Trust and service engagement among people who inject drugs after release from prison

BACKGROUND

Compounding histories of injecting drug use and incarceration can marginalise people engaging with services, making it difficult for them to address their health and social welfare needs, particularly when they navigate community re-entry service supports. Drawing on Hall and colleagues' five components of trust, this paper seeks to understand how trust in service providers fosters (or inhibits) effective service engagement from the perspective of people who inject drugs during the prison post-release period.

METHODS

Between September 2018 and May 2020, qualitative in-depth interviews were completed with 48 adults (33 men, 15 women) recruited from SuperMIX (a longitudinal cohort study of people with a history of injection drug use in Victoria, Australia). Data relating to service engagement were coded against the five components of trust: competence, fidelity, honesty, global trust, and confidence.

RESULTS

Reflections of post-release service engagement frequently focused on interactions with community corrections (parole) officers. Depictions of trust were consistently portrayed within the context of negative experiences and deficits, whereby trusting provider relationships and interactions were rarely described. Most participants recounted a stark absence of fidelity (that is, "pursuing a [client's] best interests"), with some participants detailing circumstances in which their vulnerability was purposefully, almost strategically, exploited. These encounters nearly always had the consequence of impeding the participant's positive progression in the post-release integration period.

CONCLUSION

There is an urgent need to prioritise the client in health and social service delivery in the post-release transition-to-community period and recognise the importance of trust in delivering effective services to people whose life histories make them highly vulnerable to marginalisation.

The APPLE Tree programme: Active Prevention in People at risk of dementia through Lifestyle, bEhaviour change and Technology to build REsiliEnce-randomised controlled trial

BACKGROUND

Large-scale trials of multidomain interventions show that modifying lifestyle and psychological risk factors can slow cognitive decline. We aim to determine if a lower intensity, personally tailored secondary dementia prevention programme for older people with subjective or mild objective memory decline, informed by behaviour change theory, reduces cognitive decline over 2 years.

METHODS

A multi-site, single-blind randomised controlled trial recruiting 704 older adults at high dementia risk due to mild cognitive impairment (MCI) or subjective cognitive decline (SCD). Participants are randomised using 1:1 allocation ratio to the APPLE Tree intervention versus control arm (dementia prevention information), stratified by site. The intervention explores and implements strategies to promote healthy lifestyle, increase pleasurable activities and social connections and improve long-term condition self-management. Two facilitators trained and supervised by a clinical psychologist deliver ten, 1-h group video call sessions over 6 months (approximately every fortnight), video-call 'tea breaks' (less structured, facilitated social sessions) in intervening weeks and individual goal-setting phone calls every 2 weeks. From 6 to 12 months, participants meet monthly for 'tea breaks', with those not attending receiving monthly goal-setting phone calls. Participants receive a food delivery, pedometer and website access to cognitive training and information about lifestyle modification. Follow-ups for all outcome measures are at 12 and 24 months. The primary outcome is cognition (Neuropsychological Test Battery (NTB) score) at 24 months. Secondary outcomes are quality of life, cost per quality-adjusted life year (QALY) and wellbeing and lifestyle factors the intervention targets (diet, vascular risk, body weight, activity, sleep, anxiety, depression, social networks and loneliness, alcohol intake and smoking). Participants from purposively selected sites participate in qualitative process evaluation interviews, which will be analysed using thematic analytic methods.

DISCUSSION

If effective, the intervention design, involving remote delivery and non-clinical facilitators, would facilitate intervention roll-out to older people with memory concerns.

TRIAL REGISTRATION

ISRCTN17325135 . Registration date 27 November 2019.

"I'm obviously not dying so it's not something I need to sort out today": Considering hepatitis C treatment in the era of direct acting antivirals

BACKGROUND

People who inject drugs are the group at greatest risk of hepatitis C virus (HCV) infection. The advent of new direct-acting antiviral (DAA) treatment provides opportunities for increased uptake of therapy.

METHODS

We conducted in-depth interviews with thirty HCV positive participants from the SuperMIX cohort study. Interviews were transcribed, coded, and analysed for emerging themes and similarities between participants. General descriptions and critical interpretation of themes were generated and selective quotes extracted verbatim to best illustrate the critical themes.

RESULTS

Participants described their experiences of living with HCV, their knowledge of HCV treatment accessibility, and information on the types of support ain themes: Understanding the need for treatment; Knowledge and framing of treatment access; and Support during treatment.

CONCLUSION

The new, highly effective DAAs for the treatment of HCV are heralded as the potential beginning of HCV elimination, especially in settings where scale up is high. Our data from active PWID show that the availability of DAA medications in and of themselves is likely not to be enough to ensure that PWID will come forward for HCV treatment in sufficient numbers to drive elimination.

Community-based provision of direct-acting antiviral therapy for hepatitis C: study protocol and challenges of a randomized controlled trial

BACKGROUND

To achieve the World Health Organization hepatitis C virus (HCV) elimination targets, it is essential to increase access to treatment. Direct-acting antiviral (DAA) treatment can be provided in primary healthcare services (PHCS), improving accessibility, and, potentially, retention in care. Here, we describe our protocol for assessing the effectiveness of providing DAAs in PHCS, and the impact on the HCV care cascade. In addition, we reflect on the challenges of conducting a model of care study during a period of unprecedented change in HCV care and treatment.

METHODS

Consenting patients with HCV infection attending 13 PHCS in Australia or New Zealand are randomized to receive DAA treatment at the local tertiary institution (standard care arm), or their PHCS (intervention arm). The primary endpoint is the proportion commenced on DAAs and cured. Treatment providers at the PHCS include: hepatology nurses, primary care practitioners, or, in two sites, a specialist physician. All PHCS offer opioid substitution therapy.

DISCUSSION

The Prime Study is the first real-world, randomized, model of care study exploring the impact of community provision of DAA therapy on HCV-treatment uptake and cure. Although the study has faced challenges unique to this period of time characterized by changing treatment and service delivery, the data gained will be of critical importance in shaping health service policy that enables the elimination of HCV.

TRIAL REGISTRATION

ClinicalTrials.gov , ID: NCT02555475 . Registered on 15 September 2015.

Evidence of niche partitioning among bacteria living on plastics, organic particles and surrounding seawaters

Plastic pollution is widespread in ocean ecosystems worldwide, but it is unknown if plastic offers a unique habitat for bacteria compared to communities in the water column and attached to naturally-occurring organic particles. The large set of samples taken during the Tara-Mediterranean expedition revealed for the first time a clear niche partitioning between free-living (FL), organic particle-attached (PA) and the recently introduced plastic marine debris (PMD). Bacterial counts in PMD presented higher cell enrichment factors than generally observed for PA fraction, when compared to FL bacteria in the surrounding waters. Taxonomic diversity was also higher in the PMD communities, where higher evenness indicated a favorable environment for a very large number of species. Cyanobacteria were particularly overrepresented in PMD, together with essential functions for biofilm formation and maturation. The community distinction between the three habitats was consistent across the large-scale sampling in the Western Mediterranean basin. 'Plastic specific bacteria' recovered only on the PMD represented half of the OTUs, thus forming a distinct habitat that should be further considered for understanding microbial biodiversity in changing marine ecosystems.

A decade of research using the CASP scale: key findings and future directions

Since the publication of A Measure of Quality of Life in Early Old Age: The Theory, Development and Properties of a Needs Satisfaction Model (CASP-19) just over 10 years ago, the scale has gone on to be used in a wide variety of studies in over 20 countries across the world and the original paper has become the most highly cited paper for Aging and Mental Health. Therefore it was felt that it was a good time to look back and reflect on the developments in the use of the scale as well as to look forward to what new research is being done and could be done with the measure. To this end we are extremely grateful for the editors for allowing us to bring together a collection of papers that represent cutting edge research using the CASP scale. These papers cover a wide variety of issues, from working conditions to religiosity, from a range of countries, covering Western and Eastern Europe as well as Africa. Each makes an important individual contribution to our understanding of the factors that influence quality of life in later life as well as pointing to the limitations of the measure and future work that can be done in this area.

Measurement of thyroxine and cortisol in canine and feline blood samples using two immunoassay analysers

OBJECTIVES

The AIA-360 (Tosoh Corporation) is an automated immunoassay analyser. The aims of this study were to estimate the precision of thyroxine and cortisol AIA-360 immunoassays in canine and feline samples and to compare the results produced with those obtained by a chemiluminescence analyser (Immulite® 1000, Siemens).

METHODS

Blood samples from 240 clinical cases (60 dogs and 60 cats for both thyroxine and cortisol) were analysed using both instruments.

RESULTS

Deming regression calculations showed excellent correlation (thyroxine, canine rs  = 0 · 94, feline rs  = 0 · 97; cortisol, canine rs  = 0 · 97, feline rs  = 0 · 97). Agreement between the two instruments was examined by Bland-Altman difference plots, which identified wide confidence intervals and outliers for thyroxine (canine n = 6, feline n = 4) and cortisol (canine n = 3, feline n = 4) results. Inter/intra-run precision of the AIA-360 was excellent for both cortisol and thyroxine (coefficients of variation <7%).

CLINICAL SIGNIFICANCE

The instrument showed excellent correlation for cortisol and thyroxine in canine and feline samples demonstrating that the AIA-360 can be used in clinical practice. The agreement studies suggest that the results from the AIA-360 cannot be used interchangeably with those generated by the Immulite 1000 and should be interpreted using reference intervals that have been established specific to the AIA-360.

The relationship between age and risky injecting behaviours among a sample of Australian people who inject drugs

BACKGROUND

Limited evidence suggests that younger people who inject drugs (PWID) engage in high-risk injecting behaviours. This study aims to better understand the relationships between age and risky injecting behaviours.

METHODS

Data were taken from 11 years of a repeat cross-sectional study of sentinel samples of regular PWID (The Australian Illicit Drug Reporting System, 2001-2011). Multivariable Poisson regression was used to explore the relationship between age and four outcomes of interest: last drug injection occurred in public, receptive needle sharing (past month), experiencing injecting-related problems (e.g. abscess, dirty hit; past month), and non-fatal heroin overdose (past six months).

RESULTS

Data from 6795 first-time study participants were analysed (median age: 33 years, interquartile range [IQR]: 27-40; median duration of injecting: 13 years [IQR: 7-20]). After adjusting for factors including duration of injecting, each five year increase in age was associated with significant reductions in public injecting (adjusted incidence rate ratio [AIRR]: 0.90, 95% confidence interval [CI]: 0.88-0.92), needle sharing (AIRR: 0.84, 95% CI: 0.79-0.89) and injecting-related problems (AIRR: 0.96, 95% CI: 0.95-0.97). Among those who had injected heroin in the six months preceding interview, each five year increase in age was associated with an average 10% reduction in the risk of heroin overdose (AIRR: 0.90, 95% CI: 0.85-0.96).

CONCLUSIONS

Older PWID report significantly lower levels of high-risk injecting practices than younger PWID. Although they make up a small proportion of the current PWID population, younger PWID remain an important group for prevention and harm reduction.

Vietnam moves forward with harm reduction: an assessment of progress

Historically, the response of the Vietnamese government to illicit drug use and HIV has been slow and ineffective. However, 2006 saw the government formally endorse harm reduction interventions. This paper examines the views of senior key informants inside Vietnam on the development of an advocacy strategy for harm reduction. Twenty-nine informants were interviewed across public health, public security, social affairs and other international bodies, including United Nations agencies and international non-governmental organisations. Challenges and barriers identified for harm reduction progress included: promoting a nationwide understanding and acceptance of harm reduction and the HIV Law; lack of skilled resources, training programmes and technical capacity; poor coverage of interventions; and gaps in the sharing of information. There is currently a government-led shift in Vietnam in the response to the prevailing HIV epidemic among drug users, but ensuring that the HIV Law can operate unhindered is critical. The implementation of a response to illicit drug use and HIV remains an enormous challenge. With appropriate technical education and training, ongoing advocacy, and a cohesive, coordinated multi-sectoral effort, the capacity of the government and community to adopt, support and promote measures to reduce HIV and other drug-related harms will be markedly strengthened.

Aging without agency: theorizing the fourth age

This article looks at the "fourth age" as a manifestation of the fragmentation of "old age". We argue that the fourth age emerges from the institutionalization of the infirmities of old age set against the appearance of a third-age culture that negates past representations of old age. We outline the historical marginalization of old age from early modern society to the contemporary concentration of infirmity within long-term care which makes of old age an undesirable "social imaginary". As "old age" fades from the social world, we liken this to the impact of a "black hole" distorting the gravitational field surrounding it, unobservable except for its traces. Within this perspective, the fourth age can be understood by examining not the experience itself but its impact on the discourses that surround and orientate themselves to it.

Vaginal repair with mesh versus colporrhaphy for prolapse: a randomised controlled trial

OBJECTIVE

To compare vaginal repair augmented by mesh with traditional colporrhaphy for the treatment of pelvic organ prolapse.

DESIGN

Prospective randomised controlled trial.

SETTING

Tertiary teaching hospital.

POPULATION

One hundred and thirty-nine women with stage >or=2 prolapse according to the pelvic organ prolapse quantification (POP-Q) system requiring both anterior and posterior compartment repair.

METHODS

Subjects were randomised to anterior and posterior vaginal repair with mesh augmentation (mesh group, n = 69) or traditional anterior and posterior colporrhaphy (no mesh group, n = 70).

MAIN OUTCOME MEASURES

The primary outcome was the absence of POP-Q stage >or=2 prolapse at 12 months. Secondary outcomes were symptoms, quality-of-life outcomes and satisfaction with surgery. Complications were also reported.

RESULTS

For subjects attending the 12-month review, success in the mesh group was 81.0% (51 of 63 subjects) compared with 65.6% (40/61) in the no mesh group and was not significantly different (P-value = 0.07). A high level of satisfaction with surgery and improvements in symptoms and quality-of-life data were observed at 12 months compared to baseline in both groups, but there was no significant difference in these outcomes between the two groups. Vaginal mesh exposure occurred in four women in the mesh group (5.6%). De novo dyspareunia was reported by five of 30 (16.7%) sexually active women in the mesh group and five of 33 (15.2%) in the no mesh group at 12 months.

CONCLUSION

In this study, vaginal surgery augmented by mesh did not result in significantly less recurrent prolapse than traditional colporrhaphy 12 months following surgery.

Vaginal surgery for pelvic organ prolapse using mesh and a vaginal support device

Objectives

To describe a new surgical procedure for pelvic organ prolapse using mesh and a vaginal support device (VSD) and to report the results of surgery.

Design

A prospective observational study

Setting

Two tertiary referral Urogynaecology practices.

Population

Ninety-five women with International Continence Society pelvic organ prolapse quantification stage 2 or more pelvic organ prolapse who underwent vaginal surgery using mesh augmentation and a VSD.

Methods

Surgery involved a vaginal approach with mesh reinforcement and placement of a VSD for 4 weeks. At 6 and 12 months, women were examined for prolapse recurrence, and visual analogue scales for satisfaction were completed. Women completed quality-of-life (QOL) questionnaires preoperatively and at 6 and 12 months.

Main outcome measures

Objective success of surgery at 6 and 12 months following surgery. Secondary outcomes were subjective success, complications, QOL outcomes and patients’ satisfaction.

Results

Objective success rate was 92 and 85% at 6 and 12 months, respectively. Subjective success rate was 91 and 87% at 6 and 12 months, respectively. New prolapse in nonrepaired compartments accounted for 7 of 12 (58%) failures at 12 months. Two of 4 mesh exposures required surgery. Sexual dysfunction was reported by 58% of sexually active women preoperatively and 23% at 12 months. QOL scores significantly improved at 12 months compared with baseline (P < 0.0001).

Conclusion

Vaginal surgery using mesh and a VSD is an effective procedure for pelvic organ prolapse. However, further studies are required to establish the role of the surgery described in this study.

Please cite this paper as:Carey M, Slack M, Higgs P, Wynn-Williams M, Cornish A. Vaginal surgery for pelvic organ prolapse using mesh and a vaginal support device. BJOG 2008;115:391–397.

Differences in the social networks of ethnic Vietnamese and non-Vietnamese injecting drug users and their implications for blood-borne virus transmission

The social networks of 49 ethnic Vietnamese injecting drug users (IDUs) and 150 IDUs of other ethnicities recruited in Melbourne, Australia, were examined for ethnic differences in distribution of hepatitis C virus infection risk using social network analysis and molecular epidemiology. Vietnamese IDUs were more highly connected than non-Vietnamese IDUs, and more likely to be members of dense injecting sub-networks. More related infections were detected in IDUs with discordant ethnicities than were captured in the social network data; nonetheless, most dyads and most IDU pairs with related infections had matching ethnicity, confirming that mixing was assortative on that criterion. Mixing was not obviously dissortative by risk; low-risk Vietnamese IDUs injected more frequently than did correspondingly low-risk non-Vietnamese IDUs, but results for other measures were reversed or equivocal. Network measurements suggest that ethnic Vietnamese IDUs are at elevated risk of blood-borne infection, a conclusion supported by their relatively high HIV prevalence.

MRI findings following laparoscopic sacrocolpopexy

Sacrocolpopexy is a surgical procedure that provides effective treatment for pelvic prolapse. The surgical technique and complications of laproscopic sacrocolpopexy are described. This review presents experience of MRI for postoperative assessment and illustrates normal and abnormal findings.

Life course influences on quality of life in early old age

A growing literature demonstrates life course influences on health in early old age. The present paper is the first to examine whether similar processes also influence quality of life in early old age. The question is theorised in terms of structured dependency and third age, and the life course pathways by which people arrive at these destinations in later life. The issues are investigated in a unique data set that contains health and life course information on some 300 individuals mostly aged 65-75 years, enhanced in 2000 by postal survey data on quality of life. Several types of life course effect are identified at conventional levels of statistical significance. Long-term influences on quality of life, however, are less marked than those on health. Quality of life in early old age appears to be influenced primarily by current contextual factors such as material circumstances and serious health problems, with the influence of the life course limited mostly to its shaping of an individual's circumstances in later life. The implication for policy is that disadvantage during childhood and adulthood does not preclude good quality of life in early old age.

A measure of quality of life in early old age: the theory, development and properties of a needs satisfaction model (CASP-19)

Quality of life is the subject of much research. However it lacks an agreed theoretical basis. In studies with older populations(ill) health has been used as a proxy measure for quality of life (QoL). We have developed a needs satisfaction measure of QoL in early old age. Our measure has four ontologically grounded domains: conal, autonomy, pleasure, and self-realization. The measure was piloted with focus groups, a self-completion pilot, and cognitive interview testing. This produced a 22-item scale that was included in a postal questionnaire and sent to 286 people aged 65-75 years.A 92% response rate was achieved. The scale was reduced to 19 items on the basis of statistical analysis. The domains have Cronbach's alphas between 0.6 and 0.8. Correlations between the four domains range from 0.4 to 0.7. A second order factor analysis revealed a single latent QoL factor. The scores for the 19-item scale are well distributed along the range although they exhibit a slight negative skew. Concurrent validity was assessed using the Life Satisfaction Index--wellbeing. A strong and positive association was found between the two scales (r= 0.6, p = 0.01). The CASP-19 appears to be a useful scale for measuring QoL in older people.

Risk behaviours of young Indo-Chinese injecting drug users in Sydney and Melbourne

OBJECTIVE

To investigate patterns of drug use and injection-related risk behaviours among young Indo-Chinese injecting drug users (IDUs).

METHOD

Cross-sectional survey. A structured questionnaire was administered to 184 Indo-Chinese IDUs aged 15 to 24 in Sydney and Melbourne. Participants were recruited using snowball sampling techniques; measures included patterns of heroin and other drug use, injection-related risk behaviours, perceived susceptibility to HIV and HCV infection and access to services.

RESULTS

Despite perceived high availability of sterile injecting equipment, 36% had ever shared a needle and syringe and 22% had done so in the preceding month. Lifetime sharing was significantly associated with duration of injecting, history of incarceration and residence in Sydney. Sharing of injecting paraphernalia other than needles and syringes was also common, with young women and Sydney residents significantly more likely to report sharing equipment in the preceding month.

CONCLUSIONS

Young Indo-Chinese IDUs are at high risk of infection with hepatitis C and other blood-borne viruses. Results indicate an urgent need for culturally appropriate and sustainable risk reduction programs which specifically target this population.

IMPLICATIONS

Health services must respond swiftly to implement effective blood-borne virus prevention programs for young Indo-Chinese IDUs. Failure to do so may sustain the current epidemic of hepatitis C among IDUs.

Evolutionary psychology and health: confronting an evolving paradigm

In much the same way that developments in genetics have opened up new areas of activity in health services, the 'new genetics' has also stimulated a renewal in approaches that try to explain the nature of health behaviours within the context of human biological development. Evolutionary psychology, as an umbrella term for these views, stresses the importance of the brain as an intermediary between genes and individual behaviour. From such a perspective, social context is less important than an understanding of why certain behaviours are 'chosen' by the evolutionary process and how they are predicated on reproductive success. Health policy is a key area where these ideas are likely to become important given evolutionary psychology's focus on the interplay between physiological and psychological factors in determining health behaviours. Health research provides a fertile environment because it is already seeking the hidden biological pathways connecting social status with specific diseases. The challenge represented by evolutionary psychology needs to be taken seriously because of the way in which such ideas mesh with the individualistic basis of much health promotion and health policy. In particular, it poses a challenge when it purports to explain how inequalities in health are not necessarily the result of the unequal distribution of income in society but are natural phenomena. It is also important to engage with such ideas because they increasingly seem likely to occupy the empty ideological space created by the disappearance of politics in policy and as such may have a greater impact than would otherwise be the case.

Paradigms of retirement: the importance of health and ageing in the Whitehall II study

This paper evaluates four well established sociological theories of ageing using qualitative data from the British Whitehall II study. We attempt to apply the theories to contemporary retirement and through each theory examine the issue of health in retirement. The effect of lowered income in retirement is discussed in relation to Townsend's theory of structured dependency. Change in participant's health following retirement is examined in respect of the theory of disengagement by Cumming and Henry, adjustment to retirement in relation to Laslett's theory of the third age. Parson's role theory is used to examine how social interactions and relationships change for people who have recently retired. We discuss the need for a multifaceted theory of ageing which can accommodate the continually changing experience and age of retirement. We analysed interviews conducted with 25 male and female civil servants aged between 55 and 63 years, from different grades who had been retired for less than 2 years.

Endometriomas in pregnancy

Endometriomas are rare in pregnancy, may not be large, may be difficult to diagnose definitively and although benign, may cause significant complications at any stage during gestation. They remain a management dilemma.

Routine pulmonary function tests in young adolescents with asthma in general practice

OBJECTIVE

To assess the value of performing routine pulmonary function tests by flow-loop spirometry in young adolescents with asthma.

DESIGN

A prospective clinical study comparing clinical assessment and patients' self-reporting of asthma severity with the results of pulmonary function tests.

SETTING

General practice in a small rural community of about 30,000 people.

PATIENTS

Young adolescents with asthma, aged 10-15 years, were enrolled in the study over a two-year period from July 1993 to June 1995 when they presented for either elective, interval assessments or with an acute exacerbation of asthma.

MAIN OUTCOME MEASURES

Discrepancy between (i) the doctor's and the patient's perception of asthma control (six scale measures) and the consequent management plans, and (ii) the results of pulmonary function tests that indicated less than adequate airway function (i.e., forced expiratory volume in one second as a percentage of predicted vital capacity for height and sex [FEV1%] less than 65% or average flow rate over the middle 50% of forced vital capacity as a percentage of predicted normal value [FEF25%-75%] less than 65%).

RESULTS

Twenty-seven adolescents with asthma were assessed on a total of 37 occasions. The results of pulmonary function tests did not correlate with asthma symptoms and treatment in 11 of the 37 assessments (30%; 95% confidence interval [CI], 16%-47%). The 11 assessments were performed on eight patients.

CONCLUSIONS

This small community-based study of adolescents with asthma supports the view that pulmonary function testing by flow-loop spirometry should be part of the routine assessment of acute and chronic asthmatics. Further study in a larger community is needed to clarify the frequency of over- and underestimation of asthma severity in this difficult age group.

Prospective comparative clinical trials in The Journal of Hand Surgery (American)

All issues of The Journal of Hand Surgery (American) from volume 1, number 1 through volume 19, number 6, were reviewed to identify studies that might qualify as prospective, comparative clinical trials. Prospective studies that compared two or more clinical treatments were labeled as either randomized controlled trials (RCT) if they included some form of random assignment or controlled clinical trials (CCT) if they did not. A total of 25 CCT and 8 RCT were identified among the 3,107 articles, letters, and abstracts that were reviewed. The results will be used to update the Medline Database, to make online identification of RCTs and CCTs easier.

Extension of the breeding season of the New Holland Mouse: a response to above-average rainfall

The New Holland mouse, Pseudomys novaehollandiae, has been reported to have a distinct 5-month breeding season, August to early January, with occasionally an extension to March. Hence it is classified as primarily a seasonal breeder with some of the flexibility of an opportunistic breeder. We present evidence of an extension of the 1991-92 breeding season to at least 10 months, from mid-October or earlier, to late July. In May 62.5% of females were pregnant or lactating whereas 25-44% were pregnant or lactating at different sites in July. Our data from sand-mined dunes extend from Bridge Hill Ridge at the northern end of the Myall Lakes National Park to Tomago near the mouth of the Hunter River. We collate data from studies over the last 20 years, documenting extended breeding in 8 different years, 6 from one region, and at least 4 from another. Twenty years of rainfall data from nearby weather stations in the two regions show extended breeding to be a response to climate, when rainfall between September and March exceeds a threshold value of 750-800mm (approximately 120% of the long-term average), with at least 420-480mm falling during the first three months of the year (approximately 130% of the long-term average). While rainfall appears to be the ultimate factor, we support Kemper''s hypothesis that the proximal factor is most likely to be the abundance or quality of food produced by above-average late summer rainfall.

Upper extremity impairment in workers performing repetitive tasks

A series of subjective and objective measures were chosen to determine impairment of upper extremity function in 157 workers performing repetitive tasks. Workers were asked to respond to questions regarding their perception of the presence or absence of numbness, pain, weakness, or swelling in their upper extremities. Objective tests consisted of the measurement of grip strength, pinch strength, Semmes-Weinstein monofilament sensory responses, vibrometer responses, neurometer measurement, and the presence or absence of Tinel's or Phalen's signs. These measures were considered collectively to estimate the overall levels of impairment of each individual. Overall findings show that 55 percent of workers examined had impairment scores of 2 or more and 75 percent had scores of 1 or more. Significant differences were found in impairment ratings between job types. Those jobs requiring the highest repetition with the least rest per cycle had the highest impairment ratings. Workers that rotated jobs had impairment scores significantly less (p less than 0.005) than the average of workers performing single-task jobs. We conclude that cumulative trauma disorders are more prevalent than originally believed and that the disorder is best examined from an overall functional impairment perspective.

A survey of long-term care elderly patients in the South West Thames Region

This paper describes a survey which focuses on the patients in National Health Service long-term care beds. It examines the dependency levels and mental impairment of geriatric patients in 15 Departments of Geriatric Medicine, and determines the extent and distribution of patient dependency, including the number of independent patients. The findings support the view that there is a need for National Health Service long-term care beds.