Prevention validation and accounting platform: a framework for establishing accountability and performance measures of substance abuse prevention programs

The field of substance abuse prevention has neither an overarching conceptual framework nor a set of shared terminologies for establishing the accountability and performance outcome measures of substance abuse prevention services rendered. Hence, there is a wide gap between what we currently have as data on one hand and information that are required to meet the performance goals and accountability measures set by the Government Performance and Results Act of 1993 on the other. The task before us is: How can we establish the accountability and performance measures of substance abuse prevention programs and transform the field of prevention into prevention science? The intent of this volume is to serve that purpose and accelerate the processes of this transformation by identifying the requisite components of the transformation (i.e., theory, methodology, convention on terms, and data) and by introducing an open forum called, Prevention Validation and Accounting (PREVA) Platform. The entire PREVA Platform (for short, the Platform) is designed as an analytic framework, which is formulated by a collectivity of common concepts, terminologies, accounting units, protocols for counting the units, data elements, and operationalizations of various constructs, and other summary measures intended to bring about an efficient and effective measurement of process input, program capacity, process output, performance outcome, and societal impact of substance abuse prevention programs. The measurement units and summary data elements are designed to be measured across time and across jurisdictions, i.e., from local to regional to state to national levels. In the Platform, the process input is captured by two dimensions of time and capital. Time is conceptualized in terms of service delivery time and time spent for research and development. Capital is measured by the monies expended for the delivery of program activities during a fiscal or reporting period. Program capacity is captured by fourteen measurement units, tapping into the dimensions of staff resources and community assets. Staff resources are, in turn, operationalized in terms of staff size, staff certification status, staff turnover rate, and the accreditation status of a provider agency. Community assets are operationalized by the number of community centers accessible to the funded agency, number of formalized teams or antidrug coalitions active in the catchment area, and other social/human services providers with whom the prevention agency has formalized networks. The totality of process output from all sources of program activities is reduced to eighteen classes of measures. These are operationalized by thirty-three summary measures. Some of these include: total count of events facilitated; total number of clients served; average number of clients served per event; clients served by single and multiple program sessions; classification of target population in terms of the severity of risk as defined by the Institute of Medicine; age groups and race/ethnicity of clients served; number of program participants retained by recurring programs; number of clients who have completed the program; penetration rates to the target population; client attrition rates; average referral rates per provider per time interval; referral success rates; and so on. All process output measures specified in the Platform are derived from two broad classes of events classified as either products or services. The collectivity of these measures is expected to present a cost-effective, parsimonious, yet comprehensive picture of the entire spectrum of the process output, i.e., "what came out of the program as program activities". For the measurement of performance outcomes, two types of data are incorporated into the Platform: outcome data from individuals and the behavior (or performance) of social indicators from aggregated data bases. Individual data are used to evaluate the outcome of substance abuse programs

Falling by the wayside: a phenomenological exploration of perceived breast-milk inadequacy in lactating women

OBJECTIVE

To provide insight into the lived experience of breast feeding, in primiparous women. The main focus was upon women's perceptions related to the adequacy of their breast milk, for the purpose of exclusively nourishing their babies.

DESIGN

A longitudinal, phenomenological study involving in-depth, interactive interviews, conducted at 6, 12 and 18 weeks following the birth of the women's babies.

PARTICIPANTS AND SETTING

A convenience sample of ten primiparous women were recruited prior to discharge from a maternity unit, in the north of England, in 1998.

FINDINGS

Two groups of participants emerged, three who became increasingly confident and empowered by breast feeding and the remaining seven whose confidence progressively diminished, with six of them expressing concern that their breast milk was inadequate. Four major themes related to the participants' perceptions emerged from the analysis: the quest to quantify and visualise breast milk; anxiety regarding the adequacy of their diet; breast feeding as a challenging journey, with most feeling that they had 'fallen by the wayside' (this related partly to inadequate and conflicting advice given by health professionals); and finally, unmet needs for support, nurturing and replenishment in return for 'giving out'.

CONCLUSION

Perceived breast-milk inadequacy is underpinned by a complex and synergistic interaction between socio-cultural influences, feeding management, the baby's behaviour, lactation physiology and the woman's psychological state.

IMPLICATIONS

Education of midwives and health visitors is required in relation to the needs of breast-feeding mothers within a Western industrialised society. Strong social policy is vital in the UK, to initiate socio-cultural changes, which would enable women who commence breast feeding to perceive it as an empowering and fulfilling experience and not one of 'falling by the wayside'.

Wound irrigation techniques: new Steripod normal saline

Wound cleansing is performed on a regular basis by many healthcare professionals. However, the modern concept of cleansing has not always been a priority in wound management. There are many questions which challenge those responsible for cleaning wounds such as how often a wound should be cleaned and which techniques should be used. This article begins with a brief guide to wound cleansing and then focuses on the new Steripod normal saline produced by SSL International.

Gender, adolescence and the management of diabetes

Health professionals view adolescence as a difficult time in which to manage diabetes. Adherence to treatment may be a problem, and there is also an expectation that young people should become independent in self-care. Drawing on data from a qualitative study which interviewed teenagers with diabetes and their mothers, this paper focuses on the ways in which gender and adolescence interact to affect how young people live with diabetes. Key themes explored include: the gendered meanings of diabetes; gendered management strategies; gendered dependencies; and adherence to treatment regimes. Gender was found to have a major impact on how young people managed diabetes. Gender also impacted on the involvement of mothers, with the mothers of sons much more likely to be involved in helping their sons than the mothers of daughters. In discussing some of the implications for health policy, it is suggested that in their ways of managing diabetes, young people should be seen as acting rationally within the confines of their gendered identities. Therefore, a uniform policy which promotes the independence of young people may not always be an appropriate way of working with young people or their families.

A high frequency of sequence alterations is due to formalin fixation of archival specimens

Genomic analysis of archival tissues fixed in formalin is of fundamental importance in biomedical research, and numerous studies have used such material. Although the possibility of polymerase chain reaction (PCR)-introduced artifacts is known, the use of direct sequencing has been thought to overcome such problems. Here we report the results from a controlled study, performed in parallel on frozen and formalin-fixed material, where a high frequency of nonreproducible sequence alterations was detected with the use of formalin-fixed tissues. Defined numbers of well-characterized tumor cells were amplified and analyzed by direct DNA sequencing. No nonreproducible sequence alterations were found in frozen tissues. In formalin-fixed material up to one mutation artifact per 500 bases was recorded. The chance of such artificial mutations in formalin-fixed material was inversely correlated with the number of cells used in the PCR-the fewer cells, the more artifacts. A total of 28 artificial mutations were recorded, of which 27 were C-T or G-A transitions. Through confirmational sequencing of independent amplification products artifacts can be distinguished from true mutations. However, because this problem was not acknowledged earlier, the presence of artifacts may have profoundly influenced previously reported mutations in formalin-fixed material, including those inserted into mutation databases.

Comparison of costing tools in paediatric intensive care

The cost of service provision is an issue of concern to all professionals working in health care. Department of Health reports have highlighted the need for more effective costing mechanisms for provision of paediatric intensive care (PIC). This study aimed to determine whether nurse-patient dependency scoring would be as effective as the Therapeutic Intervention Scoring System (TISS) at providing a differential costing tool for PIC. Data were collected on 251 patient admissions over 1,741 nursing shifts and analysis of variance undertaken. Findings suggest that a modified nurse-patient dependency score would be as good as TISS as a potential costing tool in PICU.

CACP, encoding a secreted proteoglycan, is mutated in camptodactyly-arthropathy-coxa vara-pericarditis syndrome

Altered growth and function of synoviocytes, the intimal cells which line joint cavities and tendon sheaths, occur in a number of skeletal diseases. Hyperplasia of synoviocytes is found in both rheumatoid arthritis and osteoarthritis, despite differences in the underlying aetiologies of the two disorders. We have studied the autosomal recessive disorder camptodactyly-arthropathy-coxa vara-pericarditis syndrome (CACP; MIM 208250) to identify biological pathways that lead to synoviocyte hyperplasia, the principal pathological feature of this syndrome. Using a positional-candidate approach, we identified mutations in a gene (CACP) encoding a secreted proteoglycan as the cause of CACP. The CACP protein, which has previously been identified as both 'megakaryocyte stimulating factor precursor' and 'superficial zone protein', contains domains that have homology to somatomedin B, heparin-binding proteins, mucins and haemopexins. In addition to expression in joint synovium and cartilage, CACP is expressed in non-skeletal tissues including liver and pericardium. The similarity of CACP sequence to that of other protein families and the expression of CACP in non-skeletal tissues suggest it may have diverse biological activities.

The influence of intermittent high-intensity shuttle running and fluid ingestion on the performance of a soccer skill

The aim of this study was to examine the effect of intermittent high-intensity shuttle running and fluid ingestion on the performance of a soccer skill. Nine semi-professional soccer players volunteered to participate in the study. Their mean (+/- s(x)) age, body mass and maximal oxygen uptake were 20.2+/-0.4 years, 73.2+/-1.8 kg and 59.1+/-1.3 ml x kg(-1) min(-1) respectively. The players were allocated to two randomly assigned trials: ingesting or abstaining from fluid intake during a 90 min intermittent exercise protocol (Loughborough Intermittent Shuttle Test: LIST). This test was designed to simulate the minimum physical demands faced by soccer players during a game. Before and immediately after performance of the test, the players completed a soccer skill test and a mental concentration test. Performance of the soccer skill test after the 'no-fluid' trial deteriorated by 5% (P<0.05), but was maintained during the fluid trial. Mean heart rate, perceived exertion, serum aldosterone, osmolality, sodium and cortisol responses during the test were higher (P<0.05) in the 'no-fluid' trial than in the fluid trial. The results of this study suggest that soccer players should consume fluid throughout a game to help prevent a deterioration in skill performance.

Variance in transneuronal retrograde ganglion cell degeneration in monkeys after removal of striate cortex: effects of size of the cortical lesion

The extent of transneuronal retrograde degeneration of ganglion cells in the primate retina depends on the age at which striate cortex was damaged, the survival time, the species, and retinal eccentricity. We here report on the effect of lesion size beyond striate cortex, which we assessed along with retinal ganglion cell degeneration in three groups of macaque monkeys who, in each group, had undergone striate cortical ablation at similar ages and survived for similar periods, which ranged from 302 days to 8 years. Where possible, the number of surviving projection neurones in the degenerated dLGN and its volume were also estimated. Results confirm that both geniculate and retinal degeneration correlate significantly with survival time but that the differences within a group can exceed differences between groups and are best accounted for by the extent of the damage to extra-striate visual cortex and underlying white matter.

Carbohydrate-electrolyte ingestion during intermittent high-intensity running

PURPOSE

The purpose of this study was to examine the effects of ingesting a carbohydrate-electrolyte beverage or a noncarbohydrate placebo on muscle glycogen utilization during 90 min of intermittent high-intensity running.

METHODS

Six trained games players (age 24.6 +/- 2.2 yr; height 179.6 +/- 1.9 cm; body mass 74.5 +/- 2.0 kg; VO2max 56.3 +/- 1.3 mL x kg(-1) x min(-1); mean +/- SEM) performed two exercise trials, 7 d apart. The subjects were university soccer, hockey, or rugby players. On each occasion, they completed six 15-min periods of intermittent running, consisting of maximal sprinting, interspersed with less intense periods of running and walking. During each trial, subjects consumed either a 6.9% carbohydrate-electrolyte solution (CHO-E: the CHO trial) or a noncarbohydrate placebo (the CON trial) immediately before exercise (5 mL x kg(-1) BM) and after every 15 min of exercise thereafter (2 mL x kg(-1) BM). Drinks were administered in a double-blind, counter-balanced order, and the total volume of fluid consumed during each trial was 1114 +/- 30 mL. Needle biopsy samples were obtained from the vastus lateralis muscle before and after 90 min of exercise. Venous blood samples were collected from an antecubital vein at rest and every 30 min during exercise.

RESULTS

Muscle glycogen utilization in mixed muscle samples was lower (P < 0.05) during CHO [192.5 +/- 26.3 mmol glucosyl units (kg x DM(-1))] than CON [245.3 +/- 22.9 mmol glucosyl units (kg x DM(-1))]. Single fiber analysis on the biopsy samples of the subjects during the CON trial showed a greater glycogen utilization in the Type II fibers compared with Type I fibers during this type of exercise [Type I: 182.2 +/- 34.5 vs Type II: 287.4 +/- 41.2 mmol glucosyl units (kg x DM(-1)); P < 0.05). After 30 min of exercise, blood lactate was significantly greater (P < 0.05) and serum insulin concentration lower (P < 0.05) in CON.

CONCLUSIONS

In summary, when trained games players ingested a carbohydrate-electrolyte beverage, muscle glycogen utilization was reduced by 22% when compared with a control condition.

Recurrent acute life-threatening events and lactic acidosis caused by chronic carbon monoxide poisoning in an infant

Acute severe carbon monoxide poisoning is usually easy to recognize and diagnose. However, chronic or less severe exposure may produce more subtle symptoms. We report on a 31/2-year-old girl who was admitted to the hospital several times with acute, life-threatening events, acidosis, and flu-like symptoms. The diagnosis was elusive, but after careful questioning of family members and a home visit, chronic carbon monoxide poisoning was diagnosed.

Dose escalation of chart in non-small cell lung cancer: is three-dimensional conformal radiation therapy really necessary?

PURPOSE

To evaluate, preclinically, the potential for dose escalation of continuous, hyperfractionated, accelerated radiation therapy (CHART) for non small-cell lung cancer (NSCLC), we examined the strategy of omission of elective nodal irradiation with and without the application of three-dimensional conformal radiation technology (3DCRT).

METHODS AND MATERIALS

2D, conventional therapy plans were designed according to the specifications of CHART for 18 patients with NSCLC (Stages Ib, IIb, IIIa, and IIIb). Further plans were generated with the omission of elective nodal irradiation (ENI) from the treatment portals (2D minus ENI plans [2D-ENI plans]). Both sets were inserted in the patient's planning computed tomographies (CTs). These reconstructed plans were then compared to alternative, three-dimensional treatment plans which had been generated de novo, with the omission of ENI: 3D minus elective nodal irradiation (3D-ENI plans). Dose delivery to the planning target volumes (PTVs) and to the organs at risk were compared between the 3 sets of corresponding plans. The potential for dose escalation of each patient's 2D-ENI and 3D-ENI plan beyond 54 Gy, standard to CHART, was also determined.

RESULTS

PTV coverage was suboptimal in the 2D CHART and the 2D-ENI plans. Only in the 3D-ENI plans did 100% of the PTV get > or = 95% of the dose prescribed (i.e., 51.5 Gy [51.3-52.2]). Using 3D-ENI plans significantly reduced the dose received by the spinal cord, the mean and median doses to the esophagus and the heart. It did not significantly reduce the lung dose when compared to 2D-ENI plans. Escalation of the dose (minimum > or = 1 Gy) with optimal PTV coverage was possible in 55.5% of patients using 3D-ENI, but was possible only in 16.6% when using the 2D-ENI planning strategy.

CONCLUSIONS

3DCRT is fundamental to achieving optimal PTV coverage in NSCLC. A policy of omission of elective nodal irradiation alone (and using 2D technology) will not achieve optimal PTV coverage or dose escalation. 3DCRT with omission of ENI can achieve true escalation of CHART in 55.5% of tumors, depending on their site and N-stage.

Examining the range of medicated and paste-impregnated bandages

Medicated and paste-impregnated bandages have been used by healthcare professionals for many years, especially in the management of problem skin surrounding leg ulcers. This article examines the range of bandages and the indications for use as well as the role of zinc in wound healing.

The effects of neurocognitive remediation on executive processing in patients with schizophrenia

Approaches to cognitive remediation have differed across studies. Most of the larger studies have concentrated on group treatments designed without the benefit of recent laboratory-based studies. The current study describes a randomized trial of an intensive cognitive remediation program involving individual daily sessions of 1 hour for up to 3 months. It targets executive functioning deficits (cognitive flexibility, working memory, and planning) that are known to be problematic in people with schizophrenia. Procedural learning, as well as the principles of errorless learning, targeted reinforcement, and massed practice, was the basis of the intervention. The program was compared with an alternative therapy (intensive occupational therapy) to control for some of the effects of therapeutic contact. Some improvements in cognition followed both therapies. A differential effect in favor of cognitive remediation therapy was found for tests in the cognitive flexibility and the memory subgroups. There was a trend for those receiving atypical antipsychotic medication to benefit more from cognitive remediation for tests of cognitive flexibility. Although there were no consistent changes in symptoms or social functioning between groups, if improvement in cognitive flexibility tasks reached a threshold then there is some evidence that social functioning improved, even over the short duration of the trial. In addition, cognitive remediation differentially improved self-esteem. This study supports the view that cognitive remediation can reduce cognitive deficits and that this reduction may affect social outcome, at least in the short term.

Context-dependent Taq-polymerase-mediated nucleotide alterations, as revealed by direct sequencing of the ZNF189 gene: implications for mutation detection

We have recently reported on the genetic organisation of a novel Krüppel-like zinc finger, ZNF189, located to 9q22-q31. In that study we found no mutations in the coding sequence when using ZNF189 as a candidate gene for sporadic basal cell cancer and squamous cell cancer. Here, by direct sequencing of the proximal promotor of ZNF189, mutations were found to appear in a small hot-spot region in over 50% of analysed tumour samples, the majority being G to A substitutions. The hot-spot region spans a 24bp G-rich region. Repeated analyses of the original sample lysates fail to confirm each of these mutations; and frequently new mutations appear at neighbouring positions. Subsequent analysis with serial dilutions of genomic DNA and a cosmid harbouring the wild-type ZNF189 gene demonstrate that these sequence-specific alterations arise in the outer PCR-amplification when 50 copies or less of template are used. Although the mechanism of how these context-specific alterations arise is not proven, the results demonstrate a previously unreported type of PCR-mediated sequence-specific alteration that easily could have been interpreted as being of clinical relevance. The phenomena observed show that mutations detected by direct sequencing can be caused by PCR-introduced alterations. Consequently, this should be of general caution in mutation analysis of disease gene candidates when using small amounts of template, such as microdissected biopsies.

Attention deficit hyperactivity disorder--a review

The topic of attention deficit hyperactivity disorder (ADHD) is fascinating and controversial. A variety of stances have been taken by different clinicians, support groups, and the media. A nature/nurture argument has developed that may have a tendency to polarize views. This review aims to present research findings that inform the debate. It deals with symptomatology, aetiology, and prevalence, with assessment for diagnosis, management, and outcome. The importance of comprehensive management taking into consideration not just attention abilities but a range of other factors that have an impact upon them is stressed. Management should be pragmatic, multifaceted, and based around the establishment of good working relationships with family and school.

Efficacy of a dentifrice containing zinc citrate for the control of plaque and gingivitis: a 6-month clinical study in adults

The objective of this 6-month, double-blind, clinical study, conducted in harmony with American Dental Association (ADA) guidelines, was to evaluate the efficacy of a dentifrice containing 2% zinc citrate and 0.76% sodium monofluorophosphate in a silica base (zinc citrate dentifrice) for the control of supragingival plaque and gingivitis, compared to a control dentifrice containing 0.76% sodium monofluorophosphate in a silica base (control dentifrice). Adult men and women from the Atlanta, Georgia, area were entered in the study and stratified into two treatment groups, which were balanced for baseline Quigley-Hein Plaque Index scores and baseline Löe-Silness Gingival Index scores. Participants received an oral prophylaxis and were instructed to brush their teeth twice daily (morning and evening) for 1 minute with their assigned dentifrice, using a soft-bristled toothbrush. Examinations for supragingival plaque and gingivitis were conducted after 3 months and again after 6 months' use of the study dentifrices. Ninety-nine participants complied with the protocol and completed the entire 6-month clinical study. At both the 3- and 6-month study examinations, the zinc citrate dentifrice group exhibited statistically significant reductions in both plaque and gingivitis compared to the control dentifrice group, based on whole-mouth data. At the 6-month examination, the magnitude of these reductions met or exceeded 18% for both plaque and gingivitis (25.3% for plaque; 18.8% for gingivitis). The effect of the zinc citrate dentifrice was most pronounced on the more severe manifestations of plaque and gingivitis, indicating a statistically significant (50.2%) reduction in severe plaque and a statistically significant (66.7%) reduction in severe gingivitis over the control dentifrice after 6 months of use. Similar findings were observed for data obtained from proximal, lingual, and posterior sites. Among the sites that indicated a tendency toward high levels of plaque or gingivitis based on the baseline scores, substantially fewer sites tended to continue to present such high levels at follow-up exams in the zinc citrate dentifrice group than in the control dentifrice group. Thus, in accordance with the 1986 guidelines published by the ADA and the 1994 revision published by the Task Force on Design and Analysis in Dental and Oral Research, the results of this study support the conclusion that a dentifrice containing 2% zinc citrate and 0.76% sodium monofluorophosphate in a silica base is clinically efficacious for the control of supragingival plaque and gingivitis.

The benefits and application of the Lyofoam product range

Foam dressings are used widely by many healthcare professionals. They provide an excellent healing environment for exuding wounds. Lyofoam is a polyurethane foam dressing that has been developed over the last few years and is available in a variety of presentations for light, moderately, and heavily exuding wounds. A new addition to complement the Lyofoam range is Lyofoam Extra Adhesive. Lyofoam is a well established and clinically proven wound dressing.

An investigation of the benefits of Aquacel Hydrofibre wound dressing

Aquacel wound dressing, produced by ConvaTec, uses the main ingredient of the hydrocolloid dressing in a new way to produce a hydrofibre dressing. Aquacel is designed for use in moderate to heavily exuding wounds as it absorbs exudate directly into its fibres. It has been shown to be effective in pressure sores, leg ulcers and surgical wounds, producing warm, moist, local wound conditions for optimum wound healing. Aquacel can lock exudate away thus protecting the surrounding skin.

Muscular soreness following prolonged intermittent high-intensity shuttle running

The aim of this study was to examine the impact of prolonged intermittent high-intensity shuttle running on soreness and markers of muscle damage. Sixteen males took part in the study, half of whom were assigned to a running group and half to a resting control group. The exercise protocol involved 90 min of intermittent shuttle running and walking (Loughborough Intermittent Shuttle Test: LIST), reflecting the activity pattern found in multiple-sprint sports such as soccer. Immediately after exercise, there was a significant increase (P < 0.05) in serum activities of creatine kinase and aspartate aminotransferase, and values remained above baseline for 48 h (P < 0.05). Median peak activities of creatine kinase and aspartate aminotransferase occurred 24 h post-exercise and were 774 and 43 U x l(-1), respectively. The intensity of general muscle soreness, and in the specific muscles investigated, was greater than baseline for 72 h after the shuttle test (P < 0.05), peaking 24-48 h post-exercise (P < 0.05). Muscle soreness was not correlated with either creatine kinase or aspartate aminotransferase activity. Soreness was most frequently reported in the hamstrings. Neither soreness nor serum enzyme activity changed in the controls over the 4 day observation period. It appears that unaccustomed performance of prolonged intermittent shuttle running produces a significant increase in both soreness and markers of muscle damage.

p53 Mutations in lung cancer associated with residential radon exposure

Unusual mutation patterns in lung tumors among underground miners have been indicated, suggesting radon-specific alterations in the genome, but the data are not consistent. To investigate the association between residential radon exposure and p53 mutations in lung tumors, we performed a study on cases from a nation-wide population-based investigation in Sweden. Our study included 83 nonsmoking lung cancer cases and 250 smoking lung cancer cases, diagnosed 1980-1984, with a time-weighted average radon exposure over 140 Bq/m3 or up to 50 Bq/m3. Radon was measured in dwellings occupied by the study subjects at some time since 1947. Information on smoking habits and other risk factors was obtained from questionnaires. After exclusions because of the initiation of treatment or insufficient material, the p53-status of 243 tumors was determined using PCR-single-stranded conformation polymorphism analysis and sequencing determination of exons 5-8. The overall mutation prevalence was 23.9%. An increased mutation prevalence was suggested among those with high exposure to residential radon [odds ratio (OR), 1.4; 95% CI, 0.7-2.6], especially among nonsmokers (OR, 3.2; 95% CI, 0.7-15.5), but no specific mutational pattern was indicated. Furthermore, the mutation prevalence seemed to be higher among smoking lung cancer cases than among nonsmoking cases (OR, 2.1; 95% CI, 0.9-5.0), and particularly among those smoking less than 10 cigarettes per day. It may be concluded that residential exposure to radon seems to contribute to a higher mutation prevalence of the p53 gene in lung tumors.