies died before 1 month. At 1 month 30 babies still had a PDA (58%), 10 of which were large (19%) and 19 were small (36%). Parameters significantly associated with large PDAs versus no PDA at 1 month were gestational age (26 weeks vs 30 weeks, p=0.002), birth weight (860 g vs 1290 g, p=0.007) and ventilator support at 48 h (80% vs 17%, p=0.001). Echo parameters revealed that ductal size on colour Doppler (2.5 mm vs 1.5 mm, p=0.003), end diastolic flow velocity (57 m/s vs 147 m/s, p<0.001) and peak systolic to end diastolic flow velocity ratio (2.29 vs 1.23, p=0.001) at 48 h were associated with large PDAs at 1 month.

CONCLUSIONS

For infants less than 32 weeks gestation a peak systolic to end diastolic flow velocity ratio>2 within 48 h of birth is associated with a persistent large PDA at 1 month of age.

Precise test of internal-conversion theory: transitions measured in five nuclei spanning 50≤Z≤78

In a research program aimed at testing calculated internal-conversion coefficients (ICCs), we have made precise measurements of αK values for transitions in five nuclei, (197)Pt, (193)Ir, (137)Ba, (134)Cs and (119)Sn, which span a wide range of A and Z values. In all cases, the results strongly favor calculations in which the final-state electron wave function has been computed using a potential that includes the atomic vacancy created by the internal-conversion process.

PAH particles perturb prenatal processes and phenotypes: protection from deficits in object discrimination afforded by dampening of brain oxidoreductase following in utero exposure to inhaled benzo(a)pyrene

The wild-type (WT) Cpr(lox/lox) (cytochrome P(450) oxidoreductase, Cpr) mouse is an ideal model to assess the contribution of P(450) enzymes to the metabolic activation and disposition of environmental xenobiotics. In the present study, we examined the effect of in utero exposure to benzo(a)pyrene [B(a)P] aerosol on Sp4 and N-methyl-D-aspartate (NMDA)-dependent systems as well as a resulting behavioral phenotype (object discrimination) in Cpr offspring. Results from in utero exposure of WT Cpr(lox/lox) mice were compared with in utero exposed brain-Cpr-null offspring mice. Null mice were used as they do not express brain cytochrome P(450)1B1-associated NADPH oxidoreductase (CYP1B1-associated NADPH oxidoreductase), thus reducing their capacity to produce neural B(a)P metabolites. Subsequent to in utero (E14-E17) exposure to B(a)P (100 μg/m(3)), Cpr(lox/lox) offspring exhibited: (1) elevated B(a)P metabolite and F(2)-isoprostane neocortical tissue burdens, (2) elevated concentrations of cortical glutamate, (3) premature developmental expression of Sp4, (4) decreased subunit ratios of NR2B:NR2A, and (5) deficits in a novelty discrimination phenotype monitored to in utero exposed brain-Cpr-null offspring. Collectively, these findings suggest that in situ generation of metabolites by CYP1B1-associated NADPH oxidoreductase promotes negative effects on NMDA-mediated signaling processes during the period when synapses are first forming as well as effects on a subsequent behavioral phenotype.

Prenatal polycyclic aromatic hydrocarbon exposure leads to behavioral deficits and downregulation of receptor tyrosine kinase, MET

Gene by environment interactions (G × E) are thought to underlie neurodevelopmental disorder, etiology, neurodegenerative disorders, including the multiple forms of autism spectrum disorder. However, there is limited biological information, indicating an interaction between specific genes and environmental components. The present study focuses on a major component of airborne pollutants, polycyclic aromatic hydrocarbons (PAHs), such as benzo(a)pyrene [B(a)P], which negatively impacts cognitive development in children who have been exposed in utero. In our study, prenatal exposure of Cpr(lox/lox) timed-pregnant dams to B(a)P (0, 150, 300, and 600 μg/kg body weight via oral gavage) on embryonic day (E14-E17) consistent with our susceptibility-exposure paradigm was combined with the analysis of a replicated autism risk gene, the receptor tyrosine kinase, Met. The results demonstrate a dose-dependent increase in B(a)P metabolite generation in B(a)P-exposed Cpr(lox/lox) offspring. Additionally, a sustained persistence of hydroxy metabolites during the onset of synapse formation was noted, corresponding to the peak of Met expression. Prenatal B(a)P exposure also downregulated Met RNA and protein levels and dysregulated normal temporal patterns of expression during synaptogenesis. Consistent with these data, transcriptional cell-based assays demonstrated that B(a)P exposure directly reduces human MET promoter activity. Furthermore, a functional readout of in utero B(a)P exposure showed a robust reduction in novel object discrimination in B(a)P-exposed Cpr(lox/lox) offspring. These results confirm the notion that common pollutants, such as the PAH B(a)P, can have a direct negative impact on the regulated developmental expression of an autism risk gene with associated negative behavioral learning and memory outcomes.