Exploring the perceptions and acceptability of an integrated lifestyle database for public health research and service commissioning: a qualitative study

AIM

Public health lifestyle databases at local authority level are currently poorly aligned across the UK. The integration of lifestyle databases at a regional level could provide a rich resource to support research and help inform public health leads and service commissioners in improving service delivery, facilitating decision-making and developing key public health policies. Prior to its implementation, the acceptability of an integrated lifestyle database should be explored. The aim of this study was to consult with public health stakeholders to explore the acceptability of developing and implementing a regional integrated lifestyle database across four key areas of public health: smoking cessation, diet, physical activity and alcohol consumption.

METHOD

Qualitative interviews were conducted with public health stakeholders recruited from across the East Midlands region of England. All interviews were conducted using video conferencing software and recorded, transcribed, and analysed using the Framework approach. Sixteen public health stakeholders were purposively identified and invited to participate in interviews.

RESULTS

Stakeholders viewed the integrated database as having potential to support research, service development and commissioning decisions. Barriers such as providers' reluctance to reveal their business strategies to rival organisations, cost of setting up and running the proposed database, complex information-sharing and governance were identified.

CONCLUSION

An integrated lifestyle database has the potential to support research and service commissioning regionally. However, several barriers were identified that must be addressed prior to the development and implementation of an integrated database.

Factors supporting career pathway development amongst advanced practice nurses in Thailand: A cross-sectional survey

BACKGROUND

Thailand has recently reformed its health care system and this change has contributed to the rapidly increasing need for skilled and experienced specialist nurses and in 2003 a new Advanced Practice Nursing role was formally introduced. While Advanced Practice Nursing is now accepted as a clinical career option, there is little understanding of the factors conducive to successful career development. This study offers the first examination of factors associated with successful career progression for Advanced Practice Nurses in Thailand.

OBJECTIVES

1. To provide a description of the Advanced Practice Nurse population in Thailand, as represented by a purposive stratified national sample. 2. To examine the factors influencing successful career pathway development of Advanced Practice Nurses in Thailand. 3. To examine the factors which influence the extent to which Advanced Practice Nurses in Thailand engage in evidence-based practice and research.

DESIGN

National cross-sectional survey.

SETTING

Thailand.

PARTICIPANTS

333 currently practicing Advanced Practice Nurses.

METHODS

A national cross-sectional survey was conducted in Thailand in order to identify and examine key influencing factors on the successful development of Advanced Practice Nurses. The research tool was a specifically designed questionnaire in the Thai language, informed by international academic literature on the development of the Advanced Practice Nurse role, validated and piloted with 30 Advanced Practice Nurses to assess its reliability using Cronbach's alpha. The data were analysed in SPSS (version 21). Initial parametric testing was done using the Kolmogorov-Smirnov test and Pearson's correlation analysis was performed to examine the relationship between the independent variables (those measuring demographic and support factors) and the dependent variables (measuring career pathway development).

RESULTS

A response rate of 90% was achieved. A lack of clear progression routes in the Advanced Practice Nurse structure was identified along with inconsistent patterns of working including variation in the number of days per week (range: 1-5 days) that nurses dedicated to the Advanced Practice Nurse role and the amount of autonomy achieved in this role. The study highlighted a lack of research productivity in and production of outputs (59% had never published) and given the expectation of Advanced Practice Nurses to both produce and utilise research evidence, this constitutes a significant gap in current practice. Other factors reported as important for career pathway development of Advanced Practice Nurses related to the environment, peer networks, institutional (hospitals) and external (government and the Thai Nursing Council) support.

CONCLUSIONS

Our study offers insights for national and local policymakers and highlights the need to firmly establish, standardised career pathways in Advanced Practice Nursing to support career progression and the implementation of evidence into practice. These findings also have implications for clinical departments which have a responsibility to ensure they provide an enabling environment for Advanced Practice Nurses to fully carry out their roles. Tweetable abstract: Our study reports findings from a first national survey in Thailand investigating the factors which support career development in Advanced Practice Nurses.

Carers of people affected by cancer and other long-term conditions at end of life: A qualitative study of providing a bespoke package of support in a rural setting

BACKGROUND

A UK charity, Macmillan Cancer Support has funded a local intervention, whereby carers of people affected by cancer and other long-term conditions at end of life are offered a bespoke package of support.

AIM

This short report describes the qualitative experiences of carers in receipt of the intervention.

DESIGN

Qualitative research utilising in-depth interviews. Discussions were digitally recorded and transcribed verbatim. Data were analysed using thematic analysis.

SETTING/PARTICIPANTS

Participants were carers ( n = 10) in receipt of the intervention. Interviews were conducted between August and September 2014 in Lincolnshire (England).

RESULTS

Five themes from the interviews were identified: (1) Awareness and advertising, (2) focus of support on the carer, (3) modes of communication, (4) personal attributes and skills of the support worker (5) streamlining and signposting.

CONCLUSION

The intervention was successful within a social care setting. The participants had no overtly negative opinions on the service in its current format and all held it in high regard. Carers felt a sense of reassurance from having background support and maintained that their situation would have been worse had this support not been there.

An Evaluation of Rural Health Care Research

This article reviews the state of the art of rural health research and evaluation with par ticular emphasis on the questions of access, health personnel, and financing. The current state of knowledge both in the published and in the unpublished literature in each area is summarized and a series of unresolved issues is proposed. A strategy for further research to include the various types of rural health care programs is described. Major findings suggest that, although rural populations do have somewhat less access to care than do urban populations, our ability to quantify precisely the extent and importance of this discrepancy is underdeveloped. Despite a substantial investment in a variety of rural health care programs there is inadequate information as to their effectiveness. Programs designed to increase the supply of health personnel to rural areas have met with mixed success. Sites staffed by National Health Service Corps personnel show consistently lower productivity than do sites under other sponsorship. Nonphysician personnel (physician assistants and nurse practitioners) offer apromising source of primary carefor rural areas; recent legislation that reimburses such care should increase their utilization. A persistent problem is the expectation (often a mandate) incorporated into many rural health care demonstration efforts that the programs become financially self-sufficient in a finite period of time. Self-sufficiency is a function of utilization, productivity, and the ability to recover charges for services. In many instances stringent enforcement of the self-suf ficiency requirement may mean those those who need the services most will be least likely to receive them.

Patterns of clinical mentorship in undergraduate nurse education: A comparative case analysis of eleven EU and non-EU countries

BACKGROUND

In spite of the number of studies available in the field and policy documents developed both at the national and the international levels, there is no reliable data available regarding the variation of roles occupied by clinical mentors (CMs) across countries.

OBJECTIVES

To describe and compare the CM's role; responsibilities; qualifications; employment requirements and experience in undergraduate nurse education as enacted in 11 European Union (EU) and non- EU countries.

DESIGN

A case study design.

PARTICIPANTS AND SETTING

A panel of expert nurse educators from 11 countries within and outside of the EU (Croatia, Czech Republic, England, Iceland, Ireland, Italy, Poland, Serbia, Slovenia, Spain, and the USA).

METHODS

A questionnaire containing both quantitative and qualitative questions was developed and agreed by the panel using a Nominal Group Technique (NGT); four cycles of data collection and analysis were conducted involving key experts in nursing education in each country.

RESULTS

In all countries, there are at least two types of clinical mentorship dedicated to undergraduate nursing students: the first is offered by higher education institutions, and the second is offered by health care providers. Variation was noted in terms of profile, responsibilities and professional requirements to act as a CM; however, the CM role is mainly carried out by registered nurses, and in most countries there are no special requirements in terms of education and experience. Those who act as CMs at the bedside continue to manage their usual caseload, thus the role adds to their work burden.

CONCLUSIONS

Whilst it is imperative to have respect for the different national traditions in undergraduate nurse education, the globalisation of the nursing workforce and greater opportunities for student mobility during the course of their undergraduate education suggests that in areas such as clinical mentorship, jurisdictions, particularly within the EU, should work towards greater system harmonisation.

The Ten Essential Shared Capabilities: reflections on education in values based practice: a qualitative study

BACKGROUND

This paper presents the findings of a study exploring the impact of a values-based training initiative on the practice of mental health workers. This work is set within the context of increasing attention on the values of nurses and other health care workers as a response to national reports on care failure and negative media attention.

OBJECTIVE

To examine written response feedback from participants on a national training programme for values-based practice (VBP) in order to examine any intention to change practice.

DESIGN

A national evaluation using quantitative and qualitative methodologies was conducted to gather data on reflections and self-report impact of the Ten Essential Shared Capabilities' training programme.

SETTING

The training was delivered in a range of hospital, community and third sector training programmes across eight regions in England.

PARTICIPANTS

The participants were predominantly nurses but all sectors in the mental health community including service users as co-facilitators and participants were represented.

METHODS

This study presents the qualitative findings from a cross-sectional survey. Using NVIVO 10 software, data were analysed using the framework method of qualitative analysis.

RESULTS

Four principal themes emerged from the data'Thinking differently''Changes to practice''Creating an effective learning environment and skills for practice development' and 'Increasing self-awareness'.

CONCLUSIONS

The quality and safety drive in the NHS has an emphasis on delivery of evidence based practice. It was concluded that an active focus on values based practice merits equal attention and status.

Clinical practice models in nursing education: implication for students' mobility

BACKGROUND

In accordance with the process of nursing globalization, issues related to the increasing national and international mobility of student and qualified nurses are currently being debated. Identifying international differences and comparing similarities for mutual understanding, development and better harmonization of clinical training of undergraduate nursing students is recommended.

AIMS

The aim of the study was to describe and compare the nature of the nursing clinical practice education models adopted in different countries.

METHODS

A qualitative approach involving an expert panel of nurses was adopted. The Nominal Group Technique was employed to develop the initial research instrument for data collection. Eleven members of the UDINE-C network, representing institutions engaged in the process of professional nursing education and research (universities, high schools and clinical institutes), participated. Three data collection rounds were implemented. An analysis of the findings was performed, assuring rigour.

RESULTS

Differences and homogeneity are reported and discussed regarding: (a) the clinical learning requirements across countries; (b) the prerequisites and clinical learning process patterns; and (c) the progress and final evaluation of the competencies achieved.

CONCLUSIONS

A wider discussion is needed regarding nursing student exchange and internalization of clinical education in placements across European and non-European countries. A clear strategy for nursing education accreditation and harmonization of patterns of organization of clinical training at placements, as well as strategies of student assessment during this training, are recommended. There is also a need to develop international ethical guidelines for undergraduate nursing students gaining international experience.

A rare cause of hypoactive delirium

A 90-year-old man was transferred to a geriatric evaluation and management (GEM) unit for management of hypoactive delirium following a pneumonia and acute myocardial infarction complicated by septic shock. He was found to have central hypothyroidism and hypoadrenalism leading to the diagnosis of hypopituitarism. Cerebral imaging confirmed this was secondary to a pituitary haemorrhage. This case illustrates the complexity of assessment of delirium and its aetiologies. Hypoactive forms of delirium in particular can be difficult to detect and therefore remain undiagnosed. While this patient's delirium was likely multifactorial, his hypopituitary state explained much of his hypoactivity. His drowsiness, bradycardia, hypotension and electrolyte imbalance provided clinical clues to the diagnosis.

Prise en charge du priapisme à Dakar

Objectif

Évaluer la prise en charge des patients présentant un priapisme.

Patients et méthodes

Il s’agit d’une étude rétrospective sur quatre ans, du 1er août 2002 au 31 juillet 2006, portant sur 35 patients. Les cadres d’étude ont été les trois grands services d’urologie du Sénégal qui sont tous à Dakar. Les paramètres suivants ont été étudiés: l’âge, le temps d’évolution du priapisme, les données anamnestiques, le type hémodynamique du priapisme, les résultats du bilan paraclinique, le traitement chirurgical (la technique chirurgicale, la technique d’anesthésie), la durée d’hospitalisation, le traitement associé, les complications per- et postopératoires, les résultats immédiats et à long terme.

Résultats

L’âge moyen des patients était de 21,2 ans. Le groupe d’âge le plus représenté était celui de 20 à 30 ans. La majorité des patients (43 %) avaient une notion de drépanocytose connue. La plupart des patients (65 %) ont été pris en charge avant 24 heures d’évolution. Chez tous nos patients, le priapisme était de bas débit. Dans 50 % des cas, les patients drépanocytaires avaient une forme SS. Dans près de la moitié des cas (62 %), la technique d’anesthésie choisie a été le bloc pénien. La ponction des corps caverneux a été le moyen thérapeutique le plus utilisé (63 %). Aucune complication postopératoire majeure n’a été déplorée dans la prise en charge des patients dans notre série. Chez presque tous les patients (95 %), la détumescence durable a été notée le jour même du début du traitement ou le lendemain. Conclusion: Le priapisme, bien que rare en Afrique, est caractérisé par la prédominance de la drépanocytose comme étiologie et le délai particulièrement long de la prise en charge.

Longitudinal health surveillance in a cohort of Gulf War veterans 18 years after first exposure to depleted uranium

As part of a longitudinal surveillance program, 35 members of a larger dynamic cohort of 79 Gulf War I veterans exposed to depleted uranium (DU) during combat underwent clinical evaluation at the Baltimore Veterans Administration Medical Center. Health outcomes and biomonitoring results were obtained to assess effects of DU exposure and determine the need for additional medical intervention. Clinical evaluation included medical and exposure histories, physical examination, and laboratory studies including biomarkers of uranium (U) exposure. Urine collections were obtained for U analysis and to measure renal function parameters. Other laboratory measures included basic hematology and chemistry parameters, blood and plasma U concentrations, and markers of bone metabolism. Urine U (uU) excretion remained above normal in participants with embedded DU fragments, with urine U concentrations ranging from 0.006 to 1.88 μg U/g creatinine. Biomarkers of renal effects showed no apparent evidence of renal functional changes or cellular toxicity related to U body burden. No marked differences in markers of bone formation or bone resorption were observed; however, a statistically significant decrease in levels of serum intact parathyroid hormone and significant increases in urinary calcium and sodium excretion were seen in the high versus the low uU groups. Eighteen years after first exposure, members of this cohort with DU fragments continue to excrete elevated concentrations of uU. No significant evidence of clinically important changes was observed in kidney or bone, the two principal target organs of U. Continued surveillance is prudent, however, due to the ongoing mobilization of uranium from fragment depots.

[Urinary incontinence in woman: epidemiologic profile in Sub Saharian countries]

The objective of this study was to describe the epidemiologic profile of urinary incontinence of the African woman of three Sub Saharan African countries.

MATERIAL AND METHODS

A multicentric study summarized the epidemiological data collected in female from Nouakchott, Dakar and Ndjamena using a questionnaire. All participants filled an anonymous questionnaire including demographic data and marital status, medical, surgical, gynecological and obstetrical history and the characteristics of the urinary incontinence.

RESULTS

Overall, 3021 questionnaires were distributed, only 2070 answers (69%) could be processed. Mean age of the overall population was 28 years. Adult women aged less than 30 years accounted for 56% of the study population. The age group 30-49 years accounted for 42% of the population and only 2% of the study group had more than 50 years. The prevalence of incontinence was 367 cases over 2070 (17,7%). The types of incontinence found were: urgency in 28.6% of cases, stress incontinence in 38.4% of cases and mixed in 33% of cases. Approximately 23,9% of nulliparous and 23,5% of the multiparous had urinary incontinence. The leakage was occasional in 75% of the cases and regular in 25% of the cases. According to gravity, in 31% of cases the volume of urines lost necessitated a change of underwear. Of the women presenting urinary incontinence, 85 (23%) consulted a doctor. A psychosocial repercussion was found in 31% of the cases.

CONCLUSION

Urinary incontinence is much more frequent in our areas than it was thought to be because it was rarely acknowledged.

Conscientious objection to termination of pregnancy: the competing rights of patients and nurses

AIMS

To highlight the potential difficulties in the management of staff with a conscientious objection to abortion, in light of expanding role of nurses.

BACKGROUND

Recent years have seen changes in the provision of abortion services. Medical procedures are now gaining popularity and some areas are seeing the integration of outpatient clinics into ward settings. This may involve nurses being required to provide care to women undergoing termination of pregnancy, which may not have previously been within their remit. This has implications for staff with a conscientious objection.

METHODS

A review of the academic literature.

RESULTS

The advent of medical abortion has led to changes in the way in which abortion services are provided which in turn has re-ignited the debate of the competing rights of nurses with a conscientious objection and those of the patient accessing abortion services.

CONCLUSIONS

This extended role of nurses creates challenges for staff working in clinical areas offering termination of pregnancy and these are further compounded when staff have expressed a conscientious objection to abortion.

IMPLICATIONS FOR NURSING MANAGEMENT

Managers face new challenges in achieving the fine balance between the rights of staff with a conscientious objection to abortion and women accessing abortion services.

Precipitation: its acidic nature

A comparison of the free hydrogen ion concentration and the total hydrogen ion concentration of rain samples shows that rain is a weak acid. The weak acid nature of rain casts doubt on the concepts that the acidity of rain is increasing and that these increases are due to strong acids such as sulfuric acid.

Profil épidémiologique et clinique de l’infertilité masculine à l’hôpital général de Grand-Yoff, Sénégal: à propos de 492 cas

Objectif

Décrire le profil général de l’infertilité masculine, au Sénégal, en milieu hospitalier.

Matériels et méthodes

Il s’agit d’une étude rétrospective, descriptive, portant sur 492 dossiers de patients vus en consultation pour infertilité conjugale du couple entre 2000 et 2004. L’ensemble des paramètres étudiés portait sur les éléments cliniques et les explorations paracliniques.

Résultats

L’âge moyen des patients était de 39 ans. La durée d’évolution de l’infertilité était en moyenne de six ans. L’infertilité était de type primaire dans 66,5 % des cas. Sur le plan clinique, la varicocèle était l’anomalie la plus souvent retrouvée, soit dans 64,6 % des cas. Le spermogramme était perturbé dans 84,3 % des cas. Les principales perturbations étaient une oligospermie inférieure à 5 millions de spermatozoïes/ml (35,6 %) et une azoospermie dans 28,6 % des cas.

Conclusion

Le profil général de l’infertilité est polymorphe. L’exploration est limitée par la non-disponibilité de la partenaire et l’absence de coordination entre gynécologues et andrologues. L’amélioration de la prise en charge de l’infertilité doit passer par de nouvelles voies de recherche, notamment génétiques et immunologiques, afin d’identifier les causes habituellement cachées de l’infertilité. Elle doit aussi reposer sur une bonne collaboration entre praticiens de santé de la reproduction et la mise en place d’unités d’assistance médicale à la procréation (AMP).

Pain and analgesic use in men with metastatic prostate cancer

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Background: Pain is an important endpoint in metastatic prostate cancer and was the basis for the 1996 FDA approval of mitoxantrone. Standards for pain assessment have evolved, and a 2006 draft FDA guidance provides new recommendations for patient- reported outcomes. Contemporary palliation models generally require pain reduction starting from baseline worst pain scores of ≥4/10, and progression models require a sufficient proportion of patients’ pain scores to worsen in order to assure an adequate effect size. The prevalence and distribution of pain severity at specific points in the prostate cancer disease continuum are not well defined. Consequently, it is unclear if sufficient numbers of patients are available to conduct prospective studies using pain palliation or prevention as primary endpoints. Methods: A questionnaire that includes the Brief Pain Inventory and additional pain/analgesia items was developed as a collaboration between the DOD/PCF-supported Prostate Cancer Clinical Trials Consortium (PCCTC) and FDA Study Endpoints and Labeling Design (SEALD) team. IRB waivers were obtained for anonymous administration at 5 PCCTC institutions (Sloan-Kettering, Duke, Johns Hopkins, Anderson, OHSU). Administration is ongoing. Results: Between August-December 2008, 325 men with prostate cancers representing different disease states being seen in outpatient clinics of participating centers were each queried once. Median age was 70 (range 49–87). More than half (n=175) self-reported metastatic disease, including 129 with bone metastases. Among those with bone metastases, 76 (59%) reported experiencing any level of pain in the last week; 49 (38%) reported a worst pain score ≥4/10 of which 38 (78%) used analgesics over the past week and 31 (63%) used daily analgesia. In addition, 70 of the 76 (92%) noted that their pain interfered with work, sleep, or enjoyment of life, with 25 (33%) noting severe interference. Among the 49 patients with pain scores ≥4/10, current or past docetaxel use was reported by 32 (65%), androgen deprivation therapy by 47 (96%), and 28 (57%) had been or were currently enrolled in a clinical trial. Conclusions: Pain is sufficiently prevalent in men with metastatic prostate cancer to enable prospective assessment of palliation endpoints in clinical trials.

No significant financial relationships to disclose.

Surveillance results of depleted uranium-exposed Gulf War I veterans: sixteen years of follow-up

As part of a longitudinal surveillance program, 35 members of a larger cohort of 77 Gulf War I veterans who were victims of depleted uranium (DU) "friendly fire" during combat underwent a 3-day clinical assessment at the Baltimore Veterans Administration Medical Center (VAMC). The assessment included a detailed medical history, exposure history, physical examination, and laboratory studies. Spot and 24-h urine collections were obtained for renal function parameters and for urine uranium (U) measures. Blood U measures were also performed. Urine U excretion was significantly associated with DU retained shrapnel burden (8.821 mug U/g creatinine [creat.] vs. 0.005 mug U/g creat., p = .04). Blood as a U sampling matrix revealed satisfactory results for measures of total U with a high correlation with urine U results (r = .84) when urine U concentrations were >/=0.1 mug/g creatinine. However, isotopic results in blood detected DU in only half of the subcohort who had isotopic signatures for DU detectable in urine. After stratifying the cohort based on urine U concentration, the high-U group showed a trend toward higher concentrations of urine beta(2) microglobulin compared to the low-U group (81.7 v. 69.0 mug/g creat.; p = .11 respectively) and retinol binding protein (48.1 vs. 31.0 mug/g creat.; p = .07 respectively). Bone metabolism parameters showed only subtle differences between groups. Sixteen years after first exposure, this cohort continues to excrete elevated concentrations of urine U as a function of DU shrapnel burden. Although subtle trends emerge in renal proximal tubular function and bone formation, the cohort exhibits few clinically significant U-related health effects.

Long-acting, reversible and permanent methods of contraception: insight into women's choice of method

BACKGROUND

This study aims to explore the views of women concerning their choice of long-acting method of contraception.

METHOD

Two-hundred and eighty-six women who had either been sterilised or fitted with an etonorgestrel (ETN) implant or the levonorgestrel intrauterine system (LNG IUS) were invited to take part. A response rate of 54% was achieved. Women from all three groups reported positive and negative experiences with their chosen method.

RESULTS

Women frequently choose sterilisation specifically because it is irreversible, does not involve hormonal treatment, and they do not wish to retain choice of future fertility. Women incorrectly regard sterilisation as more reliable than any reversible method. Regret after sterilisation was common, even if this was preceded by full counselling. Even among patients of practices with a special interest in family planning, long-acting methods, although available, were not widely known about.

CONCLUSION

This study suggests that women chose sterilisation for one of three main reasons: to avoid the possible side-effects of hormones; to avoid continually having to make decisions regarding child-bearing; and/or a lack of information regarding reversible methods. Sterilisation is often chosen by women specifically because of its irreversibility. This may explain why long-acting reversible methods have remained relatively unpopular.

What impact has England's Teenage Pregnancy Strategy had on young people's knowledge of and access to contraceptive services?

PURPOSE

To describe young people's knowledge and use of contraceptive services over initial stages of England's Teenage Pregnancy Strategy, and to investigate factors associated with use of different services.

METHODS

A random location sample of young people aged 13-21 years (n = 8879) was interviewed in 12 waves over 2000-2004. Individual data were analysed to investigate factors associated with knowledge and use of contraceptive services and to observe trends over time. Area-level data were analyzed to explore differences in key variables.

RESULTS

In all, 77% of young women and 65% of young men surveyed knew a service they could use to obtain information about sex. Amongst those who had had vaginal sexual intercourse, the most common source of contraceptive supplies was general practice for young women (54%) and commercial venues for young men (54%). Young women's use of school-based services to obtain supplies increased significantly from 15.4% in Year 1 to 24.4% in Year 4, p < .001. Young men's use of the commercial sector declined significantly over the same time period (60.3% to 50.6%, p = .002), while their use of general practice and family planning clinics increased (from 8.9% to 12.4%, p = .008, and 21.2% to 29.1%, p = .054, respectively). Use of family planning clinics and designated young people's clinics was associated with first vaginal intercourse before the 16th birthday and living in a deprived area.

CONCLUSIONS

Young people's patterns of contraceptive service use have changed since implementation of the Strategy; although no increase in overall service use was observed. The contribution of school-based services needs further exploration.

Health surveillance of Gulf War I veterans exposed to depleted uranium: updating the cohort

A cohort of seventy-four 1991 Gulf War soldiers with known exposure to depleted uranium (DU) resulting from their involvement in friendly-fire incidents with DU munitions is being followed by the Baltimore Veterans Affairs Medical Center. Biennial medical surveillance visits designed to identify uranium-related changes in health have been conducted since 1993. On-going systemic exposure to DU in veterans with embedded metal fragments is indicated by elevated urine uranium (U) excretion at concentrations up to 1,000-fold higher than that seen in the normal population. Health outcome results from the subcohort of this group of veterans attending the 2005 surveillance visit were examined based on two measures of U exposure. As in previous years, current U exposure is measured by determining urine U concentration at the time of their surveillance visit. A cumulative measure of U exposure was also calculated based on each veteran's past urine U concentrations since first exposure in 1991. Using either exposure metric, results continued to show no evidence of clinically significant DU-related health effects. Urine concentrations of retinol binding protein (RBP), a biomarker of renal proximal tubule function, were not significantly different between the low vs. high U groups based on either the current or cumulative exposure metric. Continued evidence of a weak genotoxic effect from the on-going DU exposure as measured at the HPRT (hypoxanthine-guanine phosphoribosyl transferase) locus and suggested by the fluorescent in-situ hybridization (FISH) results in peripheral blood recommends the need for continued surveillance of this population.

An analysis of deficiencies identified during investigational new drug (IND) application reviews by the Division of Drug Oncology Products (DDOP) of the US FDA

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Background: Regulations require IND application review by the FDA prior to initiation of the clinical study. Deficiencies identified in the study protocol require communication between the FDA reviewers and the Sponsor for resolution. If the deficiencies are not adequately resolved, clinical hold and subsequent delay in the start of the clinical study results. To identify and analyze the commonly encountered IND application deficiencies, data from recent reviews were collected. Methods: Eight clinical reviewers analyzed the deficiencies that had been identified in 268 IND applications reviewed in the DDOP FDA from January 2003 to June 2005. All of the study protocol deficiencies leading to a clinical hold, or requiring resolution prior to study initiation were categorized as deficiencies pertaining to: patient eligibility; starting drug dose; study conduct (toxicity management, dose adjustment, stopping criteria); statistical or endpoints; non-clinical; and other issues. Results: 268 IND applications reviewed over a 30-month period by eight medical officers were analyzed. One hundred and twelve (42%) of the applications had no deficiencies; however, 156 (58%) had one (31%) or multiple (69%) deficiencies. Deficiencies pertained to study conduct/scheme (65%), dose (48%), patient eligibility (46%), others (31%), statistics or endpoints (15%), and non-clinical (4%) issues. In 141 (90%) of the deficient applications the deficiencies were adequately addressed by FDA reviewer-Sponsor communication and the trials could start as scheduled. Fifteen (10%) deficient trials were placed on clinical hold. Fourteen (93%) of these trials had multiple deficiencies that pertained to patient eligibility in 12 (80%), starting drug dose in 12 (80%), study conduct in 11 (73%), other in 7 (47%), and non-clinical and statistical issues in 2 (13%) each. Conclusions: Deficiencies were identified in 58% of the reviewed IND applications: 90% of these were resolved by FDA-Sponsor communication. Only 10% of deficient studies were placed on clinical hold; all except one had multiple deficiencies. The most common deficiencies leading to clinical hold pertained to eligibility of study population and proposed starting drug dose.

No significant financial relationships to disclose.

Leaving the professional tennis circuit: exploratory study of experiences and reactions from elite female athletes

In 2002, Tennis Australia commissioned a report into the experiences of elite female past players on leaving the professional tennis circuit. Australian players who were in the top 800 of the Women's Tennis Association (WTA) end of year rankings and who had left the professional circuit within the previous 15 years were asked by mail to respond to a questionnaire. The questionnaire asked players to describe their feelings about leaving the tour during the time leading up to leaving the tour to two years after retirement. The main findings of the study suggested that those who planned to leave the tour found the transition process easy, whereas those who did not plan to leave the tour found the process difficult. Most players (66%) did not regret leaving the tour, and, although the remaining players responded that they regretted leaving, none attempted a comeback. Tennis Australia has implemented strategies to assist current players on the professional tour based on the results of this study.

Gremlin gene expression in bovine retinal pericytes exposed to elevated glucose

AIM

To assess the influence of high extracellular glucose on the expression of the bone morphogenetic protein (BMP) antagonist, gremlin, in cultured bovine retinal pericytes (BRPC).

METHODS

BRPC were cultured under conditions of 5 mM and 30 mM d-glucose for 7 days and total RNA was isolated. Gremlin mRNA levels were correlated, by RT-PCR, with other genes implicated in the pathogenesis of diabetic retinopathy and the signalling pathways in high glucose induced gremlin expression were probed using physiological inhibitors. Gremlin expression was also examined in the retina of streptozotocin induced diabetic mice.

RESULTS

High glucose stimulated a striking increase in BRPC gremlin mRNA levels in parallel with increases in mRNA for the growth factors vascular endothelial growth factor (VEGF), transforming growth factor beta (TGFbeta), and connective tissue growth factor (CTGF) and changes in other genes including fibronectin and plasminogen activator inhibitor-1 (PAI-1). High glucose triggered gremlin expression was modulated by anti-TGFbeta antibody, by the uncoupler of oxidative phosphorylation, CCCP, and by inhibition of MAP-kinase (MAPK) activation. Striking gremlin expression was observed in the outer retina of diabetic mice and also at the level of the vascular wall.

CONCLUSIONS

Gremlin gene expression is induced in BRPC in response to elevated glucose and in the retina of the streptozotocin induced diabetic mouse. Its expression is modulated by hyperglycaemic induction of the MAPK, reactive oxygen species, and TGFbeta pathways, all of which are reported to have a role in diabetic fibrotic disease. This implicates a role for gremlin in the pathogenesis of diabetic retinopathy.

Gender double standards in young people attending sexual health services in Northern Thailand

Concern about the sexual and reproductive health of young people has been mounting recently in Thailand. Unequal gender relations have a considerable influence on the lives of young people, especially young women, yet few studies have explored the ways in which they have impacted on provision of sexual health care. Drawing upon data from a qualitative study in Northern Thailand, this paper explores the views and experiences of young people in seeking health care, highlighting the kinds of gender double standards and power imbalances that may pose obstacles to their use of sexual and reproductive health services. Findings reveal the vulnerability of sexually active young women in seeking support and care from partners, parents, and service providers. Those who experience adverse outcomes of sexual activity, such as unwanted pregnancy or infection, report facing indifference, victim blaming, or the threat of abandonment by their partners. Because of their fear of disclosure to their parents and communities, of their sexual activity, they opt for clandestine and unsafe abortion and seek the counsel of peers and drugstores rather than parents and providers. At the service provider level, young women report facing threatening and judgemental attitudes, indifferent counselling, and possible violation of confidentiality. This is in marked contrast to the treatment of young men, who generally meet with a more sympathetic and accepting response.

Combination therapy with ribavirin and interferon in a cohort of children with hepatitis C and haemophilia followed at a pediatric haemophilia treatment center

Nearly all children with bleeding disorders who received factor concentrates prior to the late 1980s were infected with hepatitis C. Treatment of adults infected with hepatitis C with combination therapy consisting of ribavirin and interferon has shown sustained response rates of 30-60%. Little data is available on the response of children infected with hepatitis C treated with combination therapy, especially those with bleeding disorders. We wish to report a single paediatric haemophilia treatment center's results of treatment of adolescents with haemophilia and hepatitis C infection with combination therapy. All patients followed at the haemophilia treatment center with hepatitis C, who were human immunodeficiency virus (HIV) negative and had a measurable hepatitis C viral load were eligible. Study patients received at least 6 months of 3 MU interferon-alpha via subcutaneous injection three times per week and 1000 mg day(-1) of ribavirin. Eleven patients agreed to participate in the study. Three patients had an un measurable viral load after 6 months of combination therapy. All three completed 12 months of medication and continued to remain free of hepatitis C for 12 months after discontinuation of therapy. Side-effects of combination therapy were significant but tolerable. The sustained response rate in this study is similar to the historical response rate seen in adults but less than the other reported response rates seen in children treated with combination therapy. Given the toxicity of combination therapy, and natural history of hepatitis C infection in children, consideration of a liver biopsy to evaluate disease progression prior to considering antiviral medications is warranted.

Providing information for young people in sexual health clinics: getting it right

BACKGROUND

The need to improve the quality and availability of information on sexual health is identified as a key element in achieving the aims set out in the National Strategy for Sexual Health and HIV. Providing information about sexual health to young people poses particular challenges because of the sensitive nature of the issues and because of the difficulties that young people may face in sourcing information and asking questions of professionals.

The utility of computerized neuropsychological assessment of cognitive dysfunction in patients with relapsing-remitting multiple sclerosis

Traditional paper-and-pencil neuropsychological batteries used to document cognitive deficits in multiple sclerosis (MS) patients lack timing precision. This makes it difficult to accurately measure psychomotor slowing, a central cognitive symptom of MS. Additionally, traditional batteries lack multiple alternate forms necessary to control for practice effects when assessing cognition over time. Finally such batteries are lengthy and expensive. Computerized neuropsychological batteries address many of these shortcomings. They measure response time more precisely, require less administration time, include alternate forms, and are ideal for rapid screening/triage. Although there are normative data on the reliability and validity of computerized measures, there have been no controlled validation studies with MS patients. The current study was designed to validate a computerized neuropsychological battery (ANAM) for use with relapsing-remitting (RR) MS patients. Prior to initiation of interferon-beta-1a (Avonex) treatment, subjects participated in a neuropsychological evaluation consisting of traditional and computerized measures. Moderate-to-high correlations were found between computerized and traditional measures. Computerized tests accurately predicted performance on key traditional tests. The battery was also concordant with traditional measures in identifying RR MS patients with and without neurocognitive impairment. Findings are discussed with respect to increased accuracy and accessibility of neuropsychological evaluations for MS patients.