Understanding collaborative and coordinated care in a mental health and well-being context: Essential elements for effective service integration

Multiple system reforms in Australia, including the National Disability Insurance Scheme (NDIS), are changing mental health (MH) and disability-related service provision, whilst policy drivers continue to require service integration. This has necessitated service providers discovering new ways of working collaboratively to achieve an integrated model of care. This qualitative study examined what does and does not work to support collaborative and coordinated care (CCC), as essential components of service integration. The study sample (n = 59) included four cohorts: health and community service leaders (n = 16), staff (n = 23); MH service consumers with complex needs (n = 10), and MH carers (n = 10). Thematic analysis from interviews was applied to data from each cohort to identify overarching themes that described the lived experience of current CCC delivery. COREQ and EQUATOR guidelines were applied to reporting the findings. Themes emphasized CCC is enabled by the development and sustainability of positive working relationships, and depth of knowledge across health and community services. Unnavigable service systems, stigmatization, perceived power differentials, multiple and rapid service reforms and Fee-For-Service (FFS) models provide significant barriers to CCC. Recommendations include the need for accessible service navigation, consumer-friendly service environments, a stable workforce, standardization of knowledge across sectors, outcome measures and funding attached to CCC as part of a raft of potential changes.

An investigation of the reproducibility of a self-selected natural feet position when standing: Implications for the assessment of upright standing posture

BACKGROUND

Photogrammetry is often used to evaluate standing static postural alignment. Patients are often instructed to self-select a natural feet position but it's unclear whether this position can be consistently replicated across repeated assessments.

OBJECTIVE

To determine whether people can replicate a self-selected natural feet position in upright standing across three sessions on different days.

DESIGN

Between days test-retest reliability.

SETTING

University laboratory.

METHODS

Three variables - Base of Support (BoS), Foot Width (FW), Feet Opening Angle (FOA) - were measured from foot tracings of 150 participants (18-30 years) using established procedures. BoS data were assessed for systematic bias (Analysis of Variance), and absolute (Coefficient of Variation - CV%) and relative (Intraclass Correlation Coefficient - ICC) reliability.

RESULTS

There was systematic bias in the BoS data across the three testing sessions. The CV% for the BoS data was 15.2%. The ICC (95% CI) for the BoS data was 0.84 (0.79-0.87). There were moderate-large correlations between the BoS and both FOA and FW respectively within each session.

CONCLUSION

If clinicians want to allow patients to use their self-selected natural feet position for repeated photogrammetric assessment of their static postural alignment it would be better to standardise the position of the feet, for example, by creating a tracing of a patient's self-selected natural feet position.

Experiences of consumers, carers and clinicians during borderline personality disorder presentations to the emergency department-An integrative review

INTRODUCTION

People with a borderline personality disorder (BPD) diagnosis or symptoms may experience emotional crises which necessitate use of the emergency department (ED). No existing reviews focus specifically on experiences of consumersa , carersb and clinicians in relation to ED presentations by people diagnosed with BPD.

AIM/QUESTION

The aim of this study was to synthesise knowledge on consumer, carer and clinician experiences of BPD in the ED.

METHOD

An integrative review methodology was chosen as it best captures the complexity of varied perspectives and emergent phenomena from diverse literature sources. EMBASE, CINAHL, PsycInfo and Medline were searched for papers published before 16 February 2022.

RESULTS

Nine papers met the inclusion criteria (five qualitative, one quantitative, one mixed methods and two letters to the editor). Key themes were barriers to timely and adequate care, and stigmatising attitudes and practices towards people diagnosed with BPD. Negative attitudes were perceived to perpetuate harmful outcomes and further ED visits.

DISCUSSION

Predominantly negative ED experiences were expressed by clinicians, consumers and carers. Further work is needed in ED models of care and staff education to improve the experience of care for consumers, carers and clinicians alike.

IMPLICATIONS FOR PRACTICE

Opportunities for change will exist through co-designed innovation, education, advocacy and leadership.

Creating and testing a questionnaire to predict immediate and strong positive responders to spinal manipulative therapy for non-specific low back pain. A pilot study

BACKGROUND

Many chiropractors use spinal manipulative techniques (SMT) to treat spinal pain. A recent Delphi study posited 18 items across five domains as predictors of patients experiencing non-specific low back pain most likely to experience a strong and immediate positive response to SMT. We sought to create a 'pen and paper' questionnaire that would measure these items and then pilot its use in a clinical setting to determine its 'usability' for a larger study. Knowing this information would inform a more efficacious use of SMT.

METHOD

Of the 18 items identified in the Delphi study, 13 were deemed historical in nature and readily provided by the chiropractor and patient. A literature search revealed reliable and valid measures for two more items. The remaining three items were generated by creating descriptive questions matched to an appropriate Likert scale. A panel of six chiropractors who had used SMT for at least 7 years when treating non-specific low back pain was formed to evaluate the items for clarity and relevance. Ten Western Australian chiropractors were then recruited to pilot the questionnaire on ten consecutive patients with non-specific low back pain where SMT was used from March to June 2020. Ethics approval was obtained from Murdoch University.

RESULTS

COVID-19 restrictions impacted on practitioner recruitment and delayed the data collection. Of the intended 100 participants, only 63 could be recruited over a 3-month period from seven chiropractors. Time constraints forced the closure of the data collection. The measures of all predictor items demonstrated ceiling effects. Feedback from open-ended practitioner questions was minimal, suggesting an ease of use.

CONCLUSION

The length of time and level of participation required to collect the calculated sample size was inadequate and suggested that incentivization may be required for a larger investigation. Significant ceiling effects were found and suggested that participants did so because of a positive bias toward chiropractic care and the use of SMT. The questionnaires in this pilot study require alternative measures and further validation before use in a larger study.

A guide to evaluating systematic reviews for the busy clinicians or reluctant readers

Systematic reviews (SRs) provide a solution to handle information overload for busy clinicians by summarising and synthesizing studies on a specific issue. However, because SRs are complicated and often boring to read, the busy or reluctant reader may make do with the abstract. When, as it has been shown, many authors overstate efficacy or understate harm in their abstracts, not consulting the underlying article could be misleading. This means that the prudent reader must have the ability to identify the 'tender points' of SRs to avoid falling for 'spin'. To this end we briefly review the method of SRs and ways to relatively quickly determine trustworthiness.

Changing the horizontal position of a fixed backpack load: The effect on postural stability in young adults

BACKGROUND

Modifying the horizontal position of the load in a backpack will change the size of the external torque it creates on the wearer but the effect on postural stability is unclear.

OBJECTIVE

To determine if changing the horizontal position of a fixed backpack load affects postural stability in young adults.

METHODS

A backpack was attached to a steel frame with a bar protruding posteriorly. A fixed load (5% body mass) was placed at three distances along the bar - 0 m, 0.20 m, and 0.40 m. Centre of pressure (CoP) derived measurements were recorded from a force platform sampling at 100 Hz. For each condition participants performed three 90s narrow stance trials with their eyes closed whilst standing on a firm surface. A comparison was made across unloaded (no backpack) and loaded conditions.

RESULTS

There was an immediate decrease in postural stability when a loaded backpack was worn. Only two of the CoP derived measures (Total Excursion - TEx, and Mean Velocity Total Excursion - MVel TEx) differed between the loaded at 0.20 m and loaded at 0 m conditions. All CoP derived measures differed between the loaded at 0.40 m and loaded at 0 m conditions. Furthermore, three of the CoP derived measures (Anterior/Posterior Root Mean Square - A/P RMSq, TEx, and MVel TEx) differed between the loaded at 0.40 m and loaded at 0.20 m conditions.

CONCLUSION

The distribution of a load within a backpack must be carefully considered. The findings for the 0.40 m condition are important for the use and design of large backpacks used by multi-day hikers, travellers, and the military.

Who are the chiropractic students favouring a limitless scope of practice? Exploring the relationship with personality, magical thinking, and academic achievement

Introduction

Some chiropractors seem to have an inflated belief in the powers of spinal manipulation (SMT), for example aiming at preventing future spinal degeneration and health problems, activities that are without supporting evidence. Non-evidenced health beliefs have been shown to be associated with a tendency toward magical thinking. Holding such beliefs about SMT is associated with a limitless scope of practice (LLSoP). Recent studies have shown that “chiropractic conservatism” (ChiroCon) is also associated with such approaches. We wanted to understand ChiroCon and these attitudes toward SMT by exploring three different factors: intolerance to uncertainty, academic achievement, and tendency toward magical thinking and how they relate to ChiroCon and LLSoP.

Method

A cross-sectional survey of 243 chiropractic students from an Australian chiropractic program was conducted in May 2020. Students answered a questionnaire involving a patient case-scenario for LLSoP, levels of ChiroCon, validated questionnaires on (i) Intolerance of uncertainty, (ii) Academic achievement, and (iii) Magical thinking. LLSoP was defined as wanting to treat with SMT a 5-year-old asymptomatic child for future (i) Musculoskeletal (MSK) problems and/or (ii) Non-musculoskeletal diseases. Logistic regression models were used to confirm if there was an association between ChiroCon and LLSoP and to explore associations between LLSoP and (i) Intolerance of uncertainty, (ii) Academic achievement, and (iii) Magical thinking. We repeated the same analyses using ChiroCon as the outcome variable.

Results

We confirmed that chiropractic students in the more extreme ChiroCon group were more likely to want to prevent future spinal disorders in an asymptomatic 5-year-old child as compared to those with lower levels (OR = 3.9, (95%CI 1.97–7.72). This was also the case for the prevention of future diseases in the same child (OR = 6.9, (95%CI 3.11–15.06). Of the three predictor variables, magical belief was positively associated with both ChiroCon and LLSoP.

Conclusion

Not surprisingly, ChiroCon is closely related to LLSoP and both were linked to magical thinking. Therefore, the questionnaire ‘Magical Health Beliefs’ could be a useful instrument to screen future chiropractic students to prevent a mismatch between student and institution. Depending on the outlook of the school, some schools would welcome these students, whereas other institutions would want to avoid them in their education program.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-022-00440-6.

Understanding Australian female chiropractors' experiences of inappropriate patient sexual behaviour: a study using Interpretive Phenomenological Analysis

Introduction

Female practitioners are often subjected to inappropriate patient sexual behaviour (IPSB). Adverse consequences of such sexual harassment include for the practitioner psychological stress effects and negative work-related consequences that contributes to career dissatisfaction and burnout. Confronting the issue within the healthcare context has been shown to be problematic because practitioners feel an obligation to protect the therapeutic relationship above their own personal discomfort. There is an absence of research on this topic with respect to female chiropractors and we proposed a qualitative study aimed to explore female chiropractors lived experiences of managing incidents of IPSB.

Method

An Interpretive Phenomenological Analysis methodology was chosen for this study. In June and July of 2018 female chiropractors in Western Australian were recruited via Facebook sites and invited to participate in face-to-face interviews for an Honours degree study exploring the lived experience of IPSB.

Results

Participants were seven female chiropractors currently practicing in Western Australia, who had experienced an incident of IPSB. Four super-ordinate themes emerged from the analysis; (1) familiar but inarticulable, (2) the cost of conflict, (3) I’m used to it, and (4) the element of surprise. Overall, the participants recognised the incidents as inappropriate but chose to ignore the situation as a means to avoid conflict in the treatment room. Recommendations are made to better manage IPSB including greater patient awareness of appropriate behaviour, specific curriculum content and assertiveness training in undergraduate programs and continuing professional education, as well as the creation of ethical guidelines for patient behaviour by regulatory bodies.

Conclusion

This is the first study to give a forum for female chiropractors to discuss their experiences of IPSB. The domain of private practice is not immune to incidents IPSB and although similar to day-to-day non-clinical life is nonetheless surprising and impactful.

Early age at menarche is associated with post-menarche back pain: An analysis of the Raine Study

INTRODUCTION

Back pain (BP) experienced by females during adolescent years appears to predispose them to an increased likelihood of its presence in adulthood. Understanding this phenomenon by identifying risk factors of those at risk potentially fosters preventative strategies and effective treatments.

OBJECTIVES

To investigate for associations between post-menarche BP and low back pain (LBP) and age at menarche (AAM) in Australian adolescents using the Western Australian pregnancy cohort (The Raine Study).

METHODS

This study used data from a longitudinal cohort study. BP data were collected retrospectively using a questionnaire. Menarche data was split into three established age classifications early (<12-years), normal (≥12 to >14-years) and late (≥14-years). Logistic regression models examined the effect of AAM on BP.

RESULTS

666 female participants provided valid menarche data with 183 (27.5%) early AAM, 429 (64.4%) normal AAM and 54 (8.1%) with late AAM. The mean AAM was 12.59 years. BP was disclosed by 27.5% in the 14-year follow-up and 31.5% in the 17-year follow-up. Participants who had early AAM had 79% higher odds of experiencing BP compared to participants who had normal AAM, after adjusting for confounders at the 14-year follow-up (adjOR 1.79, 95% CI 1.18-2.64).

CONCLUSION

There is evidence of an association, in this cohort, of early AAM with post-menarche BP. This result identifies an area for future exploration, including understanding this mechanism which may lead to the development of effective intervention measures.

SIGNIFICANCE

Age at menarche is related to a range of health issues. This study sought to investigate if it was a risk factor for spinal pain. We used an existing Australian data base to explore this possibility and found an association with early age onset and post-menarche back pain. This result identifies an area for future exploration, including understanding this mechanism which may lead to the development of effective intervention measures.

It's not my fault although it might be: chiropractic practice and vicarious liability

Background

While chiropractic care is most commonly provided within a private practice context, the ‘traditional’ solo practice is now uncommon. Chiropractors, manual therapists and related health professionals commonly work within the same practice bringing obvious advantages to both the practitioners and their patients. However, multi-practitioner, multi-disciplinary clinics also carry often unrecognized liabilities. We refer here to vicarious liability and non-delegable duties. Vicarious liability refers to the strict liability imposed on one person for the negligent acts of another person. The typical example is an employer being held vicariously liable to the negligent acts of an employee. However, vicarious liability can arise outside of the employer-employee relationship. For example, under non-delegable duty provisions, an entity owing a non-delegable duty can be liable for an independent contractor’s wrongdoing.

After a plain English explanation of this complex area of law, we provide seven scenarios to demonstrate how vicarious liability can envelop practice principals when things go wrong. We also make suggestions for risk mitigation.

Conclusion

Practice owners may unexpectedly find themselves legally liable for another’s actions with dire consequences. A knowledge of vicarious liability along with implementing risk mitigation strategies has the potential to minimize the likelihood of this unwanted event. Recommendations are made to this end.

The global summit on the efficacy and effectiveness of spinal manipulative therapy for the prevention and treatment of non-musculoskeletal disorders: a systematic review of the literature

Background

A small proportion of chiropractors, osteopaths, and other manual medicine providers use spinal manipulative therapy (SMT) to manage non-musculoskeletal disorders. However, the efficacy and effectiveness of these interventions to prevent or treat non-musculoskeletal disorders remain controversial.

Objectives

We convened a Global Summit of international scientists to conduct a systematic review of the literature to determine the efficacy and effectiveness of SMT for the primary, secondary and tertiary prevention of non-musculoskeletal disorders.

Global summit

The Global Summit took place on September 14–15, 2019 in Toronto, Canada. It was attended by 50 researchers from 8 countries and 28 observers from 18 chiropractic organizations. At the summit, participants critically appraised the literature and synthesized the evidence.

Systematic review of the literature

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and the Index to Chiropractic Literature from inception to May 15, 2019 using subject headings specific to each database and free text words relevant to manipulation/manual therapy, effectiveness, prevention, treatment, and non-musculoskeletal disorders. Eligible for review were randomized controlled trials published in English. The methodological quality of eligible studies was assessed independently by reviewers using the Scottish Intercollegiate Guidelines Network (SIGN) criteria for randomized controlled trials. We synthesized the evidence from articles with high or acceptable methodological quality according to the Synthesis without Meta-Analysis (SWiM) Guideline. The final risk of bias and evidence tables were reviewed by researchers who attended the Global Summit and 75% (38/50) had to approve the content to reach consensus.

Results

We retrieved 4997 citations, removed 1123 duplicates and screened 3874 citations. Of those, the eligibility of 32 articles was evaluated at the Global Summit and 16 articles were included in our systematic review. Our synthesis included six randomized controlled trials with acceptable or high methodological quality (reported in seven articles). These trials investigated the efficacy or effectiveness of SMT for the management of infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. None of the trials evaluated the effectiveness of SMT in preventing the occurrence of non-musculoskeletal disorders. Consensus was reached on the content of all risk of bias and evidence tables. All randomized controlled trials with high or acceptable quality found that SMT was not superior to sham interventions for the treatment of these non-musculoskeletal disorders. Six of 50 participants (12%) in the Global Summit did not approve the final report.

Conclusion

Our systematic review included six randomized clinical trials (534 participants) of acceptable or high quality investigating the efficacy or effectiveness of SMT for the treatment of non-musculoskeletal disorders. We found no evidence of an effect of SMT for the management of non-musculoskeletal disorders including infantile colic, childhood asthma, hypertension, primary dysmenorrhea, and migraine. This finding challenges the validity of the theory that treating spinal dysfunctions with SMT has a physiological effect on organs and their function. Governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies about the use and reimbursement of SMT for non-musculoskeletal disorders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12998-021-00362-9.

Misinformation, chiropractic, and the COVID-19 pandemic

BACKGROUND

In March 2020, the World Health Organization elevated the coronavirus disease (COVID-19) epidemic to a pandemic and called for urgent and aggressive action worldwide. Public health experts have communicated clear and emphatic strategies to prevent the spread of COVID-19. Hygiene rules and social distancing practices have been implemented by entire populations, including 'stay-at-home' orders in many countries. The long-term health and economic consequences of the COVID-19 pandemic are not yet known.

MAIN TEXT

During this time of crisis, some chiropractors made claims on social media that chiropractic treatment can prevent or impact COVID-19. The rationale for these claims is that spinal manipulation can impact the nervous system and thus improve immunity. These beliefs often stem from nineteenth-century chiropractic concepts. We are aware of no clinically relevant scientific evidence to support such statements. We explored the internet and social media to collect examples of misinformation from Europe, North America, Australia and New Zealand regarding the impact of chiropractic treatment on immune function. We discuss the potential harm resulting from these claims and explore the role of chiropractors, teaching institutions, accrediting agencies, and legislative bodies.

CONCLUSIONS

Members of the chiropractic profession share a collective responsibility to act in the best interests of patients and public health. We hope that all chiropractic stakeholders will view the COVID-19 pandemic as a call to action to eliminate the unethical and potentially dangerous claims made by chiropractors who practise outside the boundaries of scientific evidence.

Informed consent, duty of disclosure and chiropractic: where are we?

BACKGROUND

The COVID-19 pandemic has seen the emergence of unsubstantiated claims by vertebral subluxation-based chiropractors that spinal manipulative therapy has a role to play in prevention by enhancing the body's immune function. We contend that these claims are unprofessional and demonstrate a disturbing lack of insight into the doctrine of informed consent. As such it is timely to review how informed consent has evolved and continues to do so and also to discuss the attendant implications for contemporary health practitioner practice. We review the origins of informed consent and trace the duty of disclosure and materiality through landmark medical consent cases in four common law (case law) jurisdictions. The duty of disclosure has evolved from a patriarchal exercise to one in which patient autonomy in clinical decision making is paramount. Passing time has seen the duty of disclosure evolve to include non-medical aspects that may influence the delivery of care. We argue that a patient cannot provide valid informed consent for the removal of vertebral subluxation. Further, vertebral subluxation care cannot meet code of conduct standards because it lacks an evidence base and is practitioner-centered. The uptake of the expanded duty of disclosure has been slow and incomplete by practitioners and regulators. The expanded duty of disclosure has implications, both educative and punitive for regulators, chiropractic educators and professional associations. We discuss how practitioners and regulators can be informed by other sources such as consumer law. For regulators, reviewing and updating informed consent requirements is required. For practitioners it may necessitate disclosure of health status, conflict of interest when recommending "inhouse" products, recency of training after attending continuing professional development, practice patterns, personal interests and disciplinary findings.

CONCLUSION

Ultimately such matters are informed by the deliberations of the courts. It is our opinion that the duty of a mature profession to critically self-evaluate and respond in the best interests of the patient before these matters arrive in court.

Predictors of instanteous relief from spinal manipulation for non-specific low back pain: a delphi study

Background

There is some evidence and anecdotal reports that high-velocity low-amplitude (HVLA) spinal manipulation therapy (SMT) for non-specific low back pain (NSLBP) may immediately reduce pain in some patients. The mechanism for such a change remains unclear and the evidence is conflicting. The aim of this study was to seek consensus among a sample of expert manual therapists as to the possible clinical predictors that could help identify patients who are most likely to receive instant relief from NSLBP with SMT intervention.

Methods

Thirty-seven expert chiropractors and manipulative physiotherapists from around the world were invited to participate in a three round online Delphi questionnaire during the second half of 2018. Participants were provided with a list of 55 potential signs and symptoms as well as offering them the option of suggesting other factors in the first round. The variables were rated using a 4-point Likert likelihood scale and a threshold of 75% agreement was required for any item to progress to the next round.

Results

Of these 37 experts, 19 agreed to participate. Agreement as to the proportion of patients who receive instantaneous relief was minimal (range 10–80%). A total of 62 items were ranked over the 3 rounds, with 18 of these retained following the third round. The highest rated of the 18 was ‘A history including a good response to previous spinal manipulation’.

Discussion/conclusion

Five categories; patient factors, practitioner factors, signs and symptoms of NSLBP presentation, an instrument of measurement (FABQ), and the presence of cavitation following SMT best describe the overall characteristics of the factors. The 18 factors identified in this study can potentially be used to create an instrument of measurement for further study to predict those patients with NSLBP who will receive instantaneous relief post-SMT.

Revisiting the psychometric properties of the Scoliosis Research Society-22 (SRS-22) French version

Background

Adolescent idiopathic scoliosis (AIS) is among the most common spinal deformities affecting adolescents. The Scoliosis Research Society-22 questionnaire is commonly used to assess health-related quality of life in AIS patients, including pain.

The objective of this study is to verify the psychometric properties of the Scoliosis Research Society-22 French version (SRS-22fv) questionnaire.

Methods

A prospective methodological design was used to verify the psychometric properties of the French version of the SRS-22fv. Participants were initially recruited from the orthopaedic scoliosis department at Sainte-Justine Hospital (Montreal, Canada) and completed the SRS-22fv and the SF-12 questionnaire. The SRS-22fv’s structure was evaluated through principal component analysis (PCA). Linear regression was used to assess convergent validity between the SRS-22fv and the SF-12.

Results

Data was available from 352 participants with AIS. Most participants were female (87%, n = 307), and the average age was 14.3 (SD = 1.8) years. The mean thoracic and lumbar Cobb angles were 27.9° (SD = 3.3) and 23.6° (SD = 9.4), respectively. Overall, 71.4% (n = 252) of the participants presented with spinal pain. About one-third (29%) reported thoracic pain, and almost half (44%) experienced lumbar pain. The PCA identified four redundant items, which resulted in a modified 18-item questionnaire. In comparison to the original questionnaire, the modified version showed higher levels of internal consistency for four of the five factors, explained a greater proportion of the total variance (63.3%), and generated higher inter-item total correlations.

Conclusion

We propose a shorter version of the SRS-22fv, thus the Canadian SRS-18fv, which showed an improved internal consistency and scale structure compared to the original SRS-22fv. We believe that this modified version would be better suited to assess the quality of life of adolescents with idiopathic scoliosis.

Isoniazid preventive therapy in HIV-infected children on antiretroviral therapy: a pilot study

SETTING

Tuberculosis (TB) is a common cause of mortality and morbidity in children infected with the human immunodeficiency virus (HIV). Data on isoniazid preventive therapy (IPT) efficacy in HIV-infected children receiving antiretroviral therapy (ART) are inconclusive.

OBJECTIVE

To assess the efficacy, tolerability and safety of isoniazid (INH) in HIV-infected children on ART.

DESIGN

A pilot randomised controlled study of INH was undertaken in HIV-infected children on ART. The primary outcome measure was TB disease or death.

RESULTS

A total of 167 children were randomised to receive INH (n = 85) or placebo (n = 82), and followed for a median of 34 months (interquartile range [IQR] 24-52). The median age was 35 months (IQR 15-65). There was one death in a child on INH and none in the placebo group. Eleven (6.6%) cases of TB occurred, 4 (5%) in the INH and 7 (9%) in the placebo group. Among the TB cases, 5 were culture confirmed-2 in the INH group and 3 in the placebo group, all susceptible to INH. Severe adverse events occurred rarely (n = 6; 2%).

CONCLUSION

IPT is safe and well tolerated in HIV-infected children on concomitant ART. This study supports the need for a larger study to assess efficacy in HIV-infected children living in TB-endemic areas.

Management of upper respiratory tract infections in children

Upper respiratory tract infection (URTI) occurs commonly in both children and adults and is a major cause of mild morbidity. It has a high cost to society, being responsible for absenteeism from school and work and unnecessary medical care, and is occasionally associated with serious sequelae. URTIs are usually caused by several families of virus; these are the rhinovirus, coronavirus, parainfluenza, respiratory syncytial virus (RSV), adenovirus, human metapneumovirus, influenza, enterovirus and the recently discovered bocavirus. This review will mainly focus on the rhinovirus, where significant advances have been made in understanding the epidemiology, natural history and relationship with other pathogens.

Burnout among chiropractic practitioners: real or imagined an exploratory study protocol

Burnout is a psychological syndrome of emotional exhaustion, depersonalization and reduced personal accomplishment that has been found to exist in a significant number of healthcare and helping professionals. It imposes a significant societal burden by shortened practitioner lifespan, decreased efficiency, negative health outcomes and poorer levels of patient care. Theoretical models suggest that it appears to be the result of a complex interaction between job resources and job demands. It may be reasonable to conclude that Chiropractic professionals experience similar vocational demands and thus experience significant levels of occupational stress and subsequent burnout. However the data on burnout within the chiropractic profession is limited. It is possible that this results in significant negative outcomes on chiropractors and their patients. Therefore, the objective of this paper is to demonstrate the need to explore burnout in chiropractic practice and offer a research protocol for a potential study.

Early antiretroviral treatment reduces risk of bacille Calmette-Guérin immune reconstitution adenitis

SETTING

Two centres in Soweto and Cape Town, South Africa.

OBJECTIVE

To assess the effects of timing of initiation of antiretroviral treatment (ART) and other factors on the risk of bacille Calmette-Guérin (BCG) related regional adenitis due to immune reconstitution inflammatory syndrome (BCG-IRIS) in human immunodeficiency virus (HIV) infected infants.

DESIGN

HIV-infected infants aged 6-12 weeks with CD4 count ≥25% enrolled in the Children with HIV Early Antiretroviral Therapy (CHER) Trial received early (before 12 weeks) or deferred (after immunological or clinical progression) ART; infants with CD4 count <25% all received early ART. All received BCG vaccination after birth. Reactogenicity to BCG was assessed prospectively during routine study follow-up.

RESULTS

Of 369 infants, 32 (8.7%) developed BCG-IRIS within 6 months of starting ART, 28 (88%) within 2 months after ART initiation. Of the 32 cases, 30 (93.8%) had HIV-1 RNA > 750 000 copies/ml at initiation. Incidence of BCG-IRIS was 10.9 and 54.3 per 100 person-years (py) among infants with CD4 count ≥25% at enrolment receiving early (at median age 7.4 weeks) vs. deferred (23.2 weeks) ART, respectively (HR 0.24, 95%CI 0.11-0.53, P < 0.001). Infants with CD4 count <25% receiving early ART had intermediate incidence (41.7/100 py). Low CD4 counts and high HIV-1 RNA at initiation were the strongest independent risk factors for BCG-IRIS.

CONCLUSIONS

Early ART initiation before immunological and/or clinical progression substantially reduces the risk of BCG-IRIS regional adenitis.

Cavitation of the Ghon focus in an HIV-infected infant who acquired tuberculosis after the initiation of HAART

Tuberculosis immune reconstitution inflammatory syndrome (IRIS) may present as new or worsening cavitation. We present an HIV-infected infant in whom TB infection and subsequent cavitation of the Ghon focus appeared to coincide with immune reconstitution due to highly active antiretroviral therapy (HAART). TB-IRIS in response to infection that occurs after starting HAART has not previously been described.

CAVITATION OF THE GHON FOCUS IN AN HIV-INFECTED INFANT WHO ACQUIRED TUBERCULOSIS AFTER THE INITIATION OF HAART

Tuberculosis immune reconstitution inflammatory syndrome (IRIS) may present as new or worsening cavitation. We present an HIV-infected infant in whom TB infection and subsequent cavitation of the Ghon focus appeared to coincide with immune reconstitution due to highly active antiretroviral therapy (HAART). TB-IRIS in response to infection that occurs after starting HAART has not previously been described.

Advanced cancer patients' prognostic information preferences: a review

Open communication in cancer care has gained increasing importance in recent years and diagnostic disclosure is now common place. However, there is a significant variability in the sharing of prognostic information. Information needs may vary significantly over the disease trajectory, and there has been relatively little work done focussing on late illness. Using systematic review procedures, 13 studies were identified that addressed this issue. The evidence shows that all patients wanted honesty from their professional team and the vast majority wanted some broad indication of their prognosis, but that preferences for quantitative information were more varied. Benefits associated with realistic awareness included enhanced control and end-of-life planning, which was seen to engender hope. However, for a proportion of patients, hope and realism were irreconcilable when presented with detailed or unequivocal information. Professionals have a responsibility to provide information to patients, but also to respect the need to maintain some ambiguity about the future, if that is a patient's wish. Therefore, prognostic discussions necessitate careful, individualised assessment, a process which can facilitate enhanced palliative care for patients with advanced cancer.

Overview and regional and temporal differences of heavy metals in Arctic whales and ringed seals in the Canadian Arctic

Concentrations of mercury, cadmium, and other heavy metals in tissues of belugas (Delphinapterus leucas), narwhal (Monodon monoceros) and ringed seals (Phoca hispida) from across the Canadian Arctic are reported. Published and new information is used to provide an overview of metals in tissues of these animals, to delineate the existence of a spatial trend of mercury and cadmium in belugas and ringed seals, and to show a temporal trend is superimposed on the geochemical trend. Mercury concentrations in tissues of Arctic whales and ringed seals were high relative to the Canadian guideline of 0.5 micrograms/g wet wt., for mercury in fish, except in the skin of belugas (0.59-0.78 micrograms/g wet wt.) and flesh of ringed seals (0.39-0.41 micrograms/g wet wt.). In the flesh of belugas (0.94-1.34 micrograms/g wet wt.), and in the liver of ringed seals, tissues that are also consumed by Native people in the Arctic (8.34-27.5 micrograms/g wet wt.), the guideline value was significantly exceeded. Mean lead concentrations in tissues of belugas, narwhal and ringed seals were generally low (0.002-0.028 micrograms/g wet wt.), except in tissues of belugas in the St. Lawrence River (0.10-0.15 micrograms/g wet wt.). The concentration of zinc in the skin of whales was two to three times higher than in other tissues. The concentration of cadmium in organs was highest in narwhal. There was a positive correlation between mercury and selenium in the liver of all three species. The concentration of mercury in tissues of belugas and ringed seals was higher in the western than the eastern Arctic. This was attributed to different natural background concentrations in the western and eastern Arctic of Canada dictated by different geological formations in the two regions. Cadmium concentrations in tissues of belugas and ringed seals were higher in the eastern than the western Arctic. Zinc and copper in some tissues of belugas and ringed seals were also higher in the eastern than the western Arctic. Mercury in the liver of belugas was found to have increased in the western and eastern Arctic over 10-12 years. Mercury in the liver of ringed seals in the western Arctic and narwhal in the eastern Arctic showed similar increases. In recently collected belugas, the rate of accumulation of mercury in the liver was approximately twice that in belugas collected 10-12 years ago. In ringed seals, the rate was three times higher in recent samples compared to 15-20 years ago. There was no temporal change in cadmium levels in tissues of belugas, ringed seals or narwhal.

Characteristics of ringed seal, Phoca hispida, subnivean structures and breeding habitat and their effects on predation

Characteristics of ringed seal (Phoca hispida) subnivean structures and breeding habitat were quantified and their potential influence on predation success by polar bears (Ursus maritimus), arctic foxes (Alopex lagopus), and humans on ringed seals was investigated in Admiralty Inlet and Strathcona Sound, Northwest Territories. A total of 237 ringed seal structures were located between April and June 1991–1993 using trained dogs. Ringed seal lairs and breathing holes were concentrated in areas of deep snow, and were associated with large, thick ice ridges. Only a small percentage of the available fast-ice habitat had sufficient snow depth for lair construction each year. A discriminant function analysis used to classify structures located in 1992, using a combination of structural and habitat measurements, correctly classified 70% of structures located in 1991 and 1993 into functional groups. The length, width, internal height, and level of "tiggak," the odour of rutting male ringed seals, associated with structures were the most important descriptors separating structure types. Seventy-three percent of structures located in the study were undisturbed by predators. The mean length and width of structures entered by predators were significantly greater than those of undisturbed structures. Polar bear success decreased as snow depth and the thickness of the roof covering the structures increased. The conditions necessary for successful arctic fox predation are unclear. Inuit hunters attacked structures close to ice ridges, and ridge height and snow depth influenced their success. All predators attacked lairs having the odour of rutting male ringed seals less often than structures with no male odour.

Surface areas of phocid seals

Standard morphometries and body surface areas were determined for 56 captive phocid seals. The mean Meeh constant, describing the relationship between maximum surface area (Amax) and body mass raised to the power 2/3 (m0.67), was 0.088 ± 0.011 m2∙kg−0.67. This value was not significantly different (P < 0.05) from the mean Meeh constant for 13 species of marine mammals (0.090 ± 0.018 m2∙kg−0.67), nor was it significantly different from the Meeh constants calculated for two samples of terrestrial mammals (0.097 ± 0.019 (N = 57) and 0.10 ± 0.013 m2∙kg−0.67 (N = 21)). The empirical allometric relationship between body mass and surface area for our phocid seals was log Amax = log 0.14 + 0.51 log m (R2 = 0.84). This relationship was not significantly different from that calculated for cetaceans, but was, however, significantly different from that calculated for terrestrial mammals. On average, surface areas of marine mammals (including pinnipeds, cetaceans, and the sea otter) were 23% smaller for their mass than those of terrestrial mammals.

Kinematics and estimated thrust production of swimming harp and ringed seals

The propulsive motions of swimming harp seals (Phoca groenlandica Erxleben) and ringed seals (Phoca hispida Schreber) were studied by filming individuals in a flume. The seals swam at velocities ranging from 0.6 to 1.42 m s-1. Locomotion was accomplished with alternate lateral sweeps of the hind flippers generated by lateral flexions of the axial body in conjunction with flexion of the flippers. The frequency of the propulsive cycle increased linearly with the swimming velocity, and the maximum angle of attack of the flipper decreased, but the amplitude remained constant. The kinematics and morphology of this hind flipper motion indicated that phocid seals do not swim in the carangiform mode as categorized by Lighthill (1969), but in a distinct mode that mimics swimming by thunniform propulsors. The hind flippers acted as hydrofoils, and the efficiency, thrust power and coefficient of thrust were calculated from unsteady wing theory. The propulsive efficiency was high at approximately 0.85. The thrust power increased curvilinearly with velocity. The drag coefficient ranged from 0.012 to 0.028 and was found to be 2.8-7.0 times higher than the theoretical minimum. The drag coefficient was high compared with that of phocid seals examined during gliding or towing experiments, indicating an increased drag encumbered by actively swimming seals. It was determined that phocid seals are capable of generating sufficient power for swimming with turbulent boundary layer conditions.

Metabolic rates of seals and whales

A critical review of metabolic rate determinations for pinnipeds (seals, sea lions, fur seals, and walrus) and cetaceans (whales, dolphins, and porpoises) does not support the widely accepted generalization that they have higher metabolic rates than terrestrial mammals of similar size. This finding necessitates a rethinking of the thermoregulatory adaptations of these marine mammals for an aquatic existence and has important implications in comparative studies of mammals, which frequently omit marine forms because they are perceived to be "different" from other mammals. It also suggests that numerous studies have overestimated food consumption by marine mammal populations.

Comparative energetics of coat colour polymorphs in the eastern grey squirrel, Sciurus carolinensis

Heat loss at various environmental temperatures was examined in colour morphs of the eastern grey squirrel, Sciurus carolinensis, during summer and winter.In winter pelage, melanistic squirrels had significantly (p < 0.05) lower heat losses and lower basal metabolic rates than grey morphs at ambient temperatures between −20 and 25 °C. No such differences were observed between colour morphs in summer pelage.Thermal conductances were significantly higher in summer animals. However, there were no significant differences in conductance associated with pelage colouration in either summer or winter squirrels.Melanistic S. carolinensis thus appear to have a lower energy cost for existence during winter than do grey morphs. This may contribute to the apparent superior fitness of melanistic morphs in the northern portion of the species' range. Lower heat loss by melanistic squirrels during winter, without a concomitant reduction in thermal conductance, may be associated with a lower body core temperature.