Systematic review of the Exploration, Preparation, Implementation, Sustainment (EPIS) framework

Background

Effective implementation of evidence-based practices (EBPs) remains a significant challenge. Numerous existing models and frameworks identify key factors and processes to facilitate implementation. However, there is a need to better understand how individual models and frameworks are applied in research projects, how they can support the implementation process, and how they might advance implementation science. This systematic review examines and describes the research application of a widely used implementation framework, the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

Methods

A systematic literature review was performed to identify and evaluate the use of the EPIS framework in implementation efforts. Citation searches in PubMed, Scopus, PsycINFO, ERIC, Web of Science, Social Sciences Index, and Google Scholar databases were undertaken. Data extraction included the objective, language, country, setting, sector, EBP, study design, methodology, level(s) of data collection, unit(s) of analysis, use of EPIS (i.e., purpose), implementation factors and processes, EPIS stages, implementation strategy, implementation outcomes, and overall depth of EPIS use (rated on a 1–5 scale).

Results

In total, 762 full-text articles were screened by four reviewers, resulting in inclusion of 67 articles, representing 49 unique research projects. All included projects were conducted in public sector settings. The majority of projects (73%) investigated the implementation of a specific EBP. The majority of projects (90%) examined inner context factors, 57% examined outer context factors, 37% examined innovation factors, and 31% bridging factors (i.e., factors that cross or link the outer system and inner organizational context). On average, projects measured EPIS factors across two of the EPIS phases (M = 2.02), with the most frequent phase being Implementation (73%). On average, the overall depth of EPIS inclusion was moderate (2.8 out of 5).

Conclusion

This systematic review enumerated multiple settings and ways the EPIS framework has been applied in implementation research projects, and summarized promising characteristics and strengths of the framework, illustrated with examples. Recommendations for future use include more precise operationalization of factors, increased depth and breadth of application, development of aligned measures, and broadening of user networks. Additional resources supporting the operationalization of EPIS are available.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0842-6) contains supplementary material, which is available to authorized users.

Multiple portions of poly(A)-binding protein stimulate translation in vivo

Translational stimulation of mRNAs during early development is often accompanied by increases in poly(A) tail length. Poly(A)-binding protein (PAB) is an evolutionarily conserved protein that binds to the poly(A) tails of eukaryotic mRNAs. We examined PAB's role in living cells, using both Xenopus laevis oocytes and Saccharomyces cerevisiae, by tethering it to the 3'-untranslated region of reporter mRNAs. Tethered PAB stimulates translation in vivo. Neither a poly(A) tail nor PAB's poly(A)-binding activity is required. Multiple domains of PAB act redundantly in oocytes to stimulate translation: the interaction of RNA recognition motifs (RRMs) 1 and 2 with eukaryotic initiation factor-4G correlates with translational stimulation. Interaction with Paip-1 is insufficient for stimulation. RRMs 3 and 4 also stimulate, but bind neither factor. The regions of tethered PAB required in yeast to stimulate translation and stabilize mRNAs differ, implying that the two functions are distinct. Our results establish that oocytes contain the machinery necessary to support PAB-mediated translation and suggest that PAB may be an important participant in translational regulation during early development.

Humeral avulsion of glenohumeral ligaments as a cause of anterior shoulder instability

The avulsion of the glenohumeral ligament labral complex at the glenoid (Bankart lesion), as well as ligamentous laxity are well known causes of anterior shoulder instability. A lesser known entity, the humeral avulsion of glenohumeral ligaments (HAGL), was studied to determine its incidence and its role in anterior glenohumeral instability. Sixty-four shoulders with the diagnosis of anterior instability were prospectively evaluated by arthroscopy for intraarticular pathology, including Bankart, capsular laxity, and HAGL lesions. Six shoulders were found to have HAGL lesions (9.3%), 11 shoulders with generalized capsular laxity (17.2%), and 47 shoulders with Bankart lesions (73.5%). In patients with documented anterior instability without a demonstratable "primary" Bankart lesion, a HAGL lesion should be ruled out. This lesion is readily recognized arthroscopically, and an appropriate repair of this lesion can restore anterior stability to the patient. The pathological anatomy of the HAGL lesion and our treatment of this lesion is discussed.

Ten recommendations for using implementation frameworks in research and practice

BACKGROUND

Recent reviews of the use and application of implementation frameworks in implementation efforts highlight the limited use of frameworks, despite the value in doing so. As such, this article aims to provide recommendations to enhance the application of implementation frameworks, for implementation researchers, intermediaries, and practitioners.

DISCUSSION

Ideally, an implementation framework, or multiple frameworks should be used prior to and throughout an implementation effort. This includes both in implementation science research studies and in real-world implementation projects. To guide this application, outlined are ten recommendations for using implementation frameworks across the implementation process. The recommendations have been written in the rough chronological order of an implementation effort; however, we understand these may vary depending on the project or context: (1) select a suitable framework(s), (2) establish and maintain community stakeholder engagement and partnerships, (3) define issue and develop research or evaluation questions and hypotheses, (4) develop an implementation mechanistic process model or logic model, (5) select research and evaluation methods (6) determine implementation factors/determinants, (7) select and tailor, or develop, implementation strategy(s), (8) specify implementation outcomes and evaluate implementation, (9) use a framework(s) at micro level to conduct and tailor implementation, and (10) write the proposal and report. Ideally, a framework(s) would be applied to each of the recommendations. For this article, we begin by discussing each recommendation within the context of frameworks broadly, followed by specific examples using the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

SUMMARY

The use of conceptual and theoretical frameworks provides a foundation from which generalizable implementation knowledge can be advanced. On the contrary, superficial use of frameworks hinders being able to use, learn from, and work sequentially to progress the field. Following the provided ten recommendations, we hope to assist researchers, intermediaries, and practitioners to improve the use of implementation science frameworks.

Axonal sprouting following lesions of the rat substantia nigra

Parkinson's disease is characterized by the progressive loss of dopaminergic neurons in the substantia nigra pars compacta. Symptoms do not appear until most nigral neurons are lost, implying that compensatory mechanisms are present. Sprouting has been proposed as one of these mechanisms. This study quantified the extent of compensatory axonal sprouting following injury of dopaminergic neurons within the substantia nigra pars compacta. Specifically, the extent of the axonal arbour and axonal varicosity morphology was measured after partial destruction (with 6-hydroxydopamine) of the substantia nigra of the adult male rat. Four months later, the substantia nigra was injected with the anterograde neuronal tracer dextran-biotin to trace the full extent of individual axons. An unbiased estimate of neuron number was performed in each animal. This demonstrated nigral neuronal loss ranging from 10 to 90% on the side that received the injection whilst a 7% reduction was observed in the side contralateral to the lesion. Coincident with this loss, some nigral neurons lose tyrosine hydroxylase expression. Vigorous axonal sprouting was observed in the terminal arbours of lesioned animals and was associated with an increased axonal varicosity size. Axonal varicosities and branching points were primarily confined to the dorsal 1.5mm of the caudate-putamen, an area predominantly innervated by nigral neurons. It appears that dopaminergic neurons were responsible for this sprouting because the density of dopamine transporter immunoreactive varicosities in the caudate-putamen was maintained until about a 70% loss of neurons. It was concluded that substantial compensation in the form of sprouting and new dopaminergic synapse formation occurs following lesions of the substantia nigra pars compacta.

A more practical guide to incorporating health equity domains in implementation determinant frameworks

BACKGROUND

Due to striking disparities in the implementation of healthcare innovations, it is imperative that researchers and practitioners can meaningfully use implementation determinant frameworks to understand why disparities exist in access, receipt, use, quality, or outcomes of healthcare. Our prior work documented and piloted the first published adaptation of an existing implementation determinant framework with health equity domains to create the Health Equity Implementation Framework. We recommended integrating these three health equity domains to existing implementation determinant frameworks: (1) culturally relevant factors of recipients, (2) clinical encounter or patient-provider interaction, and (3) societal context (including but not limited to social determinants of health). This framework was developed for healthcare and clinical practice settings. Some implementation teams have begun using the Health Equity Implementation Framework in their evaluations and asked for more guidance.

METHODS

We completed a consensus process with our authorship team to clarify steps to incorporate a health equity lens into an implementation determinant framework.

RESULTS

We describe steps to integrate health equity domains into implementation determinant frameworks for implementation research and practice. For each step, we compiled examples or practical tools to assist implementation researchers and practitioners in applying those steps. For each domain, we compiled definitions with supporting literature, showcased an illustrative example, and suggested sample quantitative and qualitative measures.

CONCLUSION

Incorporating health equity domains within implementation determinant frameworks may optimize the scientific yield and equity of implementation efforts by assessing and ideally addressing implementation and equity barriers simultaneously. These practical guidance and tools provided can assist implementation researchers and practitioners to concretely capture and understand barriers and facilitators to implementation disparities.

Dispositional mindfulness moderates the effects of stress among adolescents: rumination as a mediator

Recent research has demonstrated that higher levels of mindfulness are associated with greater psychological and physical health. However, the majority of this research has been conducted with adults; research is only beginning to examine the effects of mindfulness among adolescents. Further, research into adolescent mindfulness has typically conceptualized mindfulness as a unidimensional phenomenon and has not yet examined multidimensional models of mindfulness that have emerged in the adult literature. Further, the mechanisms through which mindfulness influences these outcomes are presently unclear. The present study examined the effects of three facets of mindfulness among adolescents. Seventy-eight adolescents (61% female, 94% Caucasian, M age = 16) completed a measure of dispositional mindfulness at baseline. Participants then completed measures of daily stress, dysphoric affect, and state rumination over a 7-day period. Multilevel modeling analyses revealed that facets of mindfulness (i.e., nonreactivity and nonjudgment) were associated with lower levels of dysphoric mood. Mindfulness interacted with daily stress to predict later dysphoria; less mindful individuals were particularly vulnerable to the negative effects of stress. Finally, analyses demonstrated that the effect of the Mindfulness × Stress Moderation was significantly mediated by increases in daily rumination. These findings support the importance of mindfulness among adolescents and help to elucidate the mechanisms through which mindfulness influences psychological health.

Rumination, worry, cognitive avoidance, and behavioral avoidance: examination of temporal effects

Recently, cross-sectional research has demonstrated that depressive rumination is significantly associated with the tendency to engage in cognitive and behavioral avoidance. This evidence suggests that rumination may be the result of attempts to avoid personally threatening thoughts, in a manner suggested by multiple contemporary theories of worry. This investigation examined the temporal relationship among daily levels of cognitive avoidance, behavioral avoidance, rumination, worry, and negative affect. Seventy-eight adolescents completed baseline questionnaires and then electronically completed daily measures of rumination, worry, behavioral avoidance, and cognitive avoidance, as well as sad and anxious affect for 7 days. Lagged-effect multilevel models indicated that increases in daily sadness were predicted by greater daily rumination and cognitive avoidance. Increases in daily anxiety were predicted by greater daily rumination, worry, and both cognitive and behavioral avoidance. Further, both daily rumination and worry were positively predicted by daily cognitive, but not behavioral, avoidance. Mediation analyses suggested that rumination mediated the effect of cognitive avoidance on both sadness and anxiety. Also, worry mediated the effect of cognitive avoidance on anxiety. Implications for models of avoidance, rumination, and worry are discussed.

Outcome of rotationally unstable pelvic ring injuries treated operatively

Twenty-nine patients with unstable rotational injuries treated operatively were observed for an average of 39 months. There were 24 associated orthopaedic injuries. Twenty-seven patients had symphysis disruption (4 with rami fractures) and 2 had rami fractures associated with an acetabular fracture. Followup evaluation of those who could be evaluated in each category revealed that 96% had no pain or pain only on strenuous activity, ambulated without assistance or limitations, and returned to work. Open reduction and internal fixation of rotationally unstable pelvic fractures results in a high functional success rate.

The cleavage and polyadenylation specificity factor in Xenopus laevis oocytes is a cytoplasmic factor involved in regulated polyadenylation

During early development, specific mRNAs receive poly(A) in the cytoplasm. This cytoplasmic polyadenylation reaction correlates with, and in some cases causes, translational stimulation. Previously, it was suggested that a factor similar to the multisubunit nuclear cleavage and polyadenylation specificity factor (CPSF) played a role in cytoplasmic polyadenylation. A cDNA encoding a cytoplasmic form of the 100-kDa subunit of Xenopus laevis CPSF has now been isolated. The protein product is 91% identical at the amino acid sequence level to nuclear CPSF isolated from Bos taurus thymus. This report provides three lines of evidence that implicate the X. laevis homologue of the 100-kDa subunit of CPSF in the cytoplasmic polyadenylation reaction. First, the protein is predominantly localized to the cytoplasm of X. laevis oocytes. Second, the 100-kDa subunit of X. laevis CPSF forms a specific complex with RNAs that contain both a cytoplasmic polyadenylation element (CPE) and the polyadenylation element AAUAAA. Third, immunodepletion of the 100-kDa subunit of X. laevis CPSF reduces CPE-specific polyadenylation in vitro. Further support for a cytoplasmic form of CPSF comes from evidence that a putative homologue of the 30-kDa subunit of nuclear CPSF is also localized to the cytoplasm of X. laevis oocytes. Overexpression of influenza virus NS1 protein, which inhibits nuclear polyadenylation through an interaction with the 30-kDa subunit of nuclear CPSF, prevents cytoplasmic polyadenylation, suggesting that the cytoplasmic X. laevis form of the 30-kDa subunit of CPSF is involved in this reaction. Together, these results indicate that a distinct, cytoplasmic form of CPSF is an integral component of the cytoplasmic polyadenylation machinery.

Translational control of cyclin B1 mRNA during meiotic maturation: coordinated repression and cytoplasmic polyadenylation

Translational control is prominent during meiotic maturation and early development. In this report, we investigate a mode of translational repression in Xenopus laevis oocytes, focusing on the mRNA encoding cyclin B1. Translation of cyclin B1 mRNA is relatively inactive in the oocyte and increases dramatically during meiotic maturation. We show, by injection of synthetic mRNAs, that the cis-acting sequences responsible for repression of cyclin B1 mRNA reside within its 3'UTR. Repression can be saturated by increasing the concentration of reporter mRNA injected, suggesting that the cyclin B1 3'UTR sequences provide a binding site for a trans-acting repressor. The sequences that direct repression overlap and include cytoplasmic polyadenylation elements (CPEs), sequences known to promote cytoplasmic polyadenylation. However, the presence of a CPE per se appears insufficient to cause repression, as other mRNAs that contain CPEs are not translationally repressed. We demonstrate that relief of repression and cytoplasmic polyadenylation are intimately linked. Repressing elements do not override the stimulatory effect of a long poly(A) tail, and polyadenylation of cyclin B1 mRNA is required for its translational recruitment. Our results suggest that translational recruitment of endogenous cyclin B1 mRNA is a collaborative effect of derepression and poly(A) addition. We discuss several molecular mechanisms that might underlie this collaboration.

Determination of the free-energy change for repair of a DNA phosphodiester bond

The repair of phosphodiester bonds in nicked DNA is catalyzed by DNA ligases. Ligation is coupled to cleavage of a phosphoanhydride bond in a nucleotide cofactor resulting in a thermodynamically favorable process. A free energy value for phosphodiester bond formation was calculated using the reversibility of the T4 DNA ligase reaction. The relative number of DNA nicks to phosphodiester bonds in a circular plasmid DNA, formed during this reaction at fixed concentrations of ATP to AMP and PP(i), was quantified. At 25 degrees C, pH 7, the equilibrium constant (K(eq)) for the ligation reaction is 3.89 x 10(4) m. This value corresponds to a standard free energy (DeltaG degrees ') of -6.3 kcal mol(-1). By subtracting the known energy contribution due to hydrolysis of ATP to AMP and PP(i), DeltaG degrees ' for the hydrolysis of a DNA phosphodiester bond is -5.3 kcal mol(-1).

Astrocyte reactivity in neonatal mice: apparent dependence on the presence of reactive microglia/macrophages

In neonatal mice, an acute injury produced by a stab wound to the cortex results in minimal astrocyte reactivity, as has been observed by others. However, if the source of the stab wound, a piece of nitrocellulose (NC) membrane, were now implanted in the cortex for a period of time (chronic NC implant injury), then extensive astroglial reactivity in the neonatal brain ensues. The astrogliosis is manifested by increased mRNA, protein content, and immunoreactivity for GFAP, and by ultrastructural changes. Given the previous reports that inflammatory cytokines are possible mediators of astrocyte reactivity (e.g., Balasingam et al: J Neurosci 14:846, 1994), we examined the brain parenchyma of neonatal mice following an NC stab or implant injury, with minimal or extensive astrogliosis, respectively, for a possible differential representation of inflammatory cells. A significant correlation (r = 0.87, P < 0.05) was observed between the occurrence of astrogliosis and the presence of reactive microglia/macrophages; no other inflammatory cell type was detected in the brain parenchyma of neonatal mice following NC implant injury. We suggest that reactive microglia/macrophages are required for the evolution of cells into reactive astrocytes following insults to the neonatal brain.

Forms and functions of bridging factors: specifying the dynamic links between outer and inner contexts during implementation and sustainment

BACKGROUND

Bridging factors are relational ties, formal arrangements, and processes that connect outer system and inner organizational contexts. They may be critical drivers of evidence-based practice (EBP) implementation and sustainment. Yet, the complex interplay between outer and inner contexts is often not considered. Bridging factors were recently defined in the updated Exploration, Preparation, Implementation, Sustainment (EPIS) framework. Further identification and specification of this construct will advance implementation models, measures, and methods. Our goal is to advance bridging factor research by identifying relevant dimensions and exemplifying these dimensions through illustrative case studies.

METHODS

We used a multiple case study design. Each case (n = 10) represented different contexts, EBPs, and bridging factor types. Inclusion criteria were the presence of clearly distinguishable outer and inner contexts, identifiable bridging factor, sufficient information to describe how the bridging factor affected implementation, and variation from other cases. We used an iterative qualitative inquiry process to develop and refine a list of dimensions. Case data were entered into a matrix. Dimensions comprised the rows and case details comprised the columns. After a review of all cases, we collectively considered and independently coded each dimension as function or form.

RESULTS

We drew upon the concepts of functions and forms, a distinction originally proposed in the complex health intervention literature. Function dimensions help define the bridging factor and illustrate its purpose as it relates to EBP implementation. Form dimensions describe the specific structures and activities that illustrate why and how the bridging factor has been customized to a local implementation experience. Function dimensions can help researchers and practitioners identify the presence and purpose of bridging factors, whereas form dimensions can help us understand how the bridging factor may be designed or modified to support EBP implementation in a specific context. We propose five function and three form bridging factor dimensions.

CONCLUSIONS

Bridging factors are described in many implementation models and studies, but without explicit reference or investigation. Bridging factors are an understudied and critical construct that requires further attention to facilitate implementation research and practice. We present specific recommendations for a bridging factors research agenda.

Ten year performance evaluation of a field-scale zero-valent iron permeable reactive barrier installed to remediate trichloroethene contaminated groundwater

The Monkstown zero-valent iron permeable reactive barrier (ZVI PRB), Europe's oldest commercially-installed ZVI PRB, had been treating trichloroethene (TCE) contaminated groundwater for about 10 years on the Nortel Network site in Northern Ireland when cores from the reactive zone were collected in December, 2006. Groundwater data from 2001-2006 indicated that TCE is still being remediated to below detection limits as the contaminated groundwater flows through the PRB. Ca and Fe carbonates, crystalline and amorphous Fe sulfides, and Fe (hydr)oxides have precipitated in the granular ZVI material in the PRB. The greatest variety of minerals is associated with a approximately 1-2 cm thick, slightly cemented crust on top (up-gradient influent entrance) of the ZVI section of the PRB and also with the discontinuous cemented ZVI material ( approximately 23 cm thick) directly below it. The greatest presence of microbial communities also occurred in the up-gradient influent portion of the PRB compared to its down-gradient effluent section, with the latter possibly due to less favorable conditions (i.e., high pH, low oxygen) for microbial growth. The ZVI filings in the down-gradient effluent section of the PRB have a projected life span of >10 years compared with ZVI filings from the continuous to discontinuous cemented up-gradient ZVI section (upper approximately 25 cm) of the PRB, which may have a life span of only approximately 2-5 more years. Supporting Information from applied, multi-tracer testing indicated that restricted groundwater flow is occurring in the upper approximately 25 cm of the ZVI section and preferential pathways have also formed in this PRB over its 10 years of operation.

Comparative studies of high performance swimming in sharks II. Metabolic biochemistry of locomotor and myocardial muscle in endothermic and ectothermic sharks

Metabolic enzyme activities in red (RM) and white (WM) myotomal muscle and in the heart ventricle (HV) were compared in two lamnid sharks (shortfin mako and salmon shark), the common thresher shark and several other actively swimming shark species. The metabolic enzymes measured were citrate synthase (CS), an index of aerobic capacity, and lactate dehydrogenase (LDH), an index of anaerobic capacity. WM creatine phosphokinase (CPK) activity, an index of rapid ATP production during burst swimming, was also quantified. Enzyme activities in RM, WM and HV were similar in the two lamnid species. Interspecific comparisons of enzyme activities at a common reference temperature (20 degrees C) show no significant differences in RM CS activity but higher CS activity in the WM and HV of the lamnid sharks compared with the other species. For the other enzymes, activities in lamnids overlapped with those of other shark species. Comparison of the HV spongy and compact myocardial layers in mako, salmon and thresher sharks reveals a significantly greater spongy CS activity in all three species but no differences in LDH activity. Adjustment of enzyme activities to in vivo RM and WM temperatures in the endothermic lamnids elevates CS and LDH in both tissues relative to the ectothermic sharks. Thus, through its enhancement of both RM and WM enzyme activity, endothermy may be an important determinant of energy supply for sustained and burst swimming in the lamnids. Although lamnid WM is differentially warmed as a result of RM endothermy, regional differences in WM CS and LDH activities and thermal sensitivities (Q(10) values) were not found. The general pattern of the endothermic myotomal and ectothermic HV muscle metabolic enzyme activities in the endothermic lamnids relative to other active, ectothermic sharks parallels the general pattern demonstrated for the endothermic tunas relative to their ectothermic sister species. However, the activities of all enzymes measured are lower in lamnids than in tunas. Relative to lamnids, the presence of lower WM enzyme activities in the thresher shark (which is in the same order as the lamnids, has an RM morphology similar to that of the mako and salmon sharks and may be endothermic) suggests that other factors, such as behavior and swimming pattern, also affect shark myotomal organization and metabolic function.

Poly(A) polymerase and the regulation of cytoplasmic polyadenylation

Translational activation in oocytes and embryos is often regulated via increases in poly(A) length. Cleavage and polyadenylation specificity factor (CPSF), cytoplasmic polyadenylation element binding protein (CPEB), and poly(A) polymerase (PAP) have each been implicated in cytoplasmic polyadenylation in Xenopus laevis oocytes. Cytoplasmic polyadenylation activity first appears in vertebrate oocytes during meiotic maturation. Data presented here shows that complexes containing both CPSF and CPEB are present in extracts of X. laevis oocytes prepared before or after meiotic maturation. Assessment of a variety of RNA sequences as polyadenylation substrates indicates that the sequence specificity of polyadenylation in egg extracts is comparable to that observed with highly purified mammalian CPSF and recombinant PAP. The two in vitro systems exhibit a sequence specificity that is similar, but not identical, to that observed in vivo, as assessed by injection of the same RNAs into the oocyte. These findings imply that CPSFs intrinsic RNA sequence preferences are sufficient to account for the specificity of cytoplasmic polyadenylation of some mRNAs. We discuss the hypothesis that CPSF is required for all polyadenylation reactions, but that the polyadenylation of some mRNAs may require additional factors such as CPEB. To test the consequences of PAP binding to mRNAs in vivo, PAP was tethered to a reporter mRNA in resting oocytes using MS2 coat protein. Tethered PAP catalyzed polyadenylation and stimulated translation approximately 40-fold; stimulation was exclusively cis-acting, but was independent of a CPE and AAUAAA. Both polyadenylation and translational stimulation required PAPs catalytic core, but did not require the putative CPSF interaction domain of PAP. These results demonstrate that premature recruitment of PAP can cause precocious polyadenylation and translational stimulation in the resting oocyte, and can be interpreted to suggest that the role of other factors is to deliver PAP to the mRNA.

Project ImPACT for Toddlers: Pilot outcomes of a community adaptation of an intervention for autism risk

This study reports child and family outcomes from a community-based, quasi-experimental pilot trial of Project ImPACT for Toddlers that is a parent-mediated, naturalistic, developmental behavioral intervention for children with or at-risk for autism spectrum disorder developed through a research-community partnership. Community early interventionists delivered either Project ImPACT for Toddlers (n = 10) or Usual Care (n = 9) to families based on Part C assigned provider. Twenty-five families participated, with children averaging 22.76 months old (SD = 5.06). Family and child measures were collected at intake, after 3 months of service, and after a 3-month follow-up. Results indicate significantly greater improvements in positive parent-child interactions for Project ImPACT for Toddlers than usual care families, as well as large, but non-significant, effect sizes for Project ImPACT for Toddlers families in children's social and communication skills.

Close encounters: an examination of UFO experiences

Ss who reported UFO experiences were divided into those whose experiences were nonintense (e.g., seeing lights and shapes in the sky) and those whose experiences were intense (e.g., seeing and communicating with aliens or missing time). On a battery of objective tests Ss in these 2 groups did not score as more psychopathological, less intelligent, or more fantasy prone and hypnotizable than a community comparison group or a student comparison group. However, Ss in the UFO groups believed more strongly in space alien visitation than did comparison Ss. The UFO experiences of Ss in the intense group were more frequently sleep-related than the experiences of Ss in the nonintense group. Among the combined UFO Ss, intensity of UFO experiences correlated significantly with inventories that assessed proneness toward fantasy and unusual sensory experiences. Implications are discussed.

Growth retardation and the development of the respiratory system in fetal sheep

In an experimental model of fetal growth retardation which involves the reduction of placental mass in ewes, we have investigated the effects of intrauterine deprivation on aspects of structural development of the trachea and lungs of fetal sheep (140 days gestation). We have also measured the volume of luminal liquid aspirated from the lungs and the phospholipid content of this liquid as an index of pulmonary surfactant production. The effects of growth retardation are evident in the trachea where the structural development of the mucosal and submucosal layers has been affected. Abnormal aspects of development include the frequent lack of a ciliated border on epithelial cells in the mucosal layer and the reduction in the extent of the folds usually characteristic of this layer in near term fetal sheep. Although the fetal lungs are smaller in growth retardation (P less than 0.01) they are appropriate for fetal weight and their structural development does not appear to have been retarded. In contrast, lung liquid volume is significantly reduced in relation to lung weight in growth retarded fetuses and the concentration of phospholipids in lung liquids is also reduced (P less than 0.01).

TUNAS AS SMALL AS 207 mm FORK LENGTH CAN ELEVATE MUSCLE TEMPERATURES SIGNIFICANTLY ABOVE AMBIENT WATER TEMPERATURE

Tunas (family Scombridae) maintain muscle temperatures (Tm) elevated significantly above ambient water temperature (Ta) by using vascular counter-current heat exchangers (retia mirabilia) to conserve metabolic heat generated by continuous contraction of red muscle fibers. Previous work has documented endothermy and both behavioral and physiological thermoregulation in tunas, but only individuals greater than approximately 1 kg body mass had been studied. The purpose of this study was to measure Tm and to examine heat exchanger morphology in smaller fish in order to determine the minimum size at which tunas can elevate Tm significantly above Ta. Measurements of Tm made immediately after capture in field-caught and laboratory-raised tunas (Euthynnus lineatus, Auxis thazard, A. rochei and Thunnus albacares) spanning a size range of 15.5&shy;667 mm fork length (FL) show that tunas 207 mm FL (162.3 g) and larger can elevate red muscle temperature by at least 3.0&deg;C above Ta. E. lineatus, A. thazard and A. rochei of this size possess blood vessels serving the red muscle that are arranged as both lateral and central heat exchangers; the smallest tuna with evidence of a rete was a 108.5 mm FL E. lineatus. In the ectothermic scombrid Scomberomorus sierra (108.7&shy;132.0 mm FL), Tm was elevated 0.2&shy;0.5&deg;C above Ta, and the greatest Tm elevation reported in any ectothermic species is only 2.7&deg;C. Taken together, these data provide evidence that tunas greater than 207 mm FL are endothermic.

Mental Health Services for Autistic Individuals Across the Lifespan: Recent Advances and Current Gaps

PURPOSE OF REVIEW

This synthesis of recent mental health services research with autistic individuals presents significant advances, current gaps, and recommendations for improving mental healthcare for this population.

RECENT FINDINGS

Recent advances include improved understanding of co-occurring mental health conditions among autistic individuals, a growing evidence base for interventions to address them, the development and implementation of new service models to support mental health for this population, and a substantial increase in mental health services and implementation research focused on autism. Ongoing challenges include a lack of mental health interventions designed for community implementation with autistic individuals, limited workforce capacity, complex and disconnected service systems, and racial, ethnic, and socioeconomic disparities in accessibility and quality of mental health services. Despite the advances in our understanding of mental health needs and mental health services for autistic individuals, several critical gaps remain. We encourage future efforts to develop and test interventions that can be used in community settings, train and incentivize the workforce to provide them, realign policies and funding with best practice, and embrace an equity-focused approach to autism research and care.

Induction of acrosome reactions by chondroitin sulfates in vitro corresponds to nonreturn rates of dairy bulls

This study was designed to relate nonreturn rates to induction of acrosome reactions by the glycosaminoglycan chondroitin sulfate. Semen samples were obtained from four bulls above and four bulls below 65% nonreturn. Washed sperm from four ejaculates from each bull were incubated for 9 h with 0, 1, 10, or 50 micrograms/ml chondroitin sulfate. Acrosome reactions were evaluated by microscopy with Nomarski optics. Sperm from the higher fertility bulls exhibited significantly higher percentages of acrosome reactions to 10 and 50 micrograms/ml of chondroitin sulfate, and the slope of their dose-response regression line was significantly greater.

A comparison of women's, providers' and ultrasound assessments of pregnancy duration among termination of pregnancy clients in South Africa

OBJECTIVE

To compare providers' and women's estimates of duration of pregnancy with ultrasound estimates for determining medical abortion eligibility.

DESIGN

Cross-sectional study.

SETTING

Public termination of pregnancy (TOP) services in three provinces.

SAMPLE

A total of 673 women attending the above services for TOP.

METHODS

Women participating in a medical abortion feasibility study in South Africa provided estimates of pregnancy duration and date of last menstrual period (LMP). Each woman also had clinical and ultrasound exams. We compared estimates using the four methods, calculating the proportion of women in the 'caution zone' (< or = 8 weeks gestation by woman or provider estimate and > 8 weeks by ultrasound).

MAIN OUTCOME MEASURES

Mean gestational age by each method; difference between provider and LMP estimates and ultrasound estimates; and percentage of women in the 'caution zone'.

RESULTS

Women's estimates of pregnancy duration were 19 days fewer than ultrasound estimates (95% CI = -27 to 63). Mean provider- and LMP-based estimates were two (95% CI = -30 to 35) and less than one day(s) (95% CI = -46 to 51) fewer than ultrasound estimates. Comparing provider and ultrasound estimates, 15% of women were in the 'caution zone'; this fell to 12% if estimates of 9 weeks or fewer were considered acceptable.

CONCLUSIONS

Provider estimates of gestational age were sufficiently accurate for determining eligibility for medical abortion. LMP-based estimates were also accurate on average, but included more extreme differences from ultrasound estimates. Medical abortion could be provided in TOP facilities without ultrasound or with ultrasound on referral.