Still in the shadows: a national study of acute mental health unit location across New Zealand hospitals

BACKGROUND

This study aimed to explore the location of acute mental health inpatient units in general hospitals by mapping their location relative to hospital facilities and community facilities and to compare their proximity to hospital facilities with that of general medical acute units.

METHODS

We obtained Google maps and hospital site maps for all New Zealand public hospitals. Geographic data were analysed and mental health units' locations in relation to hospital facilities and public amenities were mapped. Radar plots were constructed comparing acute medical and mental health units' locations in relation to hospital facilities.

RESULTS

Twenty-two mental health units were identified. They were located predominantly at the periphery of hospital campuses, but also at a distance from community facilities. Compared to acute medical units, mental health units were almost universally located further from shared hospital facilities - with distances approximately three times further to reach the main hospital entrance (2.7 times distance), the nearest public café (3.4 times), the emergency department (2.4 times), and medical imaging (3.3 times).

CONCLUSION

Despite the reforms of the 20^th Century, mental health units still appear to occupy a liminal space; neither fully integrated into the hospital, nor part of the community. The findings warrant further investigation to understand the impact of these structural factors on parity of health care provision between mental and physical health care and the ability of mental health care services to support recovery.

Relationship Between Clinicians' Inclination Toward Patients at Risk for Suicide (PRS) and Self-reported Countertransference

OBJECTIVES

We investigate the relationship between clinicians' inclination toward treating patients at risk for suicide (PRS), and self-reported countertransference (CT). We consider these observed group differences to explore two competing interpretations for observed CT patterns from a primary study; whether CT patterns are more consistent with defensive attitudes or an adaptative CT montage.

METHOD

We used one-way ANOVA, Tuckey post-hoc, and t-test, to compare clinicians (n = 267) grouped by self-ratings of positive, neutral or non-positive inclination toward working with PRS, with regard to their level of endorsement of the Therapist Response Questionnaire (TRQ) with PRS. We hypothesized that positively inclined clinicians would demonstrate greater CT literacy skills than other clinicians, reflected in lower endorsement of negative/hindering CT and higher endorsement of positive/facilitating CT to PRS.

RESULTS

Compared to non-positively inclined clinicians, positively inclined clinicians endorsed significantly lower levels of two potentially negative/hindering CT dimensions, factor 1: entrapped/rejecting and, factor 5: protective/overinvolvement, and higher levels of the only positive/facilitating CT dimension, factor 2: fulfilled/engaging. Neutral clinicians reported similar CT patterns to positively inclined clinicians.

CONCLUSIONS

Hypothesis of greater CT literacy from positively inclined clinicians appears supported. Observed differences in CT endorsement by inclination group tend to support the CT montage interpretation of our original findings more than the defense mechanism interpretation proposed. Similarities in CT patterns between positively inclined and neutral clinicians suggest that positive inclination to PRS, as assessed in this study, may not be countertransferential per se.

'My Work Matters': A Qualitative Exploration of Why Staff Love Working in Acute Mental Health

Research findings and media coverage of staff experiences of working in mental health settings tend to focus on the negative aspects of the work such as burnout and stress. These negative aspects affect job satisfaction. Job satisfaction can be understood through the lense of Self-Determination theory, which emphasises the importance of autonomy, competence and relatedness (connection) in job satisfaction. This article reports on staff views on positive aspects of working in acute mental health care, drawing on qualitative interview data collected for a larger study of the social and architectural environment of mental health inpatient facilities in New Zealand. Forty-two inpatient mental health staff participated in semi-structured interviews about their experiences of working in such facilities, sharing the positive aspects of working in this setting, including 'what they liked most'. Responses were thematically analysed using the Framework Method to identify and organise key themes that were refined iteratively, checking for agreement between researchers. Four key themes were identified: work that matters; the people; the physical and social environment and the extrinsic rewards/personal benefits. The results provide an alternative framing of working in acute mental health settings compared, with commonly reported research findings and media coverage focusing on staff burnout and stress in these settings. Despite the much-documented challenges of working in this often poorly resourced and stigmatized area of health, most participants spoke warmly and enthusiastically about what they did, with frequent use of the word 'love' in relation to their work. This was largely because they found the work and social relationships rewarding and they were able to make an important contribution to the wellbeing of mental health service users.

The Role of Courtyards within Acute Mental Health Wards: Designing with Recovery in Mind

The role of courtyards and other outdoor spaces in the recovery of acute mental healthcare users has been gaining international appreciation and recognition. However, the physical properties and conditions necessary for therapeutic and rehabilitative engagement remain to be clearly established. This paper contributes to that knowledge by triangulating evidence from the literature, exemplar case studies of good practice and first-hand accounts of the experiences of staff and service users from four acute mental health facilities. The findings are then aligned with a well-established recovery framework (CHIMES) in light of existing landscape architecture knowledge. Within the complexity of varied mental health environments, this work establishes landscape architectural design requirements and qualities essential for recovery. Rather than adopting a prescriptive quantitative approach setting out areas, numbers of elements, etc., the proposed framework recommends a performance-based model and the creation of a cohesive network of microspaces that mesh into a design of outdoor areas. In this way, design details, materials, vegetation and the variety of spaces can be modified to suit service user population demographics and site-specific needs.

'Really there because they care': The importance of service users' interpretations of staff motivations at a crisis intervention service in New Zealand

Crisis intervention services for people experiencing psychological distress and suicidal ideation are frequently described by the people accessing them as failing to meet their needs. This paper reports a prominent finding from a realist evaluation of Taranaki Retreat-a charitable, non-clinical organisation in New Zealand, which offers free respite for people experiencing acute distress. Using qualitative methods, the study aimed to move beyond vague notions regarding the helpfulness of respite, to a deeper understanding of the contextual factors and mechanisms which generate outcomes for such an intervention. Participant observation, focus groups with staff, semi-structured interviews with service users, and analysis of service users' case notes were conducted over a six-month period in 2018. The most prominent finding from the study related to 'genuine care'-care which is interpreted by the recipient as being motivated by a genuine desire to help. We present this finding as to the central mechanism in a wider programme theory developed through the realist evaluation study. We also present five key features of the care participants were offered at Taranaki Retreat which contributed to their common interpretation regarding the motivations behind this care. Upon considering the centrality of this mechanism we conclude that, in designing crisis interventions, greater consideration should be given to how the intervention can demonstrate genuine care. Having highlighted the ways in which the structure of charitable organisations appears conducive for interpretations of genuine care, we further conclude that the provision of comprehensive crisis intervention by charitable organisations should be further explored and supported.

Decoding the Psychiatric Space: Cross Country Comparison of Facilities for Mental Health Service Users

Normalisation theory made perfect sense at the onset of de-institutionalisation. To map its influence on mental health facilities, research was conducted and began with ten facilities within England (UK) and France, followed by a further two in England and four in New Zealand. A checklist tailored to mental health facilities was used to measure the extent to which the facility looked domestic or institutional. Hence, the mental health checklist architecturally measured domesticity versus institutionalisation in psychiatric architecture. It consisted of 212 features, grouped into three main categories—context and site; building; and space and room—and was based on a pre-existing checklist designed for hostels for those with learning disabilities. The mental health checklist was developed and piloted in Europe and reflected European de-institutionalisation principles. Cross-country comparison revealed that patient acuity was potentially not a determinant of institutional buildings for mental health. Institutional facilities in France were detected, and some of the most domestic facilities were within England, with the most recent sample having a greater tendency towards the more institutional end. Those in New Zealand tended towards the most institutional. Across all 16 facilities, there were very few universal institutional and domestic features, raising the ambiguity of a clearly defined stereotype of facilities for mental health service users. Consequently, the current fluidity of design across and within countries provides a significant opportunity for designers and mental health providers to consider non-institutional design, particularly at the planning stage. The use of the mental health checklist facilitates this debate. Future research in other geographical areas and through further consideration of cultural differences provides further opportunities to extend research in this area, with the potential to enhance and improve the lived experience of users of mental health services.

Places of safety? Fear and violence in acute mental health facilities: A large qualitative study of staff and service user perspectives

AIM

To understand violence on acute mental health units according to staff and service user perspectives and experiences.

BACKGROUND

The collateral damage of violence in acute inpatient mental health settings is wide-ranging, impacting on the health and wellbeing of staff and service users, and detrimental to public perceptions of people who are mentally unwell. Despite international research on the topic, few studies have examined psychiatric unit violence from both staff and service user perspectives.

METHODS

We conducted in-depth interviews with 85 people (42 staff, 43 service users) in four adult acute mental health inpatient units in New Zealand. We undertook a thematic analysis of perspectives on the contributing factors and consequences of violence on the unit.

RESULTS

Both staff and service users indicated violence was a frequent problem in acute inpatient units. Four themes regarding the causes of violence emerged: individual service user factors, the built environment, organisational factors, and the overall social milieu of the unit. Staff often highlighted complexities of the system as causal factors. These included the difficulties of managing diverse service user illnesses within an inadequate and unsafe built environment whilst having to contend with staffing issues and idiosyncrasies relating to rule enforcement. In contrast, service users talked of their needs for care and autonomy not being met in an atmosphere of paternalism, boredom due to restrictions and lack of meaningful activities, enforced medication, and physical confinement as precipitants to violence. Two broader themes also emerged, both relating to empathy. Both staff and service users exhibited 'othering' (characterised by a profound lack of empathy) in relation to acutely unwell individuals. Explanations for violent behaviour on the unit differed between groups, with service users being more likely to attribute unwanted behaviour to contextual factors and staff more likely to 'blame' mental illness. The consequences of violence included stress, physical injury, and a culture of fear and stigma.

CONCLUSION

Violence in acute inpatient mental health units in New Zealand is a significant, complex, and unresolved problem negatively impacting the therapeutic mission of these settings. Further in-depth qualitative investigations are urgently required into what is experienced as violence by service users, their view of how violence occurs, the role of fear and power relations, and the contributions of the built and organisational environment to all forms of violence to all unit users. A core function of the acute mental health unit is to offer a therapeutic environment for individuals at their most vulnerable. For this to happen, the unit must be a rewarding place to work, and a safe place to be.

There's no smoke without fire: Smoking in smoke-free acute mental health wards

BACKGROUND

People who smoke with serious mental illness carry disproportionate costs from smoking, including poor health and premature death from tobacco-related illnesses. Hospitals in New Zealand are ostensibly smoke-free; however, some mental health wards have resisted implementing this policy.

AIM

This study explored smoking in acute metal health wards using data emerging from a large sociological study on modern acute psychiatric units.

METHODS

Eighty-five in-depth, semi-structured interviews were conducted with staff and service users from four units. Data were analysed using a social constructionist problem representation approach.

RESULTS

Although high-level smoke-free policies were mandatory, most participants disregarded these policies and smoking occurred in internal courtyards. Staff reasoned that acute admissions were not the time to quit smoking, citing the sceptres of distress and possibly violence; further, they found smoking challenging to combat. Inconsistent enforcement of smoke-free policies was common and problematic. Many service users also rejected smoke-free policies; they considered smoking facilitated social connections, alleviated boredom, and helped them feel calm in a distressing environment - some started or increased smoking following admission. A minority viewed smoking as a problem; a fire hazard, or pollutant. No one mentioned its health risks.

CONCLUSION

Psychiatric wards remain overlooked corners where hospital smoke-free policies are inconsistently applied or ignored. Well-meaning staff hold strong but anachronistic views about smoking. To neglect smoking cessation support for people with serious mental illness is discriminatory and perpetuates health and socioeconomic inequities. However, blanket applications of generic policy are unlikely to succeed. Solutions may include myth-busting education for service users and staff, local champions, and strong managerial support and leadership, with additional resourcing during transition phases. Smoke-free policies need consistent application with non-judgemental NRT and, potentially, other treatments. Smoking cessation would be supported by better designed facilities with more options for alleviating boredom, expressing autonomy, facilitating social connections, and reducing distress.

Occupational exposure to suicide: A review of research on the experiences of mental health professionals and first responders

Exposure to suicide is a major factor for suicidality. Mental health professionals and first responders are often exposed to suicide while on-duty. The objective of this scoping review is to describe the state of current research on exposure to suicide among mental health professionals and first responders, focusing on the prevalence and impact of exposure to suicide, and to identify current gaps in the literature. We searched MEDLINE, Scopus, PsychNET, and Web of Science and identified 25 eligible papers. Between 31.5–95.0% of professionals had been exposed to suicide. Exposure to suicide had impacts on personal life, professional life, and mental health; and caused emotional distress. There was little research investigating exposure to suicide among police officers, firefighters, and paramedics. More research existed on mental health professionals, but none assessed exposure to suicide as a risk for suicide amongst this group. The review concludes that exposure to suicide is distressing for mental health professionals, and likely to be for first responder however, more research on these groups, especially paramedics, is required.

Silver linings of the COVID-19 lockdown in New Zealand

The COVID-19 pandemic has caused significant disruption, distress, and loss of life around the world. While negative health, economic, and social consequences are being extensively studied, there has been less research on the resilience and post-traumatic growth that people show in the face of adversity. We investigated New Zealanders’ experiences of benefit-finding during the COVID-19 pandemic and analysed qualitative responses to a survey examining mental well-being during the New Zealand lockdown. A total of 1175 of 2010 eligible participants responded to an open-ended question probing ‘silver linings’ (i.e., positive aspects) they may have experienced during this period. We analysed these qualitative responses using a thematic analysis approach. Two thirds of participants identified silver linings from the lockdown and we developed two overarching themes: Surviving (coping well, meeting basic needs, and maintaining health) and thriving (self-development, reflection, and growth). Assessing positive as well as negative consequences of the pandemic provides more nuanced insights into the impact that New Zealand’s response had on mental well-being.

Suicide and self-harm content on Instagram: A systematic scoping review

Given concerns about suicide or self-harm content on Instagram, we conducted a systematic scoping review of peer-reviewed English language primary studies published between 2010–2019. Only ten studies had been published. Looking into purposive samples of Instagram posts tagged with self-harm related hashtags, studies report finding self-harm or suicide content in between 9–66% of their studied posts. Studies assessing Instagram’s efforts to tackle such content found they had not been very effective. Despite heterogeneity in study aims, use of terminology, samples, methods of analysis, and study outcomes, we aggregated and distinguished ‘content studies’ and ‘user studies’. Most studies showed concern for self-harm risk, but only one examined the relationship between self-harm posts and actual self-harm behaviours offline. It found such content had negative emotional effects on some users and reported preliminary evidence of potential harmful effects in relation to self-harm related behaviours offline, although causal effects cannot be claimed. At the same time, some benefits for those who engage with self-harm content online have been suggested. More research directly interviewing Instagram users to understand this phenomenon from their perspective is required. Finally, some ethical issues are discussed.

Young People's Perspectives and Understanding of the Suicide Story in 13 Reasons Why

Background: The Netflix drama 13 Reasons Why (13RW) focusing on the suicide of an adolescent girl became a global phenomenon. It was accompanied by intense public debate about the risks of exposing youth to fictional portrayals of adolescent suicide. Aims: To explore adolescents' subjective perspectives and understanding of 13RW focusing on the portrayal of adolescent suicide. Method: We applied a thematic analysis to qualitative data from interviews with 25 New Zealand adolescents eliciting views on the show's portrayal of adolescent suicide. Results: Four themes were developed from the analysis: entertaining but not realistic; the unexpected shock factor; jumbled messages; and superficial conversations. Conclusion: This study contributes a youth perspective which has been missing from the debate on 13RW. This research highlights the way that youth, when given the opportunity, articulated a nuanced understanding of the representation of adolescent suicide in 13RW, viewing it as entertainment rather than a realistic depiction that added little in terms of suicide awareness and generated minimal opportunities for in-depth discussion.

Learning from clinicians' positive inclination to suicidal patients: A grounded theory model

Despite experts' contention that clinicians' positive inclination is essential to successful treatment of patients at risk for suicide (PRS), research in the area is lacking. This study used grounded theory to develop a model of clinicians' positive inclination based on interviews with 12 clinicians who "liked" working with PRS. The core process identified, a state of emotional synchrony through deep connection between clinicians and PRS, appeared to provide an intersubjective emotion regulation, associated with distress reduction in patients and deep satisfaction in clinicians. Findings suggest clinicians' deep sense of satisfaction and PRS' clinical improvement in treatment could be interdependent.

Systematic Exploration of Countertransference Phenomena in the Treatment of Patients at Risk for Suicide

Despite its critical role in clinical suicidology, empirical evidence on the nature of countertransference (CT) to patients at risk for suicide (PRS) is lacking. This study aimed to provide a systematic description of CT phenomena to PRS. Psychiatrists, psychologists, and psychotherapists completed the Therapist Response Questionnaire (TRQ) online, with reference to a PRS. Factor analysis (n = 267) yielded a 7-factor structure, including 1) entrapped/rejecting, 2) fulfilled/engaging, 3) aroused/reacting, 4) informal/boundary crossing, 5) protective/overinvolvement, 6) ambivalent/inconsistent, and 7) mistreated/controlling. On average, clinicians reported that CT dimensions tended to not apply to them, except for the positively connoted factor. Our findings suggest that patients at risk for suicide elicit specific dimensions of CT. We offer two alternative interpretations of clinicians' CT endorsement patterns.

Investigating suspected suicides: New Zealand coroners' experiences

To understand how suspected suicides are investigated in New Zealand we conducted a thematic analysis of in-depth interviews with coroners. Coroners identified the inquisitorial nature of the coronial system and coroners' wide powers of jurisdiction as key strengths of the system. Important influences in key areas of coronial decision making in cases of suspected suicides included; the need for more evidence - especially to determine intent, and family factors, including therapeutic jurisprudence. Coroners identified lack of follow up and monitoring of recommendations, poorly resourced coronial training and the personal impact of suicides as challenges of working in the coronial system.

Masculinity, Social Connectedness, and Mental Health: Men's Diverse Patterns of Practice

Men’s mental health has remained undertheorized, particularly in terms of the gendered nature of men’s social relations. While the importance of social connections and strong supportive networks for improving mental health and well-being is well documented, we know little about men’s social support networks or how men go about seeking or mobilizing social support. An in-depth understanding of the gendered nature of men’s social connections and the ways in which the interplay between masculinity and men’s social connections can impact men’s mental health is needed. Fifteen life history interviews were undertaken with men in the community. A theoretical framework of gender relations was used to analyze the men’s interviews. The findings provide rich insights into men’s diverse patterns of practice in regards to seeking or mobilizing social support. While some men differentiated between their social connections with men and women, others experienced difficulties in mobilizing support from existing connections. Some men maintained a desire to be independent, rejecting the need for social support, whereas others established support networks from which they could actively seek support. Overall, the findings suggest that patterns of social connectedness among men are diverse, challenging the social science literature that frames all men’s social relationships as being largely instrumental, and men as less able and less interested than women in building emotional and supportive relationships with others. The implications of these findings for promoting men’s social connectedness and mental health are discussed.

Preventing suicidal behaviours with a multilevel intervention: a cluster randomised controlled trial

Background

In the context of the recent surge in community based multilevel interventions for suicide prevention, all of which show promising results, we discuss the implications of the findings of such an intervention designed for and implemented in New Zealand. The multi-level intervention for suicide prevention in New Zealand (MISP-NZ) was a cluster randomised controlled community intervention trial involving eight hospital regions matched into four pairs and randomised to either the intervention or practice as usual (the control). Intervention regions received 25 months of interventions (01 June 2010 to 30 June 2012) including: 1) training in recognition of suicide risk factors; 2) workshops on mental health issues; 3) community based interventions (linking in with community events); and 4) distribution of print material and information on web-based resources.

Results

There was no significant difference between the change in rate of suicidal behaviours (ISH or self-inflicted deaths) in the intervention group compared with the control group (rate ratio = 1.07, 95% CI 0.82, 1.38).

Conclusions

This study did not provide substantive evidence that the MISP-NZ intervention had an effect on suicidal behaviours raising important questions about the potential effectiveness of the multilevel intervention model for suicide prevention for all countries. Although a range of factors may account for this unanticipated finding, including inadequate study power, differences in design and intervention focus, and country-specific contextual factors, it is possible that the effectiveness of the multilevel intervention model for reducing suicidal behaviours may have been overstated.

Trial registration

This trial was retrospectively registered on 11 April 2013. ACTRN12613000399796.

Ethical considerations in sensitive suicide research reliant on non-clinical researchers

The impact on researchers of working with sensitive data is often not considered by ethics committees when approving research proposals. We conducted interviews with eight research assistants processing clinical notes on emergency department presentations for deliberate self-harm and suicide attempts during a suicide prevention trial. Common experiences of working with the data included feeling unprepared for the level of detail in the records, being drawn deeply into individual stories, emotional exhaustion from the cumulative exposure to the data over long periods of time while working alone, and experiencing a heightened awareness of the fragility of life and the need for safety. The research assistants also reported on some of the strategies they had developed to cope with the sensitive nature of the data and the demands of the work. The ethical implications for suicide research reliant on non-clinically trained researchers exploring sensitive data are considered. These include the need for research leaders and ethics committees to be aware of the potential adverse mental health impacts for these researchers examining sensitive data and to make appropriate arrangements to minimize the mental health impacts of such work.

New Media but Same Old Tricks: Food Marketing to Children in the Digital Age

'New media' refers to digital technologies, which offer unmatched opportunities for food companies to engage with young people. This paper explores the emergence of food marketing using new media, the potential impact of this marketing on young people, and current and potential policy responses to limit exposure to these promotions. Foremost in any informed policy discussion is the need for robust evidence to demonstrate the need for intervention. In this case, such evidence relates to the extent of children's exposures to commercial food promotions via new media, and the nature of these promotions. Approaches to, and challenges of, collecting and assessing these data are discussed. There is accumulating evidence that food marketing on new media is increasing and influences children's food preferences and choices. The impact of integrated campaigns, which reinforce commercial messages across multiple platforms, and of new media, which engage personally with potential consumers, is likely to be greater than that of traditional marketing.

A systematic review of persuasive marketing techniques to promote food to children on television

The ubiquitous marketing of energy-dense, nutrient-poor food and beverages is a key modifiable influence on childhood dietary patterns and obesity. Much of the research on television food advertising is focused on identifying and quantifying unhealthy food marketing with comparatively few studies examining persuasive marketing techniques to promote unhealthy food to children. This review identifies the most frequently documented persuasive marketing techniques to promote food to children via television. A systematic search of eight online databases using key search terms identified 267 unique articles. Thirty-eight articles met the inclusion criteria. A narrative synthesis of the reviewed studies revealed the most commonly reported persuasive techniques used on television to promote food to children. These were the use of premium offers, promotional characters, nutrition and health-related claims, the theme of taste, and the emotional appeal of fun. Identifying and documenting these commonly reported persuasive marketing techniques to promote food to children on television is critical for the monitoring and evaluation of advertising codes and industry pledges and the development of further regulation in this area. This has a strong potential to curbing the international obesity epidemic besieging children throughout the world.

Addressing patient alcohol use: a view from general practice

INTRODUCTION

General practitioners (GPs) have the potential to promote alcohol harm minimisation via discussion of alcohol use with patients, but knowledge of GPs' current practice and attitudes on this matter is limited. Our aim was to assess GPs' current practice and attitudes towards discussing alcohol use with their patients.

METHODS

This qualitative study involved semi-structured, face-to-face interviews with 19 GPs by a group of medical students in primary care practices in Wellington, New Zealand.

FINDINGS

Despite agreement amongst GPs about the importance of their role in alcohol harm minimisation, alcohol was not often raised in patient consultations. GPs' usual practice included referral to drug and alcohol services and advice. GPs were also aware of national drinking guidelines and alcohol screening tools, but in practice these were rarely utilised. Key barriers to discussing alcohol use included its societal 'taboo' nature, time constraints, and perceptions of patient dishonesty.

CONCLUSION

In this study there is a fundamental mismatch between the health community's expectations of GPs to discuss alcohol with patients and the reality. Potential solutions to the most commonly identified barriers include screening outside the GP consultation, incorporating screening tools into existing software used by GPs, exploring with GPs the social stigma associated with alcohol misuse, and framing alcohol misuse as a health issue. As it is unclear if these approaches will change GP practice, there remains scope for the development and pilot testing of potential solutions identified in this research, together with an assessment of their efficacy in reducing hazardous alcohol consumption.

Acceptability of a guided self-help mental health intervention in general practice

BACKGROUND

People with subthreshold mental health syndromes are common in general practice and represent an important morbidity and disability burden. Management options are currently limited. We examined the acceptability of a novel ultra-brief guided self-help intervention designed specifically for use in this setting.

OBJECTIVE

To assess clinician and patient satisfaction with an ultra-brief guided self-help intervention to address subthreshold mental health syndromes in the primary care setting.

METHODS

Consenting patients were given the ultra-brief intervention in a series of three 15- to 30-minute coaching sessions over a 5-week period.

DESIGN

survey interview of clinician and patient satisfaction with and acceptability of the intervention.

SETTING

general practices in Wellington, New Zealand.

MAIN OUTCOME MEASURE

clinician and patient acceptability of the intervention was assessed by survey questionnaire at 3 months. Baseline and follow-up mental health status assessments were undertaken using the Kessler-10 measure of psychological distress.

RESULTS

Six clinicians recruited 19 patient participants, 16 of whom completed the intervention. Based on questionnaire feedback, clinician and patient satisfaction ratings were very positive. However, clinicians expressed a concern that the length of the sessions was sometimes inadequate. The psychological well-being of the patients, as measured by the Kessler-10, was also significantly improved post-intervention.

CONCLUSION

The intervention appeared to improve the psychological well-being of the patients and was regarded positively by both clinicians and patient participants. Further testing of the efficacy of the intervention on a larger sample with a randomized controlled trial study design is warranted.

Progesterone and oestrogen in pregnancy and parturition: comparative aspects and hierarchical control

The different ways in which the progesterone requirements of pregnancy are met in various species are reviewed here. Progesterone production expressed in terms of metabolic body weight lies within about one order of magnitude in several species (but not in the rat), whether the hormone is predominantly ovarian or placental in origin. Parturition is usually preceded by a decrease in the plasma concentration of progesterone and the evidence which suggests that a decrease in secretion involves enzyme induction is summarized. In the sheep a sequence of well-marked hormonal changes can be discerned--an increase in fetal cortisol secretion followed by a fall in placental progesterone and a rise in oestrogen and prostaglandin F2alpha secretion. This sequence has been interpreted in terms of hierarchical control theory which envisages a series of levels placed in a descending order of importance and in which there is a downward transmission of a signal from a higher level that modifies activity at a lower level. A dominant level in the hierarchy in the sheep and pig seems to be the fetal hypothalamus and pituitary, but in the rabbit the maternal hypothalamus, pituitary and ovary play a more dominant role.

434. Identification of differentially expressed proteins in ovine chorion rupture sites at preterm and term using proteomics

Introduction: A significant number of babies are delivered preterm and many of these deliveries are due to spontaneous rupture of fetal membranes. However, the mechanisms underlying fetal membrane rupture are not well defined. The sheep has proved to be a valuable model for elucidating the physiology of birth, with many of the findings clearly relevant to human parturition. In the current study we have used the sheep model to investigate changes in protein expression in the chorion in relation to the onset of spontaneous full term labour. Methods: Proteomic analysis was used to compare the protein profiles at the chorion rupture site between mid/late gestation (136 days, n = 6) and term delivery (145days, n = 6). Proteins were solubilised and separated into soluble and insoluble fractions which were separated by 2D-electrophoresis. Relative protein expression was quantified using the PROGENESIS software and protein spots were picked and identified using Matrix Assisted Laser Desorption Ionisation-Time of Flight (MALDI-TOF) mass spectrometry. Data-mining used gene ontology (GO terms) for each protein and these were clustered into networks using DAVID bioinformatics resource (http://david.abcc.ncifcrf.gov/home.jsp). Results: A total of 150 protein spots were identified of which 60 proteins were found to differ by more than 2-fold between preterm and term samples. This group was significantly enriched for proteins from the several functional GO categories including; Oxidoreductase activity (7 proteins); negative regulation of apoptosis (4); structural molecule activity (7); protease inhibitor activity (7); Carbohydrate metabolism (10); Glucose metabolism (5); Glycolysis (5); response to stress (8) and heat shock (3). Of the differentially regulated proteins, 10 were found to be significantly upregulated at term (ANOVA P < 0.05) including isocitrate dehydrogenase, glutamate dehydrogenase 1, malate dehydrogenase 2. A further 10 proteins, including serpin peptidase inhibitor SERPINA12, serpin peptidase inhibitor SERPINH1 precursor and heat shock protein 90 kDa β were found to be downregulated.

Childhood social disadvantage and smoking in adulthood: results of a 25-year longitudinal study

AIM

To examine the associations between exposure to socio-economic disadvantage in childhood and smoking in adulthood.

DESIGN

A 25-year longitudinal study of the health, development and adjustment of a birth cohort of 1265 New Zealand children.

MEASUREMENTS

Assessments of childhood socio-economic disadvantage, smoking in adulthood and potential mediating pathways, including: parental education, family socio-economic status, family living standards and family income; smoking frequency and nicotine dependence at age 25 years; child IQ, educational achievement by age 18 years, conduct problems ages 14-16 years, parental smoking 0-16 years and peer smoking at 16 years.

FINDINGS

Smoking at age 25 was correlated significantly (P < 0.0001) with increasing childhood socio-economic disadvantage. Further, indicators of childhood socio-economic disadvantage were correlated significantly (P < 0.0001) with the intervening variables of childhood intelligence, school achievement, conduct problems and exposure to parental and peer smoking; which in turn were correlated significantly (P < 0.0001) with measures of smoking at age 25. Structural equation modelling suggested that the linkages between the latent factor of childhood disadvantage and later smoking were explained largely by a series of pathways involving cognitive/educational factors, adolescent behavioural adjustment and exposure to parental and peer smoking.

CONCLUSIONS

The current study suggested that smoking in adulthood is influenced by childhood socio-economic disadvantage via the mediating pathways of cognitive/educational factors, adolescent behaviour and parental and peer smoking.

Chronic fetal hypoxia increases activin A concentrations in the late-pregnant sheep

OBJECTIVE

To determine whether activin A concentrations are altered in chronic fetal hypoxemia and intrauterine fetal growth restriction (IUGR).

DESIGN

In vivo animal experimental model.

SETTING

Department of Physiology, Monash University.

POPULATION

Chronically catherised fetal sheep in late pregnancy.

METHODS

Chronic fetal hypoxia and IUGR were experimentally induced by single umbilical artery ligation (SUAL) in catheterised fetal sheep. Maternal and fetal blood samples and amniotic fluid (AF) samples were collected during surgery and thereafter on alternate days, until the time of delivery for analyte measurement. Fetal blood gas parameters were measured daily.

MAIN OUTCOME MEASURES

Plasma and AF was used to analyse activin A, prostaglandin E2 (PGE2) and cortisol and fetal blood gas analysis was undertaken in whole blood.

RESULTS

SUAL produced asymmetric IUGR and non-acidaemic chronic fetal hypoxia and resulted in preterm labour (129 [3] days). AF activin A concentrations were 10-fold higher in the SUAL group than in controls whereas levels in the fetal and maternal circulations were similar between groups.

CONCLUSIONS

SUAL-induced IUGR and fetal hypoxaemia increases AF activin A. This may be an important adaptive or protective response to IUGR.

Effects of age and pregnancy on the circulatory activin response of sheep to acute inflammatory challenge by lipopolysaccharide

The release of activin A in response to intravenous injection of the bacterial cell-wall component lipopolysaccharide (LPS) was investigated in an ovine model of acute inflammatory challenge in newborn and adult sheep, and in non-pregnant and pregnant ewes. Neonatal lambs (<20 days of age) showed a quantitatively similar response in terms of circulating concentrations of activin A, its binding protein follistatin and the cytokine interleukin-6 compared with adult ewes challenged with an equivalent dose (300 ng/kg bodyweight) of LPS. The fever response and plasma tumour necrosis factor-alpha release in response to LPS, however, were significantly (P < 0.01) less in lambs than in the adult group. Pregnant ewes in the last trimester of gestation had similar responses to LPS, in all aspects measured, compared with their non-pregnant counterparts, apart from an ablated fever response. Although the adult and neonatal sheep responded to LPS, a similar response was not apparent in the fetal circulation, possibly due to a protective effect of the placenta. A 10-fold increase in the dose of LPS (from 300 ng to 3 microg/kg bodyweight) given to neonatal lambs elicited an increase in several cytokine responses measured, with a significant (P< 0.05) increase in follistatin release. In contrast, the amount of activin released by the increased dose of LPS was similar to that invoked by the lower dose. The effect of tolerance to LPS was investigated by giving a second challenge of LPS 5 days after the initial injection. In all animals studied, there was an ablated (P < 0.05) response to the subsequent LPS injection, apart from a similar temperature-response profile. These data provide further evidence that activin A concentrations in the bloodstream are acutely responsive to inflammatory challenge in post-natal life and suggest that the response forms a significant component of the innate immune system.

The New Zealand Socio-economic Index of Occupational Status: methodological revision and imputation for missing data

OBJECTIVES

To revise and update the New Zealand Socio-economic Index (NZSEI) in the light of methodological issues in its construction, and to develop an imputation method for use where occupational information is not available.

METHODS

Data were drawn from the following New Zealand national surveys: 1996 Population Census; 1996/97 and 1997/98 Household Economic Surveys; 1996/97 Household Health Survey. Three sets of statistical analyses were applied: alternating least squares to generate socio-economic scores; cluster and discriminant function analyses to identify cut-points; and regression and logistic regression to develop and test imputation methods.

RESULTS

Socio-economic scores for the full-time workforce in 1996 showed a different distribution, but much the same occupational ordering, as in 1991. The introduction of part-time workers and income adjustment multipliers for self-employed workers significantly affected scores for management and agricultural titles. The application of cluster and discriminant function analyses generated six groupings that were relatively distinct occupationally. An imputation method based on an averaging of scores within age/qualification categories was found to achieve acceptable results.

CONCLUSIONS

Methodological improvements in the construction of the NZSEI have enhanced its empirical robustness, while a simple imputation technique has widened the potential application of the scale.

Mechanisms responsible for parturition; the use of experimental models

In this review, our knowledge, gleaned from a range of species, of what determines gestation length, how fetal maturation and birth are synchronized and how the uterotonic mechanisms are activated at birth are discussed. Accumulated data indicate that fetal glucocorticoids are involved in, but do not necessarily play a causative role in, the initiation of parturition in eutherian mammals generally. Present observations are consistent with a complex, positive regulatory interaction between estrogens, prostaglandins and oxytocin and are consistent with a role for prostaglandins as the final, common effector in myometrial activation. We are, however, left with the possibility that the initial mechanism for the timing of birth is encoded in the fetal genome and is closely linked to, and activated when, certain prerequisite developmental events have occurred in the fetus. Our understanding of these events in the sheep have led to its extensive use as an experimental model for the study of human clinical correlates of fetal maturation and development and the control of the initiation of parturition.

Effect of graded hypoxia on activin A, prostaglandin E2 and cortisol levels in the late-pregnant sheep

The aim of the present study was to determine whether activin A concentrations are dependent on feto–placental oxygen availability and to investigate the temporal relationship of activin A with prostaglandin (PG) E2 and cortisol. Nine fetal sheep (six hypoxic and three control) were instrumented and catheterised at 0.8 gestation. Reduced uterine blood flow was used to achieve three levels of hypoxia (mild = fetal SaO2 40–50%; moderate = fetal SaO2 30–40%; severe = fetal SaO2 20–30%), for 4 h on 3 consecutive days. Activin A, PGE2 and cortisol levels were determined in maternal and fetal blood and amniotic fluid. Moderate and severe hypoxia produced a significant (P < 0.05) increase in fetal plasma activin A concentrations. The amniotic fluid activin A concentrations were 15-fold higher than those in the fetal circulation, but were unchanged by hypoxia. The fetal PGE2 response reflected the degree of hypoxia over the 3 days, with moderate and severe hypoxia producing a significant (P < 0.05) increase in PGE2 concentrations. Fetal plasma cortisol concentrations were increased (P < 0.05) during all levels of hypoxia. Fetal arterial activin A was increased in response to moderate and severe hypoxia, but levels were not maintained over the hypoxic period. The increases in activin A and cortisol concentrations preceded the increase in PGE2.

221.Effects of exogenous gonadotrophin stimulation on ovarian tissue grafts in the mouse

Ovarian tissue grafts commonly contain only limited numbers of follicles. The functional life span and ability to retrieve as many mature oocytes as possible from ovarian grafts is important when grafting is used to restore fertility. This study aimed to determine whether ovarian grafts responded to exogenous hormones in a similar manner to that of in situ ovaries. Ovaries of C57BlxCBA F1 mice were cut in half and grafted to one of three different graft sites in females of the same F1 line; bursal capsule (BC, n = 12), kidney capsule (KC, n = 6), subcutaneous tissue (SC, n = 24). Three weeks after grafting, half of the graft recipients in each group were treated with 5IU PMSG followed by 5IU hCG 48 hours later. Oocytes were collected directly from the grafted ovaries 10 hours after the hCG injection and fertilized in vitro. Oocytes from the ovaries of superovulated normal mice (n = 4) of the same hybrid strain were used as controls. Two-cell embryos were transferred to pseudopregnant recipients and collected at day 15 of gestation or the animals were allowed to go to term. Mature fertilisable MII oocytes were retrieved from stimulated grafts from all graft sites, however, the number (BC 9, KC 5, SC 2 oocytes per ovary) and proportion of two-cell embryos in each grafted group (BC 52%, KC 32%, SC 32%) was significantly (P < 0.05) lower than in the in vivo matured control (16 oocytes, 85% two-cell). The fetal and placental weights of fetuses produced from graft-derived oocytes were not significantly different to the control group. Phenotypically normal pups were born in each of the graft and control groups. In conclusion, ovarian grafts treated with exogenous gonadotrophins produce significantly fewer mature oocytes and two cell embryos compared to in situ ovaries. Work supported by ARC and NIH RFA.

Influence of hormone environment and donor age on cryopreserved common wombat (Vombatus ursinus) ovarian tissue xenografted into nude mice

Developmentally competent oocytes can be collected from xenografted ovarian tissues; however, optimal xenograft conditions need to be established for this technique to be of use in assisted reproduction. In the present study, common wombat ovarian tissue was xenografted under the kidney capsule of nude mice to clarify the role of recipient gonadal status and donor tissue age on graft establishment, follicle development and oocyte recovery. Eighty-nine per cent of all grafts were recovered; of these, 78% contained growing follicles. In female graft recipients, follicle development to the antral stage occurred earlier in ovariectomised recipients compared with intact graft recipients. Similarly, follicle development occurred earlier in recipients of pouch young ovarian tissue grafts when compared with subadult xenografts. Follicle development proceeded to the antral stage in subadult grafts placed under the kidney capsule of male recipient mice, albeit at a slower rate than subadult grafts placed in female recipients. Oocytes were collected from grafts placed in female and male recipients, but no mature oocytes were observed at the time of collection, nor could these oocytes be matured in vitro. The present study demonstrated that common wombat pouch young tissue xenografted to female recipient mice, and subadult ovarian tissue xenografted to male recipient mice, can develop to the antral stage and can therefore facilitate oocyte collection. However, mature oocytes were not obtained using the current protocol.

Effect of ovariectomy and graft position on cryopreserved common wombat (Vombatus ursinus) ovarian tissue following xenografting to nude mice

Ovarian tissue xenografting may be applied to increase the population size of rare or endangered animals. However, optimal grafting conditions, such as graft position and recipient hormonal status, are yet to be established. The present study, using common wombat ovarian tissue, showed that development of xenografted ovarian tissue to the antral follicle stage can be achieved irrespective of graft position. However, increased graft recovery rates and follicle survival were evident after grafting under the kidney capsule compared with grafting to subcutaneous sites. No increase in follicle development was observed after placing grafts both under the kidney capsule and subcutaneously in the one recipient compared with grafts placed under the kidney capsule alone or subcutaneously alone. Removal of the recipient’s own ovaries at the time of grafting accelerated graft follicle development, with antral follicles seen by Week 12 after grafting compared with by Week 16 in recipients that retained their own ovaries. More oocytes were collected from xenograft recipients receiving hormonal stimulation before collection compared with non-stimulated recipients. No oocytes were mature (extruded a polar body) at the time of collection or after a subsequent period of in vitro maturation. This is the first study to demonstrate that antral follicle development can occur and oocytes can be collected from xenografted common wombat ovarian tissue.

Fertility of mice following receipt of ovaries slow cooled in dimethyl sulphoxide or ethylene glycol is largely independent of cryopreservation equilibration time and temperature

Cryopreservation procedures generally depend on both the cryoprotectant used and the equilibration conditions to which the material is exposed. The aim of the present study was to examine the effect of cryoprotectants (dimethyl sulphoxide (DMSO) and ethylene glycol (EG)) and equilibration conditions (0, 30 or 120 min at 0°C or 120 min at room temperature) on the fertility of mice receiving cryopreserved mouse ovaries. The study compared the fertility of cryopreserved Day 14 mouse pup ovaries following grafting to adult recipient mice for 4 months. There was no effect of the cryoprotectant or equilibration condition used on the interval to the first plugging/mating or on the interval to the birth of the first litter, the size of litters, the number of litters produced or the total number of offspring produced. Despite this, when compared with control females (untreated, sham and fresh transplant) the cryopreservation and transplantation procedures delayed fertility. However, the size of litters was equivalent for all cryopreserved and control groups (P > 0.05). The results show that, for the equilibration conditions examined, DMSO and EG are equally efficient cryoprotective agents for mouse ovarian tissue.

In vitro maturation of oocytes from non-stimulated common wombats

Assisted reproductive techniques, such as in vitro oocyte maturation in conjunction with in vitro fertilisation, may be used as a tool to manipulate reproduction. Using the common wombat as a model for the critically endangered northern hairy-nosed wombat, the present study examined whether oocyte maturation could be achieved under field conditions. At the time of collection, no oocytes were at the metaphase II (MII) stage (0/42). After 60 h culture using the submarine incubation system, 34% of oocytes (24/70) matured to telophase/MII, as indicated by the presence of a polar body. The proportion of oocytes that reached MII was higher for oocytes collected from follicles >2 mm in diameter compared with follicles <2 mm (40% v. 22%, respectively). The presence of cumulus cells alone did not influence the maturation potential. Oocytes without cumulus cells collected from follicles >2 mm in diameter had the highest maturation rate (58%). Maturation was not affected by the reproductive status of the common wombat or a delay of up to 5 h before oocyte collection. In conclusion, the present study demonstrated that oocytes collected from non-stimulated common wombats can mature to MII in culture.

Comparison of the effects of in vitro and in situ storage on the viability of mouse ovarian tissue collected after death

Ovarian tissues, collected or salvaged from endangered species at the time of gonadectomy or following their death, are being transported to genebanks for storage with the assumption that they will (subsequently) yield sufficient numbers of germ cells to help preserve the species. The present study aimed to quantify the impact of delays in collecting and/or processing ovarian tissue on the number of follicles in this tissue that remained normal after grafting. The study compared the viability of ovarian tissue stored in vitro (in phosphate-buffered saline) versus in situ (in the body) either on ice or at room temperature for 0 (non-stored fresh grafts), 3, 6, 12, 24 or 48 h. The conditions of storage had significant effects on the total number of morphologically normal follicles, with significantly more follicles in grafts developing from in vitro-stored tissue than in situ-stored tissue. Storage temperature and duration of storage, but not the storage temperature alone, influenced follicle survival. Tissue that was grafted immediately after collection (0 h) was best, but normal follicles were recovered in grafts stored in vitro (on ice or at room temperature) or in situ (on ice only) for up to 48 h before grafting. The rate of follicle loss over time was very rapid, with approximately 50% fewer follicles in grafts derived from tissue stored for only 3 h compared with non-stored fresh grafts (0 h). The results show that viable ovarian tissue can be salvaged from animals up to 48 h after death; however, in order to best protect the follicle population, the ovaries should be removed from the animal's body as soon as possible.

Inhibition of prostaglandin synthesis and its effect on uterine activity during established premature labor in sheep

OBJECTIVE

Continuous infusion of the selective prostaglandin synthase type-2 inhibitor nimesulide, together with the oxytocin receptor antagonist atosiban, inhibits glucocorticoid induction of labor in sheep. We evaluated the effectiveness of this treatment commencing after the onset of premature labor when prostaglandin concentrations are already significantly elevated.

METHODS

Premature labor was induced in chronically cannulated fetuses by constant fetal dexamethasone infusion. After the onset of active labor in each ewe, defined as uterine electromyographic (EMG) activity twice basal levels, ewes received combined nimesulide and atosiban (20.0 and 4.12 mg/kg per day, respectively; n = 6) or vehicle (n-methyl-2-pyrrolidone and saline each 1 mL/hour; n = 4) infusions for 48 hours. Maternal and fetal plasma PGFM (13,14-dihydro-15-keto PGF2alpha, the stable metabolite of prostaglandin (PG) F2alpha) and PGE2 concentrations were measured before, during, and after infusions.

RESULTS

Four nimesulide- and atosiban-treated ewes successfully completed the 48-hour infusion period with no deliveries occurring during inhibitor treatment, or up to 6 hours after inhibitor treatment. Delivery was delayed in two other ewes, compared with control animals. Uterine EMG activity in nimesulide- and atosiban-treated ewes (n = 4) was significantly reduced during the 48-hour inhibitor treatment period. Maternal and fetal prostaglandin concentrations were significantly decreased in inhibitor-treated ewes during and after the infusions.

CONCLUSIONS

The combination of nimesulide and atosiban treatment for 48 hours successfully inhibited the progression of active premature labor to delivery. This study further supports the potential value of this treatment regime for the inhibition of premature labor.

Physiological and regulatory roles of activin A in late pregnancy

Unexplained fetal death in utero in late pregnancy represents an increasing proportion of perinatal deaths. It has been assumed that critical hypoxia is the likely mechanism underlying these losses, but the lack of a physiological marker has hampered both confirmation and prediction which could lead to timely intervention. In this paper, we report studies on hypoxia that we have performed in chronically cannulated late pregnant sheep, complemented by parallel investigations undertaken in human pregnancies. Our initial studies were directed towards determining activin secretion in the fetus and mother during late gestation, and immediately after fetal surgery using a sheep model. This led us to propose that there may be a relationship between hypoxia and activin A, follistatin and prostaglandin (PG) release from the feto-placental unit. Subsequent studies have been directed towards examining this potential relationship in sheep and in humans with compromised pregnancies. As a result of these studies, we have identified a potential mechanism by which activin A may be involved in regulating the response of the fetus to hypoxic insult. Activin A and follistatin concentrations increased in late gestation in ovine maternal plasma and in fetal fluids. Feto-placental hypoxemia or maternal isocapnic hypoxemia, leading to fetal hypoxia, were specific triggers for an acute increase in fetal activin A and follistatin concentrations during late gestation. The source and secretion of activin A, follistatin, and the associated release of PGE(2,) from within the feto-placental unit varied according to the site of the insult. The concomitant secretion of activin A and PGE(2) into the fetal circulation and amniotic fluid during reduced uterine blood flow provides an insight into the physiological regulatory mechanisms that might be involved. Changes observed in maternal activin A concentrations in mid and late gestation in the human may also be associated with fetal compromise. In human pregnancies, elevated activin A concentrations were observed in maternal plasma in mid and late gestation, in association with severe pre-eclampsia and with severe fetal growth restriction, compared to those observed in pregnancies with constitutionally small, healthy fetuses. Activin A was also elevated in maternal and arterial cord plasma in women at term during labour and immediately prior to undergoing emergency Caesarean section for failure to progress. These findings offer exciting new possibilities to gain insights into the mechanisms that underlie the maintenance of fetal wellbeing and provide a rationale for the potential that activin A may prove to be a useful clinical marker of fetal distress.

Cryopreservation of mouse ovarian tissue following prolonged exposure to an Ischemic environment

In cases in which ovarian tissue is to be cryopreserved for tissue or gene banking it is important to maintain its integrity and viability. This study examined how delays between the death of an animal and the collection/cryopreservation of its ovarian tissue influenced follicle viability. Mouse ovaries were placed in PBS+antibiotic (in vitro) or left within the body (in situ) at room temperature for 0, 3, 6, 12, or 24 h following the death of the donor. These ovaries were cryopreserved at 1 degrees C/min on dry ice or in a -84 degrees C freezer using a passive cooling device or by conventional slow cooling (0.3 degrees C/min). The ovaries were grafted under the kidney capsule of ovariectomized recipient mice and collected 2 weeks later, and the size and number of follicles were determined. Cryopreserved ovarian tissue grafted immediately after the death of the donor contained numerous viable and healthy follicles independent of the cooling procedure (dry ice, 134 +/- 32; -84 degrees C, 165 +/- 54; slow, 214 +/- 55 follicles per half ovary). Tissues stored in vitro before cryopreservation retained viable follicles up to 12 h after death (dry ice, 30 +/- 15; -84 degrees C, 86 +/- 45; slow, 93 +/- 33), whereas tissue left in situ had significantly reduced follicle numbers within 3 h of death (dry ice, 36 +/- 12; -84 degrees C, 19 +/- 6; slow, 28 +/- 7). No significant difference was found between the cooling rates tested, indicating that a passive cooling container which cools at 1 degrees C/min is a suitable alternative to conventional slow cooling. We conclude that ovarian tissues for cryobanking should be cryopreserved as soon as possible after collection or death of the animal to ensure maximal follicular survival.