Utilizing program evaluation as a strategy to promote community change: evaluation of a comprehensive, community-based, family violence initiative

This paper describes the authors' work in a community that received Federal funding for an integrated system of care to reduce the impact and incidence of exposure to violence for children less than six years of age. The paper includes a review of the conceptual framework that guided the work of the authors and provides a brief overview of the issue of family violence, the impact of this violence on young children, and the Federal response to this issue. In addition, a description of the Initiative and the community in which it was based is provided along with some aspects of the evaluation plan. Finally, the authors discuss how their work with this Initiative depicts an approach to facilitating change within communities.

Development and evaluation of an interactive multimedia clinical skills teaching program designed for the pediatric clerkship

BACKGROUND AND PURPOSE

We evaluated the physical-examination section of a multimedia program developed to teach infant history and physical-examination skills.

METHODS

A total of 71 students participated: one group viewed only the physical-examination section (PX), one the history section (HX), one none of the program (CX). We assessed physical-examination skills by direct observation of medical students performing an abdominal exam and scored using a checklist at baseline, immediately after intervention, and at the end of the pediatric clerkship. We analyzed results using analysis of variance with repeated measures.

RESULTS

Baseline scores were PX = 2.5, HX = 2.8. The PX group scored significantly higher immediately postintervention at 6.8 compared to the HX group (3.1). At the end of the clerkship, significant differences between the groups remained. Final group mean scores were PX = 5.5, HX = 4.4, and CX = 2.7.

CONCLUSION

The program improved examination skills with attenuation over 6 weeks.

Facilitating phenomenological interviewing by means of reflexology

The aim of this article is to show how reflexology could facilitate phenomenological interviewing by probing the life-world of individual participants. It presents a hybrid study of phenomenological interviewing and reflexology as a holistic method of health care. In this sense, it is an interparadigmatic study, since it rests on the interface of Western and Oriental thought. This article reports on seven cases which were included in the qualitative, empirical investigation. During the sessions, reflexological readings served as impetus for inquiry into the experiences of the participants, as congestions on reflex points and along meridians were interpreted in terms of physical organs and functions. These readings were related to corresponding emotions as accepted within the reflexology paradigm. It was, however, up to the participants to inform the researcher of events and/or circumstances that caused the emotions. Thus, nonverbal data communicated information that facilitated verbal exchange concerning the life-world of each individual participant.

Cell surface display system for Lactococcus lactis: a novel development for oral vaccine

The food-grade Lactococcus lactis is a potential vector to be used as a live vehicle for the delivery of heterologous proteins for vaccine and pharmaceutical purposes. We constructed a plasmid vector pSVac that harbors a 255-bp single-repeat sequence of the cell wall-binding protein region of the AcmA protein. The recombinant plasmid was transformed into Escherichia coli and expression of the gene fragment was driven by the T7 promoter of the plasmid. SDS-PAGE showed the presence of the putative AcmA' fragment and this was confirmed by Western blot analysis. The protein was isolated and purified using a His-tag affinity column. When mixed with a culture of L. lactis MG1363, ELISA and immunofluorescence assays showed that the cell wall-binding fragment was anchored onto the outer surface of the bacteria. This indicated that the AcmA' repeat unit retained the active site for binding onto the cell wall surface of the L. lactis cells. Stability assays showed that the fusion proteins (AcmA/A1, AcmA/A3) were stably docked onto the surface for at least 5 days. The AcmA' fragment was also shown to be able to strongly bind onto the cell surface of naturally occurring lactococcal strains and Lactobacillus and, with less strength, the cell surface of Bacillus sphericus. The new system designed for cell surface display of recombinant proteins on L. lactis was evaluated for the expression and display of A1 and A3 regions of the VP1 protein of enterovirus 71 (EV71). The A1 and A3 regions of the VP1 protein of EV71 were cloned upstream to the cell wall-binding domains of AcmA protein and successfully expressed as AcmA/A1 and AcmA/A3. Whole-cell ELISA showed the successful display of VP1 protein epitopes of EV71 on the surface of L. lactis. The success of the anchoring system developed in this study for docking the A1 and A3 epitopes of VP1 onto the surface of L. lactis cells opens up the possibilities of peptide and protein display for not only Lactococcus but also for other gram-positive bacteria. This novel way of displaying epitopes on the cell surface of L. lactis and other related organisms should be very useful in the delivery of vaccines and other useful proteins.

The effect of repetition lag on electrophysiological and haemodynamic correlates of visual object priming

The modulation of repetition effects by the lag between first and second presentations of a visual object during a speeded semantic judgment task was examined using both scalp event-related potentials (ERPs) and event-related functional magnetic resonance imaging (efMRI). Four levels of lag were used within a single session, from zero to one, to tens of intervening stimuli, and which allowed partial separation of the effects of interference from the effects of time. Reaction times (RTs) showed that the magnitude of repetition priming decreased as lag increased. The ERP data showed two distinct effects of repetition, one between 150 and 300 ms post stimulus and another between 400 and 600 ms. The magnitude of both effects, particularly the earlier one, decreased as lag increased. The fMRI data showed a decrease in the haemodynamic response associated with repetition in several inferior occipitotemporal regions, the magnitude of which also typically decreased as lag increased. In general, and contrary to expectations, lag appeared to have mainly quantitative effects on the three types of dependent variable: there was little evidence for qualitative differences in the neural correlates of repetition effects at different lags.

Cough augmentation with mechanical insufflation/exsufflation in patients with neuromuscular weakness

Adults and children with neuromuscular disease exhibit weak cough and are susceptible to recurrent chest infections, a major cause of morbidity and mortality. Mechanical insufflation/exsufflation may improve cough efficacy by increasing peak cough flow. It was hypothesised that mechanical insufflation/exsufflation would produce a greater increase in peak cough flow than other modes of cough augmentation. The acceptability of these interventions was also compared. Twenty-two patients aged 10-56 yrs (median 21 yrs) with neuromuscular disease and 19 age-matched controls were studied. Spirometry was performed and respiratory muscle strength measured. Peak cough flow was recorded during maximal unassisted coughs, followed in random order by coughs assisted by physiotherapy, noninvasive ventilation, insufflation and exsufflation, and exsufflation alone. Subjects rated strength of cough, distress and comfort on a visual analogue scale. In the neuromuscular disease group, mean +/- SD forced expiratory volume in one second was 0.8 +/- 0.6 L x s(-1), forced vital capacity 0.9 +/- 0.8 L, maximum inspiratory pressure 25 +/- 16 cmH2O, maximum expiratory pressure 26 +/- 22 cmH2O and unassisted peak cough flow 169 +/- 90 L x min(-1). The greatest increase in peak cough flow was observed with mechanical insufflation/exsufflation at 235 +/- 111 L x min(-1) (p<0.01). All techniques showed similar patient acceptability. Mechanical insufflation/exsufflation produces a greater increase in peak cough flow than other standard cough augmentation techniques in adults and children with neuromuscular disease.

The relationship between levels of mood, interest and pleasure and 'challenging behaviour' in adults with severe and profound intellectual disability

BACKGROUND

Research on affective disorders in adults with intellectual disability (ID) suggests that depression may not present a 'classic picture' in individuals with severe and profound ID, but may include challenging behaviours, which are referred to as 'atypical symptoms', such as self-injury, aggression and irritability. The aim of the present study was to explore whether there is an association between constructs relating closely to the core symptoms of depression and challenging behaviours in adults with severe and profound ID.

METHOD

Mood and levels of interest and pleasure were measured in 53 adults with severe or pro-found ID using the Mood, Interest and Pleasure Questionnaire (MIPQ).

RESULTS

Two groups of adults were identified based on MIPQ scores: (1) a 'low mood' group (lowest score = 12); and (2) a comparison group (highest scoring = 12). The groups were clearly differentiated on the MIPQ (P < 0.0001), but were comparable on age, gender and medication use. The Challenging Behaviour Interview showed no difference between the two groups in self-injury, aggression or disrupting the environment. A secondary analysis revealed that participants who showed challenging behaviour scored significantly lower on the MIPQ than those who did not show challenging behaviour.

CONCLUSIONS

Possible reasons for these results and considerations for future studies are discussed.

Characterisation and molecular cloning of an erythromycin resistance plasmid of Lactococcus lactis isolated from chicken cecum

An erythromycin resistance plasmid, pAJ01 was isolated from Loctococcus lactis isolate C5 that was isolated from a healthy two-week-old chicken cecum. A 4 kb plasmid was transformed into plasmidless L. lactis MG1363 before a restriction endonuclease map was constructed. It was then fused with pUC19 to form pAJ02, which can replicate in Escherichia coli XLI-Blue as well as L. lactis MG1363. The plasmid was stably maintained in Lactococcus for more than 100 generations.

Moving towards rational pharmacological management of pain with an improved classification system of pain

Recognition that untreated pain can have serious deleterious effects has lead to significant resources being devoted towards understanding physiology, controlling nociception and implementing standards that promise to improve treatment of pain. Recently, improved knowledge and the appreciation of the need for a polypharmaceutical approach has lead to an appreciation that the classification of pain syndromes is the best approach towards rationalising treatment approaches. Older classification approaches such as acute and chronic, neuropathic, or nociceptive have not been universally useful for the clinician [1]. These classification schemes do not recognise that patients with pain often have mixed pain syndromes and do not fall neatly into these schemes. In addition, these classification schemes cannot represent newer advances in the understanding of pain and its physiology. Due to the growing variety of treatment approaches, classification of pain syndromes is often the best first step towards understanding a patient's pathophysiological process, initiating appropriate treatment and improving patient outcomes.

The current practices, training and concerns of a group of hospital-based speech therapists working in the area of dysphagia

The aim of the study was to investigate the current practices, training, and concerns of a group of hospital-based speech therapists regarding the area of dysphagia practice. Questionnaires were posted to 75 speech therapists working in the major hospitals around Gauteng, Kwa-Zulu Natal and the Cape Province and responses were obtained from 50 therapists within the stipulated time. Closed-ended questions were analysed quantitatively using descriptive statistics, while open-ended items were subjected to content analysis of themes articulated by respondents. Results indicated that the overwhelming majority of the respondents were involved in assessing and treating dysphagia patients. Specific problems faced by respondents included limited staff to share their workloads, large caseloads, restricted access to supervision/mentor systems and poor knowledge by other health personnel of their role in dysphagia. Almost half of the respondents also reported that they were involved in student training which included the area of dysphagia. Investigation of respondents' undergraduate and postgraduate training in dysphagia suggested that there were gaps in the theoretical content of these courses as well as a limited focus on practical training. Another finding was that respondents showed an awareness of the specific roles of the speech therapist in dysphagia intervention as well as the roles of the professionals constituting a multidisciplinary dysphagia team. Most of the respondents reported that they had access to dysphagia team members as well as to diet modification services. However, many of the respondents showed decreased knowledge of and awareness regarding accessibility of diagnostic procedures and suctioning methods used in dysphagia. The majority of the respondents rated their knowledge about specific theoretical areas as well as their counselling abilities to be better than their actual skills and confidence in assessing and treating dysphagia patients. Implications of the study included the need for clinicians, universities and professional organizations to work together to improve the existing situation.

Cost-effectiveness of vitamin therapy to lower plasma homocysteine levels for the prevention of coronary heart disease: effect of grain fortification and beyond

CONTEXT

A high homocysteine level has been identified as an independent modifiable risk factor for coronary heart disease (CHD) events and death. Since January 1998, the US Food and Drug Administration has required that all enriched grain products contain 140 microg of folic acid per 100 g, a level considered to decrease homocysteine levels.

OBJECTIVES

To examine the potential effect of grain fortification with folic acid on CHD events and to estimate the cost-effectiveness of additional vitamin supplementation (folic acid and cyanocobalamin) for CHD prevention.

DESIGN AND SETTING

Cost-effectiveness analysis using the Coronary Heart Disease Policy Model, a validated, state-transition model of CHD events in adults aged 35 through 84 years. Data from the third National Health and Nutrition Examination Survey (NHANES III) were used to estimate age- and sex-specific differences in homocysteine levels.

INTERVENTION

Hypothetical comparison between a diet that includes enriched grain products projected to increase folic acid intake by 100 microg/d with the same diet without folic acid fortification; and a comparison between vitamin therapy that consists of 1 mg of folic acid and 0.5 mg of cyanocobalamin and the diet that includes grains fortified with folic acid.

MAIN OUTCOME MEASURES

Incidence of myocardial infarction and death from CHD, quality-adjusted life-years (QALYs) saved, and medical costs.

RESULTS

Grain fortification with folic acid was predicted to decrease CHD events by 8% in women and 13% in men, with comparable reductions in CHD mortality. The model projected that, compared with grain fortification alone, treating all patients with known CHD with folic acid and cyanocobalamin over a 10-year period would result in 310 000 fewer deaths and lower costs. Over the same 10-year period, providing vitamin supplementation in addition to grain fortification to all men aged 45 years or older without known CHD was projected to save more than 300 000 QALYs, to save more than US $2 billion, and to be the preferred strategy. For women without CHD, the preferred vitamin supplementation strategy would be to treat all women older than 55 years, a strategy projected to save more than 140 000 QALYs over 10 years.

CONCLUSIONS

Folic acid and cyanocobalamin supplementation may be cost-effective among many population subgroups and could have a major epidemiologic benefit for primary and secondary prevention of CHD if ongoing clinical trials confirm that homocysteine-lowering therapy decreases CHD event rates.