A Risk Assessment and Planning Tool to Prevent Sudden Unexpected Death in Infancy: Development and Evaluation of The Baby Sleep Planner

BACKGROUND

Successful national safer sleep campaigns in the United Kingdom have lowered the death rates from sudden unexpected death in infancy (SUDI) over the past 3 decades, but deaths persist in socioeconomically deprived families. The circumstances of current deaths suggest that improvements in support for some families to follow safer sleep advice more consistently could save lives.

OBJECTIVE

This study aimed to develop and evaluate a risk assessment and planning tool designed to improve the uptake of safer sleep advice in families with infants at increased risk of SUDI.

METHODS

A co-design approach was used to develop the prototype interface of a web-based tool with 2 parts: an individual SUDI risk assessment at birth and a downloadable plan for safety during times of disruption. The advice contained within the tool is concordant with national guidance from the Lullaby Trust, the United Nations International Children's Emergency Fund (UNICEF), and the National Institute for Health and Care Excellence. User testing of the prototype tool was conducted by inviting health visitors, midwives, and family nurses to use it with families eligible for additional support. Qualitative interviews with health professionals and families allowed for iterative changes to the tool and for insights into its function and influence on parental behavior.

RESULTS

A total of 22 health professionals were enrolled in the study, of whom 20 (91%) were interviewed. They reported appreciating the functionality of the tool, which allowed them to identify at-risk families for further support. They felt that the tool improved how they communicated about risks with families. They suggested expanding its use to include relevance in the antenatal period and having versions available in languages other than English. They reported using the tool with 58 families; 20 parents gave consent to be interviewed by the research team about their experiences with the tool. Families were positive about the tool, appreciated the trustworthy information, and felt that it was useful and appropriate and that the plans for specific infant sleeps would be of benefit to them and other family members.

CONCLUSIONS

Our tool combines risk assessment and safety planning, both of which have the potential to improve the uptake of lifesaving advice. Refinements to the tool based on these findings have ensured that the tool is ready for further evaluation in a larger study before being rolled out to families with infants at increased risk.

Changes in background characteristics and risk factors among SIDS infants in England: cohort comparisons from 1993 to 2020

OBJECTIVES

Using the National Child Mortality Database, this work aims to investigate background characteristics and risk factors in the sleeping environment associated with sudden infant death syndrome (SIDS) and compare the prevalence with previous English SIDS case-control studies.

DESIGN

Cohort of SIDS in 2020 compared with a combined analysis of two case-control studies conducted in 1993-1996 and 2003-2006.

SETTING

England, UK PARTICIPANTS: 138 SIDS deaths in 2020 compared with 402 SIDS deaths and 1387 age-equivalent surviving controls, combined from previous studies.

RESULTS

The increased vulnerability of SIDS infants identified in previous studies has become more marked. The infants who died in 2020 were younger (median=66 days (IQR: 34-118) vs 86 days (IQR: 52-148), p=0.003) with an increased prevalence of low birth weight (30.5% vs 21.6%, p=0.04) and preterm births (29.6% vs 19.3%, p=0.012). The excess of socioeconomically deprived families, male infants and high levels of maternal smoking during pregnancy were still evident. Among recent deaths, fewer infants were put down or found on their side; however, there was no significant change in the proportion of infants who were put down (15.6% vs 14.6%, p=0.81) and found prone (40.4% vs 35.3%, p=0.37), despite population wide risk reduction advice over three decades. The proportional increase observed in 2003-2006 of half the deaths occurring while sleeping next to an adult was maintained in 2020, and for the vast majority (90%), this was in hazardous circumstances (adult had consumed alcohol, smoked, slept on a sofa, or the infant was premature or low birth weight and less than 3 months old). More deaths also occurred when there was a disruption in infant care routine compared with previous observations (52.6% vs 20.7%, p<0.001).

CONCLUSIONS

A more targeted approach is needed with vulnerable families emphasising the importance of sleeping infants on their back and proactive planning infant sleep when there are disruptions to the normal routine, in particular to avoid hazardous co-sleeping.

Relationships among owner consideration of euthanasia, caregiver burden, and treatment satisfaction in canine osteoarthritis

Although diagnosis of osteoarthritis (OA) has been recently linked to euthanasia in dogs, no prior work has examined the roles of caregiver burden or treatment satisfaction in this relationship. We expected that there would be an indirect effect of caregiver burden on the association between consideration of euthanasia and clinical signs of OA, but that this effect would be influenced by owner satisfaction. Cross-sectional online evaluations were completed by 277 owners of dogs with OA recruited through social media. Canine OA-related pain and functional impairment, owner consideration of euthanasia, caregiver burden, and satisfaction were examined. Relationships among OA-related pain and functional impairment, owner consideration of euthanasia, caregiver burden, and satisfaction were statistically significant (P 0.01 for all). Cross-sectional mediation analysis demonstrated a statistically significant indirect effect of caregiver burden on the relationship between consideration of euthanasia and OA-related clinical signs (bias-corrected 95% confidence interval [BC 95% CI], 0.001-0.009), which was significantly moderated by owner satisfaction (BC 95% CI, -0.003 to -0.0002). Findings align with prior work connecting canine OA to euthanasia. The current study extends past research to demonstrate that caregiver burden in the owner may be partially responsible for this relationship. The moderating role of owner satisfaction suggests that optimizing owner impressions of treatment and the veterinary team could attenuate these relationships, potentially decreasing the likelihood of premature euthanasia for dogs with OA.

Implementing a Memory Clinic Model to Facilitate Recruitment into Early Phase Clinical Trials for Mild Cognitive Impairment and Alzheimer's Disease

BACKGROUND

The recruitment challenges for MCI and AD subjects into clinical trials are well known, and this is particularly true for early phase studies. Currently, only 10-20% of all patients who are referred for research from the community are trial eligible (Grill and Karlawish, 2011). Due to the limited and specific study objectives in early phase study designs, these rates drop to approximately one patient every two months. Barriers to research recruitment are multi-factorial, involving patient centered factors, issues related to caregiver/study partner participation, and aspects related to the involvement of their treating physicians. To address this challenge, we implemented a Memory Clinic within PAREXEL's Early Phase Clinical Pharmacology Unit. Our objective was to significantly facilitate recruitment into AD clinical trials by providing resources and education to patients, their treating physicians, and caregivers in the community.

METHOD

The Clinic's primary goals were to increase research visibility and partnerships with local organizations and referring physicians. Members of the research team co-sponsored community outreach events with local organizations, thereby increasing awareness about the services of this memory clinic. Secondly, physician outreach was expanded to include those who were not previously amenable to clinical trial referrals. Finally, Memory Clinic patients were given clinical evaluations, free of charge and the results were discussed with the patients and their caregivers. If the patients were interested in hearing more about possible research opportunities, they were referred to the early phase unit for a screening visit.

RESULTS

We found that new referrals for research participation significantly increased as a result of this new paradigm. In 2016, 12 patients diagnosed with MCI or AD per protocol, were referred to a research study and 3 were randomized. In 2017, 98 patients were referred and 16 were enrolled In addition, our referral network increased with 30 physicians over a 20 mile radius. Collaborations with national non-profit organizations also increased, thereby increasing public awareness about the importance of research participation in the development of new treatments for Alzheimer's Disease.

CONCLUSIONS

In summary, community engagement and providing referring physicians with a clinical service improved recruitment significantly for our phase 1 unit. Resource education, staff training, and dedicated medical professionals can significantly improve awareness about clinical research participation and provide additional participants over and above traditional recruitment methods and trial registry enrollment in a large urban area.

Current, future and potential use of mobile and wearable technologies and social media data in the ABCD study to increase understanding of contributors to child health

Mobile and wearable technologies and novel methods of data collection are innovating health-related research. These technologies and methods allow for multi-system level capture of data across environmental, physiological, behavioral, and psychological domains. In the Adolescent Brain Cognitive Development (ABCD) Study, there is great potential for harnessing the acceptability, accessibility, and functionality of mobile and social technologies for in-vivo data capture to precisely measure factors, and interactions between factors, that contribute to childhood and adolescent neurodevelopment and psychosocial and health outcomes. Here we discuss advances in mobile and wearable technologies and methods of analysis of geospatial, ecologic, social network and behavioral data. Incorporating these technologies into the ABCD study will allow for interdisciplinary research on the effects of place, social interactions, environment, and substance use on health and developmental outcomes in children and adolescents.

Does the social environment moderate associations of the built environment with Latinas' objectively-measured neighborhood outdoor physical activity?

Favorable perceptions of the built and social neighborhood environment may promote outdoor physical activity (PA). However, little is known about their independent and interactive effects on neighborhood-specific outdoor PA. We examined associations of perceived built and social neighborhood environment factors, and their interactions, with objectively-measured neighborhood outdoor moderate-to-vigorous physical activity (MVPA) among a sample of Latina women in San Diego, CA. Analyses included baseline data collected in 2011-2013 from 86 Latinas with ≥ 2 days of combined accelerometer and global positioning system data and complete survey measures. We examined objective neighborhood outdoor MVPA within 500-meter home buffers. Generalized linear mixed models examined associations of 3 perceived built (e.g., sidewalk maintenance) and 3 social environmental (e.g., safety from crime) factors with engaging in any daily neighborhood outdoor MVPA. Models tested interactions between the built and social environmental factors. Although the perceived neighborhood environmental factors were not significantly related to daily neighborhood outdoor MVPA, we found 2 significant interactions: perceived sidewalk maintenance x safety from crime (p = 0.05) and neighborhood aesthetics x neighborhood social cohesion (p = 0.03). Sidewalk maintenance was positively related to daily neighborhood outdoor MVPA only among Latinas that reported low levels of safety from crime. Neighborhood aesthetics was positively related to daily neighborhood outdoor MVPA only among Latinas with high neighborhood social cohesion. Findings suggest several built and social environmental factors interact to influence Latinas' neighborhood outdoor MVPA. Interventions are needed targeting both built and social neighborhood environmental factors favorable to outdoor PA in the neighborhood.

Feasibility of tuberculosis treatment monitoring by video directly observed therapy: a binational pilot study

BACKGROUND

Although directly observed therapy (DOT) is recommended worldwide for monitoring anti-tuberculosis treatment, transportation and personnel requirements limit its use.

OBJECTIVE

To evaluate the feasibility and acceptability of 'video DOT' (VDOT), which allows patients to record and transmit medication ingestion via videos watched remotely by health care providers to document adherence.

METHODS

We conducted a single-arm trial among tuberculosis (TB) patients in San Diego, California, USA, (n = 43) and Tijuana, Mexico (n = 9) to represent high- and low-resource settings. Pre-/post-treatment interviews assessed participant characteristics and experiences. Adherence was defined as the proportion of observed doses to expected doses.

RESULTS

The mean age was 37 years (range 18-86), 50% were male, and 88% were non-Caucasian. The mean duration of VDOT use was 5.5 months (range 1-11). Adherence was similar in San Diego (93%) and Tijuana (96%). Compared to time on in-person DOT, 92% preferred VDOT, 81% thought VDOT was more confidential, 89% never/rarely had problems recording videos, and 100% would recommend VDOT to others. Seven (13%) participants were returned to in-person DOT and six (12%) additional participants had their phones lost, broken or stolen.

CONCLUSIONS

VDOT was feasible and acceptable, with high adherence in both high- and low-resource settings. Efficacy and cost-effectiveness studies are needed.

Outcomes of a 1-year randomized controlled trial to evaluate a behavioral 'stepped-down' weight loss intervention for adolescent patients with obesity

BACKGROUND

Stepped-care approaches to weight loss have shown some success among adults. A 'stepped-down' version of the stepped-care approach to adolescent weight loss has never been evaluated.

OBJECTIVES

We conducted a one-year randomized controlled trial to compare a stepped-down weight loss intervention versus enhanced usual care (EUC).

METHODS

Study participants were obese adolescents age 11-13 (N = 106, 51% girls, and 82% Hispanic) recruited from primary care clinics in San Diego, California. The stepped-down intervention was delivered through clinician and health educator counseling (in-person and by phone) and mailed content. The intervention consisted of four-month 'steps' beginning with the most intensive contact followed by reduced contact if treatment goals were met. The EUC group received an initial physician visit, one session with a health counselor, and monthly mailed materials. Body mass index (BMI kg/m(2) ) was measured at baseline, 4, 8, and 12 months. Mixed-model regression analyses were stratified by sex.

RESULTS

Results indicated a clinically significant treatment effect for boys on BMI (p < 0.001) but not girls. No between group differences were found for adiposity and biometric outcomes. Only 13% of intervention participants succeeded in stepping down from step 1 to step 2 or step 3.

CONCLUSIONS

A stepped-down approach to weight loss showed some evidence of efficacy for weight loss in boys but not girls. The findings suggest the program as designed was not intensive enough to result in weight loss in this population segment.

Major ABO incompatible BMT in children: determining what residual volume of donor red cells can safely be infused following red cell depletion

Major ABO incompatible BM transplantation carries a risk of acute haemolysis. Red cell depletion reduces this risk but not all incompatible RBC (iRBCs) are removed and in children the residual volume can be significant relative to body weight. We sought to determine the volume of iRBCs that can be safely given to children. All patients receiving fresh BM from a donor with a major ABO blood group mismatch between January 2000 and July 2013 at the Hospital for Sick Children, Toronto, were included. Seventy-eight patients were identified. The median volume of iRBCs transfused was 1.6 mL/kg (range 0.1-10.6 mL/kg). Thirty-five patients had minor haemolytic events and five patients had clinically significant adverse events. Two patients, who received 3.66 and 3.9 mL iRBCs/kg, developed renal impairment and in one case hypoxia and hyperbilirubinaemia. One patient had mild hypotension that resolved with i.v. fluid. Two patients developed hypotension secondary to sepsis and unrelated to BM infusion. Although signs of haemolysis occur, with appropriate hydration and monitoring of renal function, clinically significant adverse events related to the infusion of ABO incompatible BM are rare, and, in this study, were only seen in patients receiving >3 mL/kg of iRBCs per kg.

Relationships between depression, gender, and unhealthy weight loss practices among overweight or obese college students

INTRODUCTION

Unhealthy weight loss practices are common among female college students. It is unknown if these practices are also most common among women in the subset of overweight or obese college students or if these practices are related to depression. We examined the relationship between gender, depression, and unhealthy weight loss practices among overweight or obese college students.

METHODS

Students (body mass index between 25.0 and 34.9 kg/m(2)) from three Southern California universities (M(age) = 22 years, SD = 4; 70% women) were recruited from May 2011 to May 2012 for participation in a weight loss clinical trial (N = 404). Logistic regressions were performed with baseline data to assess the cross-sectional relationship between self-reported unhealthy weight loss practices and gender and depression as measured by the Center for Epidemiologic Studies Depression short form.

RESULTS

Twenty-nine percent of participants reported engaging in at least one unhealthy weight loss behavior (e.g., fasting, purging) over the last 30 days, with no differences by gender. Self-report of at least one unhealthy weight loss behavior was associated with report of symptoms of depression (e(B) = 1.14 [confidence interval, CI: 1.08-1.20]), adjusting for potential confounders. Interactions between gender and depression were not significant (e(B) = 1.04 [CI: 0.93-1.16]).

CONCLUSION

Among an overweight or obese sample of college students, unhealthy weight loss practices were equally common in both genders, and students with depressive symptomatology were at greatest risk. Obesity interventions targeting overweight or obese college students should educate both men and women about the dangers of unhealthy weight loss practices. In addition, screening for depression can help identify students who would benefit from additional supportive and coping strategies and resources.

Design and implementation of a randomized controlled social and mobile weight loss trial for young adults (project SMART)

PURPOSE

To describe the theoretical rationale, intervention design, and clinical trial of a two-year weight control intervention for young adults deployed via social and mobile media.

METHODS

A total of 404 overweight or obese college students from three Southern California universities (M(age) = 22( ± 4) years; M(BMI) = 29( ± 2.8); 70% female) were randomized to participate in the intervention or to receive an informational web-based weight loss program. The intervention is based on behavioral theory and integrates intervention elements across multiple touch points, including Facebook, text messaging, smartphone applications, blogs, and e-mail. Participants are encouraged to seek social support among their friends, self-monitor their weight weekly, post their health behaviors on Facebook, and e-mail their weight loss questions/concerns to a health coach. The intervention is adaptive because new theory-driven and iteratively tailored intervention elements are developed and released over the course of the two-year intervention in response to patterns of use and user feedback. Measures of body mass index, waist circumference, diet, physical activity, sedentary behavior, weight management practices, smoking, alcohol, sleep, body image, self-esteem, and depression occur at 6, 12, 18, and 24 months. Currently, all participants have been recruited, and all are in the final year of the trial.

CONCLUSION

Theory-driven, evidence-based strategies for physical activity, sedentary behavior, and dietary intake can be embedded in an intervention using social and mobile technologies to promote healthy weight-related behaviors in young adults.

Body mass index, sexual difficulties and sexual satisfaction among people in regular heterosexual relationships: a population-based study

BACKGROUND/AIMS

The aims of this study were to clarify the relationship between body mass index (BMI) and sexual difficulties and to investigate if BMI influenced sexual satisfaction, over and above the effects of sexual difficulties.

METHODS

Cross-sectional analyses of a nationally representative computer-assisted telephone interview. Eight thousand, six hundred and fifty-six respondents were recruited by random digit dialling in 2004-2005. Only those in a sexually active, heterosexual relationship were included in the current analyses.

RESULTS

After adjustments for demographic factors, both overweight and obese male and female participants were more likely to report worrying during sex about whether their body was unattractive. Among women, associations were also found between higher BMI and lack of interest in sex. No other significant associations between BMI and sexual difficulties were evident. There was an association between BMI and extreme physical pleasure for women but not men over and above the effects of sexual difficulties, with obese women being more likely than normal weight women to report extreme physical pleasure. No associations were found for either men or women between BMI and whether or not they reported extreme emotional or sexual satisfaction with their relationship.

CONCLUSIONS

With the exception of body image difficulties, there is little association between BMI and self-reported sexual difficulties. Furthermore, extreme sexual and emotional satisfaction appeared to be associated with the presence or absence of sexual difficulties and not overly influenced by BMI. Overall, clinicians and patients should be aware that being overweight is not necessarily detrimental to sexual functioning.

Changes in the maternal hypothalamic-pituitary-adrenal axis during the early puerperium may be related to the postpartum 'blues'

Most women experience time-limited and specific mood changes in the days after birth known as the maternity blues (Blues). The maternal hypothalamic-pituitary-adrenal (HPA) axis undergoes gradual changes during pregnancy because of an increasing production of placental corticotrophin-releasing hormone (CRH). The abrupt withdrawal of placental CRH at birth results in a re-equilibration of the maternal HPA axis in the days post-delivery. These changes may be involved in the aetiology of the Blues given the central role of the HPA axis in the aetiology of mood disorders in general, and in perinatal depression in particular. We aimed to test the novel hypothesis that the experience of the Blues may be related to increased secretion of hypothalamic adrenocorticotrophic hormone (ACTH) secretagogue peptides, after the reduction in negative-feedback inhibition on the maternal hypothalamus caused by withdrawal of placental CRH. We therefore examined hormonal changes in the HPA axis in the days after delivery in relation to daily mood changes: our specific prediction was that mood changes would parallel ACTH levels, reflecting increased hypothalamic peptide secretion. Blood concentrations of CRH, ACTH, cortisol, progesterone and oestriol were measured in 70 healthy women during the third trimester of pregnancy, and on days 1-6 post-delivery. Blues scores were evaluated during the postpartum days. Oestriol, progesterone and CRH levels fell rapidly from pregnancy up to day 6, whereas cortisol levels fell modestly. ACTH concentrations declined from pregnancy to day 3 post-delivery and thereafter increased up to day 6. Blues scores increased, peaking on day 5, and were positively correlated with ACTH; and negatively correlated with oestriol levels during the postpartum days, and with the reduction in CRH concentrations from pregnancy. These findings give indirect support to the hypothesis that the 'reactivation' of hypothalamic ACTH secretagogue peptides may be involved in the aetiology of the Blues.

Increased pituitary-adrenal activation and shortened gestation in a sample of depressed pregnant women: a pilot study

BACKGROUND

Major depression (MD) is frequently accompanied by a relatively increased production of the stress hormone cortisol. During pregnancy corticotrophin releasing hormone (CRH) is secreted from the placenta and critically high levels of CRH are one of the key triggers for parturition. Maternal cortisol promotes the secretion of placental CRH. In this study, we examined the hypothesis that women suffering with MD in pregnancy would have relatively increased cortisol secretion, a time-advanced rise in placental CRH production and an earlier delivery of the baby.

METHODS

A group of medication-free pregnant women, free of know obstetric and medical complications, with (n=27) and without (n=38) MD were recruited. Blood concentrations of CRH, adrenocorticotrophic hormone (ACTH) and diurnal salivary cortisol concentrations were measured at fixed time points.

RESULTS

Maternal cortisol concentrations were highly correlated with placental CRH secretion for the entire group. Second trimester CRH concentrations and mean evening salivary cortisol concentrations were significantly higher in the depressed women. Although pregnancy length was shorter in the depressed women there were no statistical relationships between the stress hormone measures and pregnancy length.

LIMITATIONS

The sample size was small and highly selected.

CONCLUSIONS

These findings suggest that depressed pregnant women hypersecrete cortisol in a diurnal pattern similar to that typical of MD, and that this leads to a time-advanced rise in placental CRH secretion. Factors other than this stress-delivery mechanism may be contributing to the shortened pregnancy length in depressed women.

The role of primary care in promoting children's physical activity

Regular physical activity enhances health during childhood and adolescence and is important in setting the stage for participation in physical activity across the lifespan. Physician-patient interactions during childhood and adolescence provide important opportunities for clinicians to influence physical activity behaviours. This article reviews current physical activity recommendations for youth and the wide range of health benefits provided to youth from engaging in regular physical activity. It also outlines a practical counselling model, the 5As approach, that can guide clinical counselling for physical activity, and reviews how an increasingly important model of practice organisation, the Care Model, can be used to promote physical activity in children and adolescents. Family, social and environmental influences on child and adolescent physical activity are also addressed.

The impact of optimal (<1cm) surgical debulking on survival at the time of recurrence in patients with uterine leiomyosarcoma (LMS)

16067

Objective: Uterine leiomyosarcoma (LMS) is an uncommon female malignancy with limited treatment options. To evaluate whether there exists a role for surgery at the time of recurrence, we performed an outcomes analysis from over 25 years of treating LMS at a single institution. Methods: Patients with uterine leiomyosarcoma who presented for treatment at the H. Lee Moffitt Cancer Center from 1981–2005 were identified from the cancer registry database. Patients who underwent surgery (with or without adjuvant treatment) at the time of first recurrence were compared to those patients who did not undergo surgery and were managed medically. Cox regression analysis (multivariate) was used to evaluate whether demographic or pathologic characteristics were associated with survival. Survival curves were estimated using the Kaplan-Meier method and p-values with 95% confidence intervals were generated using the log rank test. Results: Forty-six charts were reviewed to identify forty-one patients with leiomyosarcomas arising from the uterus and treated during 1981–2005. Of the forty-one patients identified, only 7% (N=3) are currently in remission, with a mean follow-up of 40 months from the time of first recurrence. Sixteen patients underwent surgery at the time of first recurrence, with 60% (N=10) of these patients having an optimal cytoreduction (<1cm). On multivariate analysis, post-menopausal status (p=0.011), the presence of tumor necrosis (p=0.038) and high pathologic grade (p=0.056) were significant variables associated with decreased survival. Median survival for optimally cytoreduced patients compared to patients medically managed patients was 55.5 months and 20 months, respectively. A trend towards improved survival in the optimally cytoreduced group was suggested but was not statistically significant (P=0.26) Conclusions: Uterine leiomyosarcoma is a disease with a poor prognosis and a high likelihood of recurrence. We have identified post-menopausal status, tumor necrosis, and pathologic grade as significant predictors of survival. Given the limited treatment options available and with a suggested trend toward improved survival, cytoreductive surgery at the time of recurrence may be worthy of future investigation.

No significant financial relationships to disclose.

Anticholinergic drugs versus non-drug active therapies for overactive bladder syndrome in adults

BACKGROUND

Overactive Bladder Syndrome (OAB) is defined as urgency, with or without urgency incontinence, usually with frequency and nocturia. Pharmacotherapy with anticholinergic drugs is often the first line medical therapy, either alone or as an adjunct to various non-pharmacological therapies. The commonest non-pharmacologic therapies are: bladder training, pelvic floor muscle training with or without biofeedback and electric stimulation to affect detrusor muscle activity.

OBJECTIVES

To compare the effects of various anticholinergic drugs with various non-pharmacologic therapies for idiopathic overactive bladder syndrome in adults.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group Specialised Register (searched 29 November 2005), The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (January 1966 to September 2004), PREMEDLINE, Dissertation Abstracts and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised, or quasi-randomised, controlled trials of treatment with anticholinergic drugs for overactive bladder syndrome or urge urinary incontinence in adults, in which at least one management arm involved a non-drug new therapy. Trials amongst patients with neuropathic bladder dysfunction were excluded.

DATA COLLECTION AND ANALYSIS

Two authors evaluated the trials for appropriateness for inclusion and methodological quality. Three authors were involved in the data extraction. Data extracted was based on predetermined criteria. Data analysis was based on standard statistical approaches used in Cochrane reviews.

MAIN RESULTS

Thirteen trials with 1770 participants were included; all were designed as parallel groups except for one cross-over trial. Trial groups were well matched for baseline characteristics in all trials. Treatment duration was 3 to 12 weeks, with one trial carrying out a follow-up analysis at 24 weeks after starting treatment. During treatment, symptomatic improvement was more common amongst those on anticholinergic drugs compared with bladder training (RR 0.73; 95% CI 0.59 to 0.90). Combination of anticholinergics with bladder training was also associated with more improvement than bladder training alone but with wide confidence intervals (RR 0.55; 95% 0.32 to 0.93). Similarly, the limited data favoured a combination of anticholinergics with bladder training compared with anticholinergics during treatment but the difference was not statistically significant (RR for improvement 0.81; 95% CI 0.61 to 1.06). For all comparisons, there were too few data to compare symptoms after treatment had ended. Adverse effects, such as dry mouth, were reported by around a third of those taking anticholinergics.

AUTHORS' CONCLUSIONS

The use of anticholinergic drugs in the management of OAB is well established. During initial treatment there was more symptomatic improvement when (a) anticholinergics were compared with bladder training alone, and (b) anticholinergics combined with bladder training were compared with each modality alone. Anticholinergics have well recognised side effects, such as dry mouth. There were too few data to assess whether or not effects are sustained after stopping treatment.

A multicomponent program for nutrition and physical activity change in primary care: PACE+ for adolescents

BACKGROUND

Most adolescents do not meet national recommendations for nutrition and physical activity. However, no studies of physical activity and nutrition interventions for adolescents conducted in health care settings have been published. The present study was an initial evaluation of the PACE+ (Patient-centered Assessment and Counseling for Exercise plus Nutrition) program, delivered in primary care settings.

PARTICIPANTS

Adolescents aged 11 to 18 years (N = 117) were recruited from 4 pediatric and adolescent medicine outpatient clinics. Participants' mean (SD) age was 14.1 (2.0) years, 37% were girls, and 43% were ethnic minorities.

INTERVENTION

Behavioral targets were moderate physical activity, vigorous physical activity, fat intake, and fruit and vegetable intake. All patients completed a computerized assessment, created tailored action plans to change behavior, and discussed the plans with their health care provider. Patients were then randomly assigned to receive no further contact or 1 of 3 extended interventions: mail only, infrequent telephone and mail, or frequent telephone and mail.

MEASURES

Brief, validated, self-report measures of target behaviors were collected at baseline and 4 months later.

RESULTS

All outcomes except vigorous physical activity improved over time, but adolescents who received the extended interventions did not have better 4-month outcomes than those who received only the computer and provider counseling components. Adolescents who targeted a behavior tended to improve more than those who did not target the behavior, except for those who targeted vigorous physical activity.

CONCLUSIONS

A primary care-based interactive health communication intervention to improve physical activity and dietary behaviors among adolescents is feasible. Controlled experimental research is needed to determine whether this intervention is efficacious in changing behaviors in the short- and long-term.

In vivo gene expression revealed by cDNA arrays: the pattern in relapsing-remitting multiple sclerosis patients compared with normal subjects

OBJECTIVES

To use DNA arrays to identify differences in gene expression associated with relapsing-remitting (RR) MS.

METHODS

Total RNA was isolated from monocyte depleted peripheral blood mononuclear cells of 15 RR MS patients and 15 age- and sex-matched controls. The RNA was reverse transcribed to radiolabeled cDNA and the resultant cDNA was used to probe a DNA array containing over 4000 named human genes. The binding of radiolabeled cDNA to the probes on the array was measured by phosphorimager.

RESULTS

Of more than 4000 genes tested, only 34 were significantly different in RR-MS patients from controls. Of these, 25 were significantly increased and 9 significantly decreased in the RR MS patients. Twelve of these genes have inflammatory and/or immunological functions that could be relevant to the MS disease process. The potentially relevant genes that were elevated (15% to 28%) were P protein, LCK, cAMP responsive element modulator, IL-7 receptor, matrix metalloproteinase-19, M130 antigen, and peptidyl-prolyl isomerase. Those that were significantly decreased (15% to 35%) were SAS transmembrane 4 superfamily protein, STRL22 (C-C chemokine receptor 6), AFX protein, DNA fragmentation factor-45 and immunoglobulin gamma 3 (Gm marker).

CONCLUSIONS

The RR-MS disease effect was relatively restricted and most of the mRNAs tested were not different from the normal controls. However, there were significant differences identified in the expression of a subset of mRNAs, including 13 with inflammatory/immune functions that could be relevant to MS. The systematic use of DNA arrays can provide insight into the dynamic cellular pathways involved in MS pathogenesis and its phenotypic heterogeneity.

Incorporating new recipes into the Armed Forces Recipe File: determination of acceptability

As part of a project of decrease fat, cholesterol, and sodium in soldiers' diets, new ethnic and breakfast items were developed and standardized for 100 portions. Acceptability data were collected after initial recipe development, during recipe validation at a collaborating university, and in an actual Army garrison. Acceptability was determined using a nine-point hedonic scale; products rating > or = 6.0 in initial tests were prepared in garrison. Acceptability data were compared among test settings, ethnic categories, and food type. When grouped by ethnic categories, acceptability ratings varied more than when grouped by food type. Ratings varied most between development and validation settings (7.2 vs. 6.6; p < 0.05) and least between validation and actual Army settings (6.6 vs. 6.6; not significant). Because acceptability ratings were similar between the validation site and the Army garrison, future recipe development may continue without additional testing at actual Army garrisons, leading to more timely armed forces recipe file additions.

PACE+: interactive communication technology for behavior change in clinical settings

BACKGROUND

Interactive health communication technologies have the potential to eliminate or greatly reduce many of the barriers to delivery of preventive services. This paper describes the process of developing and evaluating interactive health communication programs for primary care settings. We present as examples the Patient-centered Assessment and Counseling for Exercise plus Nutrition (PACE+) programs, designed to promote physical activity and healthy nutrition with adolescents and adults.

METHODS

The PACE+ programs use interactive communication technology to screen multiple behaviors, prioritize areas for intervention, and initiate intervention. Patient information is synthesized for ease of use by clinicians. The patient completes the program on a computer in the clinic waiting room before the provider encounter. Acceptability of the program was evaluated with adolescents (n=252), adults (n=285), and their health care providers.

RESULTS

The PACE+ programs were developed, evaluated, modified, and re-evaluated. Feasibility testing indicated that a diverse group of adolescents and adults found the PACE+ computer programs acceptable. Modifications to shorten and refine the programs were identified.

CONCLUSIONS

Development of interactive health technologies is an iterative process dependent on feedback from intended users and systems of care. Interactive health communication technologies can be incorporated into clinical settings.

Detection of cytochrome P450 and other drug-metabolizing enzyme mRNAs in peripheral blood mononuclear cells using DNA arrays

The purpose of this study was to determine whether the expression of cytochrome P450 (CYP) enzyme mRNAs, other drug-metabolizing enzyme mRNAs, and transporter mRNAs can be detected using DNA arrays. Total RNA was isolated from peripheral blood mononuclear cells of 10 multiple sclerosis patients and 10 age- and sex-matched controls. The mRNA was reverse transcribed to radiolabeled cDNA, and the resultant cDNA was used to probe a DNA array containing several thousand known human genes. The signals corresponding to several CYPs, drug-metabolizing, and transporter mRNAs was substantially above background. The results demonstrate that the DNA array technique has the sensitivity and the selectivity for applications in the pharmaceutical sciences. The mean values for mRNAs of specific CYPs and drug-metabolizing enzymes in peripheral blood cells were compared with reported values for liver. The capabilities of DNA arrays may prove useful for characterizing CYP expression in a variety of clinical samples.

Policy issues relevant to evaluation of interactive health communication applications. The Science Panel on Interactive Communication and Health

This article provides an analysis of policy-related issues associated with the evaluation of interactive health communication (IHC) applications. These include an assessment of the current health and technology policy environment pertinent to public (government, education, public health) and private (medical care providers, purchasers, consumers, IHC developers) IHC stakeholders and discussion of issues likely to merit additional consideration by these stakeholders in the future.

Access to health information and support: a public highway or a private road?

Information and communication technologies may help reduce health disparities through their potential for promoting health, preventing disease, and supporting clinical care for all. Unfortunately, those who have preventable health problems and lack health insurance coverage are the least likely to have access to such technologies. Barriers to access include cost, geographic location, illiteracy, disability, and factors related to the capacity of people to use these technologies appropriately and effectively. A goal of universal access to health information and support is proposed to augment existing initiatives to improve the health of individuals and the public. Both public- and private-sector stakeholders, particularly government agencies and private corporations, will need to collaboratively reduce the gap between the health information "haves" and "have-nots." This will include supporting health information technology access in homes and public places, developing applications for the growing diversity of users, funding research on access-related issues, ensuring the quality of health information and support, enhancing literacy in health and technology, training health information intermediaries, and integrating the concept of universal access to health information and support into health planning processes.

An evidence-based approach to interactive health communication: a challenge to medicine in the information age. Science Panel on Interactive Communication and Health

OBJECTIVE

To examine the current status of interactive health communication (IHC) and propose evidence-based approaches to improve the quality of such applications.

PARTICIPANTS

The Science Panel on Interactive Communication and Health, a 14-member, nonfederal panel with expertise in clinical medicine and nursing, public health, media and instructional design, health systems engineering, decision sciences, computer and communication technologies, and health communication, convened by the Office of Disease Prevention and Health Promotion, US Department of Health and Human Services.

EVIDENCE

Published studies, online resources, expert panel opinions, and opinions from outside experts in fields related to IHC.

CONSENSUS PROCESS

The panel met 9 times during more than 2 years. Government agencies and private-sector experts provided review and feedback on the panel's work.

CONCLUSIONS

Interactive health communication applications have great potential to improve health, but they may also cause harm. To date, few applications have been adequately evaluated. Physicians and other health professionals should promote and participate in an evidence-based approach to the development and diffusion of IHC applications and endorse efforts to rigorously evaluate the safety, quality, and utility of these resources. A standardized reporting template is proposed to help developers and evaluators of IHC applications conduct evaluations and disclose their results and to help clinicians, purchasers, and consumers judge the quality of IHC applications.

Principles for assuring the health of college students: a California perspective

Given the rapidity of change in both higher education and health care, re-examining the values and precepts that undergird the profession of college health is an ongoing need. Reported in this article are the results of a structured process in which a group of college health professionals from California, along with others interested in the health of college students, examined several trends affecting higher education and health; considered possible scenarios for these sectors; created a shared vision for the future of college health; and developed strategies useful in attaining that vision. The results of these deliberations are presented as a set of principles that, if followed, should increase the likelihood that college health centers will be responsive to user needs. Although the article is based on a California-based conference, the principles discussed are almost certainly valuable for all in college health.

Binge drinking among college students: a comparison of California with other states

California college students (1,864 students from 15 colleges) were compared with students who participated in the Harvard School of Public Health College Alcohol Study, which surveyed 17,592 students in 140 colleges nationwide. California college students, in comparison with the remainder of the nation, were less frequent drinkers; less frequent binge drinkers; exhibited fewer personal problems and risks associated with heavy episodic drinking, including drinking and driving; and reported fewer "secondhand" effects of binge drinking, such as being physically assaulted or experiencing an unwanted sexual advance. Many of these differences appear to be related to the California college students' being older, more likely to be married, and less likely to live on campus than those in the Harvard study. The findings suggest that, in developing programs tailored to local needs, there is significant value in augmenting national surveillance of college student health risk behaviors with the development of regional, state, and local surveillance systems.