Implementation and evaluation of a two-eyed seeing approach using traditional healing and seeking safety in an indigenous residential treatment program in Northern Ontario

Indigenous clients in need of residential care for substance use disorders (SUD) often present with the diagnosis of substance use disorder (SUD) combined with intergenerational trauma (IGT) or both. SUD is exceedingly prevalent amongst Indigenous peoples due to the health impacts of colonisation, residential school trauma, and IGT on this population’s health. We evaluated the effectiveness of a Two-Eyed Seeing approach in a four-week harm reduction residential treatment programme for clients with a history of SUD and IGT. This treatment approach blended Indigenous Healing practices with Seeking Safety based on Dr. Teresa Marsh’s research work known as Indigenous Healing and Seeking Safety (IHSS). The data presented in this study was drawn from a larger trial. This qualitative study was undertaken in collaboration with the Benbowopka Treatment Centre in Blind River, Northern Ontario, Canada. Patient characteristic data were collected from records for 157 patients who had enrolled in the study from April 2018 to February 2020. Data was collected from the Client Quality Assurance Survey tool. We used the qualitative thematic analysis method to analyse participants’ descriptive feedback about the study. Four themes were identified: (1) Motivation to attend treatment; (2) Understanding Benbowopka’s treatment programme and needs to be met; (3) Satisfaction with all interventions; and (4) Moving forward. We utilised a conceptualised descriptive framework for the four core themes depicted in the medicine wheel. This qualitative study affirmed that cultural elements and the SS Western model were highly valued by all participants. The impact of the harm reduction approach, coupled with traditional healing methods, further enhanced the outcome. This study was registered with clinicaltrials.gov (identifier number NCT0464574).

Community trial evaluating the integration of Indigenous healing practices and a harm reduction approach with principles of seeking safety in an Indigenous residential treatment program in northern Ontario

Objective

Our primary objective was to evaluate how the Indigenous Healing and Seeking Safety (IHSS) model impacted residential addiction treatment program completion rates. Our secondary objective was to evaluate health service use 6 months before and 6 months after residential treatment for clients who attended the program before and after implementing IHSS.

Methods

We observed clients of the Benbowopka Residential Treatment before IHSS implementation (from April 2013 to March 31, 2016) and after IHSS implementation (from January 1, 2018 – March 31, 2020). The program data were linked to health administration data, including the Ontario Health Insurance Plan (OHIP) physician billing, the Registered Persons Database (RPDB), the National Ambulatory Care Reporting System (NACRS), and the Discharge Abstract Database (DAD). Chi-square tests were used to compare patient characteristics in the no-IHSS and IHSS groups. We used logistic regression to estimate the association between IHSS and treatment completion. We used generalized estimating equation (GEE) regression model to evaluate health service use (including primary care visits, ED visits overall and for substance use, hospitalizations and mental health visits), Results: There were 266 patients in the no-IHSS group and 136 in the IHSS group. After adjusting for individual characteristics, we observed that IHSS was associated with increased program completion rates (odds ratio = 1.95, 95% CI 1.02-3.70). There was no significant association between IHSS patients’ health service use at time one or time two. Primary care visits time 1: aOR 0.55, 95%CI 0.72-1.13, time 2: aOR 1.13, 95%CI 0.79-1.23; ED visits overall time 1: aOR 0.91, 95%CI 0.67-1.23, time 2: aOR 1.06, 95%CI 0.75-1.50; ED visits for substance use time 1: aOR 0.81, 95%CI 0.47-1.39, time 2: aOR 0.79, 95%CI 0.37-1.54; Hospitalizations time 1: aOR 0.78, 95%CI 0.41-1.47, time 2: aOR 0.76, 95%CI 0.32-1.80; Mental health visits time 1: aOR 0.66, 95%CI 0.46-0.96, time 2: aOR 0.92 95%CI 0.7-1.40.

Conclusions

Our results indicate that IHSS positively influenced program completion but had no significant effect on health service use.

Trial registration

This study was registered with clinicaltrials.gov (identifier number NCT04604574). First registration 10/27/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08406-3.

A Comparison of Different Textured and Non-Textured Anti-Reflective Coatings for Planar Monolithic Silicon-Perovskite Tandem Solar Cells

Multijunction solar cells offer a route to exceed the Shockley-Queisser limit for single-junction devices. In a few short years, silicon-perovskite tandems have significantly passed the efficiency of the best silicon single-junction cells. For scalable solution processing of silicon-perovskite tandem devices, with the avoidance of vacuum processing steps, a flat silicon sub-cell is normally required. This results in a flat top surface that can lead to higher optical reflection losses than conformal deposition on textured silicon bottom cells. To overcome this, textured anti-reflective coatings (ARCs) can be used on top of the finished cell, with textured polydimethylsiloxane (PDMS), a promising candidate. In this work, we vary the texture geometry and film thickness of PDMS anti-reflective foils to understand the effect of these parameters on reflectance of the foil. The best film is selected, and anti-reflective performance is compared with two common planar ARCs-lithium fluoride (LiF) and magnesium fluoride (MgF₂) showing considerable reduction in reflectance for a non-textured silicon-perovskite tandem cell. The application of a PDMS film is shown to give a 3-5% increase in integrated J _SC in each sub-cell of a silicon-perovskite tandem structure.

American College of Rheumatology/Association of Rheumatology Professionals (ACR/ARP) 2021 Annual Meeting (November 5-9, 2021 - Virtual Meeting)

ACR Convergence is the annual meeting of the American College of Rheumatology (ACR). This year, ACR Convergence was to be held in San Francisco, California, but due to the COVID-19 crisis and subsequent travel restrictions, it was changed to a virtual meeting format. The meeting comprised several days of live sessions and on-demand virtual content including posters and prerecorded presentations.

Association between social deprivation status, age of presentation, and survival following ST-segment elevation myocardial infarction

Introduction

Many factors influence age of presentation with and survival following ST-segment myocardial infarction (STEMI). These include age, mode of, and time-delay to emergency treatment, diabetes and smoking. We sought to assess whether overall social deprivation status is associated with age of presentation and mortality following STEMI patients treated with primary PCI.

Methods

All patients treated emergently for STEMI in a large Northern Irish tertiary hospital from 2013 – 2017 were reviewed. Social deprivation is determined as a composite score relating to income, crime etc, and assigned to small geographical regions by the Northern Ireland Statistics and Research Agency. Deprivation score was assigned to patients based on their postcode. The database was ranked by social deprivation score and divided in to quintiles. The most (Grp 1) and least (Grp 5) deprived quintiles were compared. Mortality was determined from a national electronic health record.

Results

1,192 patients were included in the analysis. Mean follow up was 52.5 months (SD 15.6), minimum follow up was 35.6 months. There was no difference in gender: 70.1% male in Grp 1 vs 75.2% male in Grp 5 (p=0.68); no difference in ECG to balloon time: mean 89.9mins (95% CI 84.9–94.9) Grp 1 vs 90.5mins (95% CI 86.2–94.9) Grp 5 (p=0.86). The more deprived group was younger: mean age 60.6 (95% CI 59.5–61.6) vs 65.2 (95% CI 64.2–66.3) (p<0.000). Crude survival measured by Log-rank test was the same between the groups (p=0.52). Following Cox-regression adjustment for age, survival was longer in the least deprived group (p=0.042).

Conclusion

Social deprivation is associated with both a younger age of presentation with, and a higher mortality following STEMI. This is important variable is often overlooked in medical literature and should be further studied.

Funding Acknowledgement

Type of funding sources: None.

A study protocol for a quasi-experimental community trial evaluating the integration of indigenous healing practices and a harm reduction approach with principles of seeking safety in an indigenous residential treatment program in Northern Ontario

Background

Indigenous communities in Canada face significant challenges with intergenerational trauma, which manifests in substance use disorders. There is consensus that connecting treatment approaches to culture, land, community, and spiritual practices is a pathway to healing trauma and substance use disorders for Indigenous peoples. Indigenous residential addiction treatment programs have been established as the primary intervention to provide healing for Indigenous peoples with substance use disorders and intergenerational trauma. However, there is limited evidence demonstrating the effectiveness of these programs. In collaboration with the Benbowopka Treatment Centre, this paper describes a study protocol which aims to evaluate the effectiveness of blending Indigenous Healing Practices and Seeking Safety for the treatment of Indigenous patients with intergenerational trauma and substance use disorders.

Methods

We will conduct a pre/post Quasi Experimental Community trial, to compare historical treatment outcomes for patients following the implementation of Indigenous Healing and Seeking Safety. We will conduct quantitative and qualitative analyses to understand the differences before and after the intervention is implemented. The pre- Indigenous Healing and Seeking Safety intervention study window will span from 2013 to 2016; n = 343, and the post-Indigenous Healing and Seeking Safety intervention study window from 2018 to 2020; n > 300. All participants will be enrolled in the Benbowopka residential treatment for the first time during the study periods. All data will be anonymized at the time of data entry. Propensity matching will be undertaken for patient characteristics, including sex/gender, age, and substance use type.

Results and conclusions

The study findings could be used to inform intergenerational trauma and substance use disorders residential treatment programming for Indigenous communities across Canada. Our work will contribute to the field of community-based intergenerational trauma and substance use disorders programming by addressing objectives that consider: (a) the patient perspective, (b) the program perspective, and (c) the community perspective. The study findings may validate an innovative approach for evaluating the effectiveness of residential addiction treatment and particularly the effective and appropriate care for Indigenous patients with intergenerational trauma and substance use disorders.

Referral of patients to diabetes prevention programmes from community campaigns and general practices: mixed-method evaluation using the RE-AIM framework and Normalisation Process Theory

BACKGROUND

Each year around 5-10% of people with non-diabetic hyperglycaemia will develop type 2 diabetes mellitus. Diabetes prevention is a national and global public health concern. Diabetes Prevention Programmes, which seek to identify at-risk individuals and support entry to health improvement initiatives, recognise that enhanced identification and referral of at-risk individuals is required within primary care and beyond, through community-focused prevention approaches. We report an evaluation of a demonstrator site for the NHS Diabetes Prevention Programme in the UK, which piloted an enhanced Primary Care referral programme (sampling from patients identified as at-risk from general practice databases) and a Community identification programme (sampling from the general population through opportunistic identification in community locations) in an effort to maximise participation in prevention services.

METHODS

We used mixed-methods evaluation to assess the impact of the two referral routes on participation in the Diabetes Prevention Programmes in line with the RE-AIM Framework (Reach, Effectiveness, Adoption, Implementation and Maintenance). Individual level patient data was descriptively analysed to assess identifications and eligible referrals made in each route. Semi-structured interviews conducted with referral staff and key stakeholders were analysed using thematic analysis and informed by Normalisation Process Theory.

RESULTS

The nurse facilitated primary care referral route provided 88% of all referrals to the telephone DPP, compared to the community referral route which provided 5%, and the proportion joining the programme was higher among primary care referrals (45%) than community referrals (22%), and retention rates were higher (73% compared to 50%). The nurse-facilitated route integrated more easily into existing clinical processes. The community programme was impeded by a lack of collaborative inter-agency working which obscured the intended focus on high-risk populations despite conversion rates (numbers identified at risk who entered prevention programmes) being highest in areas of high deprivation.

CONCLUSIONS

The study demonstrates the interaction of components, with effective Adoption and Implementation necessary to support Reach. The NPT analysis demonstrated the importance of consensus around not only the need for such programmes but agreement on how they can be delivered. Future programmes should support inter-agency communication and collaboration, and focus identification efforts on areas of high-risk.

A qualitative study of professional stakeholders' perceptions about the implementation of a stepped care pain platform for people experiencing chronic widespread pain

Background

Chronic widespread pain (CWP) is a major public health problem. Many people experiencing CWP experience mental health problems such as anxiety or depression. Complete relief of skeletal and body pain symptoms is unlikely but with appropriate treatment the impact upon quality of life, functioning and mental health symptoms can be reduced. Cognitive behavioural therapy (CBT) is widely used for a range of health conditions and can have short and long-term improvements in patients with CWP. This research aimed to explore, from a professional stakeholder perspective, the implementation of a local Pain Platform offering a stepped care approach for interventions including telephone delivered CBT (T-CBT).

Methods

Fourteen professional stakeholders holding various roles across primary and secondary care services within the Pain Platform took part in semi-structured interviews. Their views and experiences of the implementation of the Pain Platform were explored. Interviews were recorded, transcribed verbatim and analysed according to Normalisation Process Theory (NPT).

Results

Professional stakeholders were positive about the Pain Platform and its potential to overcome previously identified existing access issues to psychological interventions for CWP patients. It was considered a valuable part of ensuring that patients’ preferences and needs are more readily addressed. In some circumstances, however, introducing psychological interventions to patients was considered challenging and the introduction of new referral processes was raised concerns. To ensure sustainability more work is required to reduce professional isolation and ensure efficient referral procedures between primary and secondary care services are established to reduce concerns over issues related to clinical governance and potential risk to patient.

Conclusions

The findings provide professional insight into the key challenges of introducing a Pain Platform incorporating psychological support across primary and secondary care services within a local service. These included development of sustainable procedures and closer working relationships. Areas requiring future development are identified.

Assessing the suitability of a manometric test system for determining the biodegradability of volatile hydrocarbons

Manometric test systems, adapted from those used to measure biochemical oxygen demand (BOD), and the OxiTop^® test system in particular, are being increasingly used to determine the biodegradability of chemicals in accordance to OECD 301F guidelines. In this study, the suitability of the OxiTop^® test system for determining the biodegradability of volatile hydrophobic substances has been explored. Experiments in biotic and abiotic systems were conducted with readily biodegradable complex aliphatic hydrocarbons covering a range of volatilities. Results indicated that abiotic losses of test substances were occurring due to sorption of the test substance to plastic components used in the OxiTop^® system. A further 'plastic-free' biodegradation test system was designed using PreSens optical dissolved oxygen (DO) sensors. This significantly improved the measured biodegradation due to reduced abiotic losses and better retention of the test substance. These results highlight the importance of considering the physico-chemical properties of test substances when selecting test methods and equipment. They also highlight the value of incorporating chemical analysis and abiotic controls to improve the interpretation of biodegradation studies.

Getting messier with TIDieR: embracing context and complexity in intervention reporting

Background

The Template for Intervention Description and Replication (TIDieR) checklist and guide was developed by an international team of experts to promote full and accurate description of trial interventions. It is now widely used in health research. The aim of this paper is to describe the experience of using TIDieR outside of trials, in a range of applied health research contexts, and make recommendations on its usefulness in such settings.

Main body

We used the TIDieR template for intervention description in six applied health research projects. The six cases comprise a diverse sample in terms of clinical problems, population, settings, stage of intervention development and whether the intervention was led by researchers or the service deliverers. There was also variation in how the TIDieR description was produced in terms of contributors and time point in the project. Researchers involved in the six cases met in two workshops to identify issues and themes arising from their experience of using TIDieR.

We identified four themes which capture the difficulties or complexities of using TIDieR in applied health research: (i) fidelity and adaptation: all aspects of an intervention can change over time; (ii) voice: the importance of clarity on whose voice the TIDieR description represents; (iii) communication beyond the immediate context: the usefulness of TIDieR for wider dissemination and sharing; (iv) the use of TIDieR as a research tool.

Conclusion

We found TIDieR to be a useful tool for applied research outside the context of clinical trials and we suggest four revisions or additions to the original TIDieR which would enable it to better capture these complexities in applied health research:

An additional item, ‘voice’ conveys who was involved in preparing the TIDieR template, such as researchers, service users or service deliverers.

An additional item, ‘stage of implementation’ conveys what stage the intervention has reached, using a continuum of implementation research suggested by the World Health Organisation.

A new column, ‘modification’ reminds authors to describe modifications to any item in the checklist.

An extension of the ‘how well’ item encourages researchers to describe how contextual factors affected intervention delivery.

Electronic supplementary material

The online version of this article (10.1186/s12874-017-0461-y) contains supplementary material, which is available to authorized users.

Involving healthcare professionals and family carers in setting research priorities for end-of-life care

It is important to ensure regional variances are considered when setting future end-of-life research priorities, given the differing demographics and service provision. This project sought to identify end-of-life research priorities within Greater Manchester (United Kingdom). Following an initial scoping exercise, six topics within the 10 national priorities outlined by The Palliative and end-of-life care Priority Setting Partnership were selected for exploration. A workshop involving 32 healthcare professionals and a consultation process with 26 family carers was conducted. Healthcare professionals and carers selected and discussed the topics important to them. The topics selected most frequently by both healthcare professionals and carers were 'Access to 24 hour care', 'Planning end-of-life care in advance' and 'Staff and carer education'. Healthcare professionals also developed research questions for their topics of choice which were refined to incorporate carers' views. These questions are an important starting point for future end-of-life research within Greater Manchester.

Effect of implementation of a preconception counselling resource for women with diabetes: A population based study

AIM

To evaluate the effect of regional implementation of a preconception counselling resource into routine diabetes care on pregnancy planning indicators.

METHODS

A preconception counselling DVD was distributed to women by diabetes care teams and general practices. Subsequently, in a prospective population-based study, pregnancy planning indicators were evaluated. The post-DVD cohort (n=135), including a viewed-DVD subgroup (n=58), were compared with an historical cohort (pre-DVD, n=114). Primary outcome was HbA1c at first diabetes-antenatal visit. Secondary outcomes included preconception folic acid consumption, planned pregnancy and HbA1c recorded in the 6 months preconception.

RESULTS

Mean first visit HbA1c was lower post-DVD vs. pre-DVD: 7.5% vs. 7.8% [58.4 vs. 61.8mmol/mol]; p=0.12), although not statistically significant. 53% and 20% of women with type 1 and 2 diabetes, respectively, viewed the DVD. The viewed-DVD subgroup were significantly more likely to have lower first visit HbA1c: 6.9% vs. 7.8% [52.1 vs. 61.8mmol/mol], P<0.001; planned pregnancy (88% vs. 59%, P<0.001); taken folic acid preconception (81% vs. 43%, P=0.001); and had HbA1c recorded preconception (88% vs. 53%, P<0.001) than the pre-DVD cohort.

CONCLUSIONS

Implementation of a preconception counselling resource was associated with improved pregnancy planning indicators. Women with type 2 diabetes are difficult to reach. Greater awareness within primary care of the importance of preconception counselling among this population is needed.

The role of boundary spanners in delivering collaborative care: a process evaluation

Background

On average, people with schizophrenia and psychosis die 13–30 years sooner than the general population (World Psychiatry 10 (1):52–77, 2011). Mental and physical health care is often provided by different organisations, different practitioners and in different settings which makes collaborative care difficult. Research is needed to understand and map the impact of new collaborative ways of working at the primary/secondary care interface (PloS One 7 (5); e36468). The evaluation presented in this paper was designed to explore the potential of a Community and Physical Health Co-ordinator role (CPHC) (CPHCs were previously Care Co-ordinators within the Community Mental Health Team, Community in the title CPHC refers to Community Mental Health) and Multi-Disciplinary Team (MDT) meetings across primary and community care, with the aim of improving collaboration of mental and physical health care for service users with Severe Mental Illness (SMI).

Methods

Data collection took place across five general practices (GPs) and a Community Mental Health Team (CMHT) in the Northwest of England, as part of a process evaluation. Semi-structured interviews were conducted with a purposive sample of GP staff (n= 18) and CMHT staff (n=4), a focus group with CMHT staff (n=8) and a survey completed by 13 CMHT staff, alongside cardiovascular risk data and MDT actions. Framework analysis was used to manage and interpret data.

Results

The results from the evaluation demonstrate that a CPHC role and MDT meetings are effective mechanisms for improving the collaboration and co-ordination of physical health care for SMI service users. The findings highlight the importance of embedding and supporting the CPHC role, with an emphasis on protected time and continuing professional roles and integrating multiple perspectives through MDT meetings. Considering the importance of physical health care for SMI service users and the complex environment, these are important findings for practitioners, researchers and policy makers in the field of primary care and mental health.

Conclusion

There is an increasing focus on integration and collaborative working to ensure the delivery of quality care across the whole patient pathway, with a growing need for professionals to work together across service and professional boundaries. The introduction of a two pronged approach to collaboration has shown some important improvements in the management of physical health care for service users with SMI.

High Risk Aortic Valve Replacement - The Challenges of Multiple Treatment Strategies with an Evolving Technology

OBJECTIVES

Deciding on the optimal treatment strategy for high risk aortic valve replacement is challenging. Transcatheter Aortic Valve implantation (TAVI) has been available in our centre as an alternative treatment modality for patients since 2008. We present our early experience of TAVI and SAVR (surgical Aortic Valve Replacement) in high risk patients who required SAVR because TAVI could not be performed.

METHODS

The database for Surgical aortic valve and Transcatheter aortic valve replacement referrals was interrogated to identify relevant patients.

RESULTS

Survival to hospital discharge was 95.5% in the forty five patients who had SAVR when TAVI was deemed technically unsuitable. One year survival was 86%.

CONCLUSION

Defining who is appropriate for TAVI or high risk SAVR is challenging and multidisciplinary team discussion has never been more prudent in this field of evolving technology with ever decreasing risks of surgery. The introduction of TAVI at our institution has seen a rise in our surgical caseload by approximately by 25%. Overall, the option of aortic valve intervention is being offered to more patients in general which is a substantial benefit in the treatment of aortic valve disease.

Quantifying consumer portion control practices. A cross-sectional study

The use of portion control practices has rarely been quantified. The present study aimed to: (1) explore which portion control practices are actually used by the general population and their association with cognitive restraint, demographic background and general health interest (GHI), and (2) examine how the usage of portion control practices predicts the estimated consumption of an energy dense food (i.e. pizza). Twenty-two portion control practices were rated in terms of their frequency of use from 'never' to 'very often' by a representative sample of 1012 consumers from the island of Ireland. Three factors were extracted and named: measurement-strategy scale, eating-strategy scale, and purchasing-strategy scale. The eating-strategy scale score was the highest, while the measurement-strategy scale carried the lowest frequency score. For each strategy scale score, the strongest predictor was GHI, followed by gender. Having higher GHI and being female were independently associated with more frequent portion control. Both the eating-strategy scale score and the purchasing-strategy scale score were negatively associated with pizza portion size consumption estimates. In conclusion, while this study demonstrates that the reported use of portion control practices is low, the findings provide preliminary evidence for their validity. Further studies are needed to explore how portion control practices are used in different kinds of portion size decisions and what their contribution is to the intake of food over an extended period of time.

Facilitating large-scale implementation of evidence based health care: insider accounts from a co-operative inquiry

Background

Facilitators are known to be influential in the implementation of evidence-based health care (EBHC). However, little evidence exists on what it is that they do to support the implementation process. This research reports on how knowledge transfer associates (KTAs) working as part of the UK National Institute for Health Research ‘Collaboration for Leadership in Applied Health Research and Care’ for Greater Manchester (GM CLAHRC) facilitated the implementation of EBHC across several commissioning and provider health care agencies.

Methods

A prospective co-operative inquiry with eight KTAs was carried out comprising of 11 regular group meetings where they reflected critically on their experiences. Twenty interviews were also conducted with other members of the GM CLAHRC Implementation Team to gain their perspectives of the KTAs facilitation role and process.

Results

There were four phases to the facilitation of EBHC on a large scale: (1) Assisting with the decision on what EBHC to implement, in this phase, KTAs pulled together people and disparate strands of information to facilitate a decision on which EBHC should be implemented; (2) Planning of the implementation of EBHC, in which KTAs spent time gathering additional information and going between key people to plan the implementation; (3) Coordinating and implementing EBHC when KTAs recruited general practices and people for the implementation of EBHC; and (4) Evaluating the EBHC which required the KTAs to set up (new) systems to gather data for analysis. Over time, the KTAs demonstrated growing confidence and skills in aspects of facilitation: research, interpersonal communication, project management and change management skills.

Conclusion

The findings provide prospective empirical data on the large scale implementation of EBHC in primary care and community based organisations focusing on resources and processes involved. Detailed evidence shows facilitation is context dependent and that ‘one size does not fits all’. Co-operative inquiry was a useful method to enhance KTAs learning. The evidence shows that facilitators need tailored support and education, during the process of implementation to provide them with a well-rounded skill-set. Our study was not designed to demonstrate how facilitators contribute to patient health outcomes thus further prospective research is required.

Does a diet high or low in fat influence the oxidation potential of VLDL, LDL and HDL subfractions?

BACKGROUND AND AIMS

High-fat diets have become increasingly popular for weight-loss, but their effect on the oxidation potential of lipoprotein subfractions has not been studied. Therefore, this study compared the effects of high-fat vs. low-fat weight reduction diets on this parameter.

METHODS AND RESULTS

Very-low, low- and high-density lipoprotein (VLDL, LDL & HDL) subfractions were isolated by rapid ultracentrifugation from 24-overweight/obese subjects randomised to a high- or low-fat diet. The lipoprotein subfractions were assessed for oxidation potential by measuring conjugated diene (CD) production and time at half maximum. We found a significant between-group difference in oxidation potential. Specifically, a high-fat diet led to increased CD production in VLDL(A-D) and HDL(2&3), and a prolongation of time at half maximum. Within-group differences found that CDs increased in VLDL(A&D), LDL(I-III) and HDL(2&3) in the high-fat group and fell in VLDL(A-C) and HDL(2&3) and increased in LDL(I&II), in the low-fat group. Furthermore, following both diets all lipoprotein subfractions, except LDL(II) in the low-fat group, were protected against oxidation.

CONCLUSION

These results demonstrate that at first glance, a high-fat diet may be indicative of having heart-protective properties. However, this may be erroneous, as although the time for oxidation to occur was prolonged, once this occurred these lipoproteins had the potential to produce significantly more oxidised substrate. Conversely, a low-fat diet may be considered anti-atherogenic, as these subfractions were protected against oxidation and mainly contained fewer oxidised substrate. Thus, increased fat intake may, by increasing the oxidation product within lipoprotein subfractions, increase cardiovascular disease.

Evaluation of a DVD for women with diabetes: impact on knowledge and attitudes to preconception care

AIMS

To determine if an educational DVD increases knowledge and changes attitudes of women with diabetes towards preconception care.

METHODS

Ninety-seven women with diabetes (Type 1, n = 89; Type 2, n = 8), aged 18-40 years, completed a pre-DVD and post-DVD intervention study by postal questionnaire. Beliefs and attitudes associated with preventing an unplanned pregnancy and seeking preconception care were assessed using a validated questionnaire; scales included benefits, barriers, personal attitudes and self-efficacy. Knowledge of pregnancy planning and pregnancy-related risks were assessed by a 22-item questionnaire.

RESULTS

After viewing the DVD there was significant positive change in women's perceived benefits of, and their personal attitudes to, receiving preconception care and using contraception: change in score post-DVD viewing 0.7 (95% confidence interval 0.3, 1.2), P = 0.003, and 0.8 (0.3, 1.2), P = 0.001, respectively. The DVD significantly improved self-efficacy, that is, self-confidence to use contraception for prevention of an unplanned pregnancy and to access preconception care [3.3 (1.9, 4.7), P < 0.001], and significantly reduced perceived barriers to preconception care [-0.7 (-1.2, -0.2), P = 0.01]. Knowledge of pregnancy planning and pregnancy-related risks increased significantly after viewing the DVD: mean increase was 37.6 ± 20.0%, P < 0.001, and 16.9 ± 21.2%, P < 0.001, respectively.

CONCLUSIONS

This study demonstrates the effectiveness of a DVD in increasing knowledge and enhancing attitudes of women with diabetes to preconception care. This DVD could be used as a prepregnancy counselling resource to prepare women with diabetes for pregnancy.

An exploration of knowledge and attitudes related to pre-pregnancy care in women with diabetes

AIMS

Pre-pregnancy care optimizes pregnancy outcome in women with pre-gestational diabetes, yet most women enter pregnancy unprepared. We sought to determine knowledge and attitudes of women with Type 1 and Type 2 diabetes of childbearing age towards pre-pregnancy care.

METHODS

Twenty-four women (18 with Type 1 diabetes and six with Type 2 diabetes) aged 17-40 years took part in one of four focus group sessions: young nulliparous women with Type 1 diabetes (Group A), older nulliparous women with Type 1 diabetes (Group B), parous women with Type 1 diabetes (Group C) and women with Type 2 diabetes of mixed parity (Group D).

RESULTS

Content analysis of transcribed focus groups revealed that, while women were well informed about the need to plan pregnancy, awareness of the rationale for planning was only evident in parous women or those who had actively sought pre-pregnancy advice. Within each group, there was uncertainty about what pre-pregnancy advice entailed. Despite many women reporting positive healthcare experiences, frequently cited barriers to discussing issues around family planning included unsupportive staff, busy clinics and perceived social stereotypes held by health professionals.

CONCLUSIONS

Knowledge and attitudes reported in this study highlight the need for women with diabetes, regardless of age, marital status or type of diabetes, to receive guidance about planning pregnancy in a motivating, positive and supportive manner. The important patient viewpoints expressed in this study may help health professionals determine how best to encourage women to avail of pre-pregnancy care.

From Dangerous to Discharged: An Application of Social-Learning-Based Procedures in an Acute Hospital Setting

Psychiatric inpatients who demonstrate persistent aggressive behavior present unique treatment planning and placement challenges. This article presents the case of a severely Veteran who demonstrated high levels of aggressive behavior as well as persistent adaptive behavior deficits. A comprehensive Treatment Recovery and Rehabilitation Plan (TRRP) based on Social-Learning Program procedures resulted in rapid improvements in recovery-related outcomes and discharge within 31 days of TRRP initiation. This intervention significantly reduced maladaptive behavior and increased treatment participation.These improvements were unrelated to pharmacotherapy changes during the hospitalization. Following discharge, a re-emergence of problematic behaviors in a community placement resulted in a more restrictive rehospitalization. The absence of TRRP implementation at this placement likely contributed to the re-emergence of problem behavior. This case illustrates the importance of implementing evidence-based psychosocial interventions in acute settings, engaging in recovery-oriented treatment planning, and maintaining continuity of care across settings.

Radiographic abnormalities and exposure to asbestos-contaminated vermiculite in the community of Libby, Montana, USA

Mining, handling, processing, and personal or commercial use of asbestos-contaminated vermiculite have led to widespread contamination of the Libby, Montana, area. We initiated a medical testing program in response to reports of respiratory illness in the community. The purpose of this analysis was to identify and quantify asbestos-related radiographic abnormalities among persons exposed to vermiculite in Libby and to examine associations between these outcomes and participants' self-reported exposures. A cross-sectional interview and medical testing were conducted in Libby from July through November 2000 and from July through September 2001. A total of 7,307 persons who had lived, worked, or played in Libby for at least 6 months before 31 December 1990 completed the interview. Of those, 6,668 participants > or = 18 years of age received chest radiographs to assess the prevalence of pleural and interstitial abnormalities. We observed pleural abnormalities in 17.8% of participants and interstitial abnormalities in < 1% of participants undergoing chest radiography. We examined 29 occupational, recreational, household, and other exposure pathways in the analysis. The prevalence of pleural abnormalities increased with increasing number of exposure pathways, ranging from 6.7% for those who reported no apparent exposures to 34.6% for those who reported > or = 12 pathways. The factors most strongly associated with pleural abnormalities were being a former W.R. Grace worker, being older, having been a household contact of a W.R. Grace worker, and being a male. In addition to being a former W.R. Grace worker, environmental exposures and other nonoccupational risk factors were also important predictors of asbestos-related radiographic abnormalities.

A comparison of the sampling efficiencies of a range of atmosphere samplers when collecting polymeric diphenylmethane di-isocyanate (MDI) aerosols

Polymeric diphenylmethane di-isocyanate (PMDI) is a precursor or an intermediate in the manufacture of pure MDI and is used in many industrial applications. Potential health effects of diisocyanates are generally considered to include irritation and respiratory sensitization, dictating the need for low occupational hygiene standards and robust hygiene monitoring methods. A wide range of methods has been developed or adopted for this purpose but questions concerning their ability to accurately sample MDI aerosols in the occupational environment have often been raised. In order to provide such information, studies have been conducted to compare several MDI sampling systems: the Institute of Occupational Medicine (IOM) 25-mm open-faced inhalable dust sampler; the 13-mm Millipore Swinnex Cassette sampler; the 37-mm open-face Millipore cassette; the midget-impinger, the glass tube containing glass wool, and two direct reading paper tape monitors. The program was comprised of two phases, the first being a preliminary comparison of the collection efficiencies of the IOM, 13 mm and midget-impinger at a range of orientations to air flow, aerosol particle sizes, and sampling flow rates, using inert polyethylene glycol aerosols. The second phase compared all samplers operating according to each manufacturer's recommendations and sampling PMDI aerosols at a range of particle sizes and concentrations. All studies were conducted in a wind tunnel. All filter methods performed well in atmospheres containing small particles except impingers that required a filter backup. In general, the variability of all the samplers was high for larger particle size ranges. Direct reading monitors showed low efficiencies.

CAM evaluation: what are the research questions?

Much effort is being directed towards the evaluation of CAM therapies. Yet evaluation is often encouraged before truly considering the research questions which need to be asked. Research questions like 'Does this CAM therapy work?' must be clearly distinguished from 'Does this particular CAM treatment work?' and the latter question needs to be replaced by even more specific ones like 'Does it work when administered by therapist X?' and 'Is therapist X effective?'. Suggestions for the study of the therapeutic process and the evaluation of therapist effectiveness are presented.

Beating heart coronary artery bypass grafting. A theatre nurse's perspective

Coronary artery bypass graft (CABG) surgery has been going through a time warp. The development of cardiopulmonary bypass (CPB), together with continuing advances in equipment and refinement of techniques, introduced a high level of safety for CABG operations. Recently, however, with pharmacological and technological advances, surgeons have been able to 'go back in time' and undertake complex CABG surgery without CPB.

Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial

OBJECTIVES

To determine whether postal prompts to patients who have survived an acute coronary event and to their general practitioners improve secondary prevention of coronary heart disease.

DESIGN

Randomised controlled trial.

SETTING

52 general practices in east London, 44 of which had received facilitation of local guidelines for coronary heart disease.

PARTICIPANTS

328 patients admitted to hospital for myocardial infarction or unstable angina.

INTERVENTIONS

Postal prompts sent 2 weeks and 3 months after discharge from hospital. The prompts contained recommendations for lowering the risk of another coronary event, including changes to lifestyle, drug treatment, and making an appointment to discuss these issues with the general practitioner or practice nurse.

MAIN OUTCOME MEASURES

Proportion of patients in whom serum cholesterol concentrations were measured; proportion of patients prescribed beta blockers (6 months after discharge); and proportion of patients prescribed cholesterol lowering drugs (1 year after discharge).

RESULTS

Prescribing of beta bockers (odds ratio 1.7, 95% confidence interval 0.8 to 3.0, P>0.05) and cholesterol lowering drugs (1.7, 0. 8 to 3.4, P>0.05) did not differ between intervention and control groups. A higher proportion of patients in the intervention group (64%) than in the control group (38%) had their serum cholesterol concentrations measured (2.9, 1.5 to 5.5, P<0.001). Secondary outcomes were significantly improved for consultations for coronary heart disease, the recording of risk factors, and advice given. There were no significant differences in patients' self reported changes to lifestyle or to the belief that it is possible to modify the risk of another coronary event.

CONCLUSIONS

Postal prompts to patients who had had acute coronary events and to their general practitioners in a locality where guidelines for coronary heart disease had been disseminated did not improve prescribing of effective drugs for secondary prevention or self reported changes to lifestyle. The prompts did increase consultation rates related to coronary heart disease and the recording of risk factors in the practices. Effective secondary prevention of coronary heart disease requires more than postal prompts and the dissemination of guidelines.

Why do we continue to take unnecessary smears?

A questionnaire survey of all general practices and family planning doctors in Manchester Health Authority was undertaken to determine why many more smears are taken in primary care than are scheduled by the screening programme. An 82% response rate was obtained. The indications for additional smear tests most frequently cited by responders were postcoital (88%), postmenopausal (84%), or intermenstrual bleeding (55%); genital warts (87%); and multiple sexual partners (52%). Forty-six per cent think that a woman should have a repeat test within one year of her first ever test. We discuss why these are not valid indications for additional smear tests.

Exon and intron variants in the human tryptophan 2,3-dioxygenase gene: potential association with Tourette syndrome, substance abuse and other disorders

Defects in serotonin metabolism, and abnormalities in both blood serotonin and tryptophan levels, have been reported in many psychiatric disorders. Tryptophan 2,3-dioxygenase (TDO2) is the rate limiting enzyme for the breakdown of tryptophan to N-formyl kenurenine. Functional variants of this gene could account for the observed simultaneous increases or decreases of both serotonin and tryptophan in various disorders. We have identified four different polymorphisms of the human TDO2 gene. Association studies show a significant association of one or more of these polymorphisms and Tourette syndrome (TS), attention deficit hyperactivity disorder (ADHD) and drug dependence. The intron 6G-->T variant was significantly associated with platelet serotonin levels. Only the association with TS was significant with a Bonferroni correction (p = 0.005). Our purpose here is not to claim these associations are proven, but rather to report preliminary results and show that easily testable polymorphisms are available. We hope to encourage additional research into the potential role the TDO2 gene in these and other psychiatric disorders.

Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London

OBJECTIVE

To determine whether locally developed guidelines on asthma and diabetes disseminated through practice based education improve quality of care in non-training, inner city general practices.

DESIGN

Randomised controlled trial with each practice receiving one set of guidelines but providing data on the management of both conditions.

SUBJECTS

24 inner city, non-training general practices.

SETTING

East London.

MAIN OUTCOME MEASURES

Recording of key variables in patient records (asthma: peak flow rate, review of inhaler technique, review of asthma symptoms, prophylaxis, occupation, and smoking habit; diabetes: blood glucose concentration, glycaemic control, funduscopy, feet examination, weight, and smoking habit); size of practice disease registers; prescribing in asthma; and use of structured consultation "prompts."

RESULTS

In practices receiving diabetes guidelines, significant improvements in recording were seen for all seven diabetes variables. Both groups of practices showed improved recording of review of inhaler technique, smoking habit, and review of asthma symptoms. In practices receiving asthma guidelines, further improvement was seen only in recording of review of inhaler technique and quality of prescribing in asthma. Sizes of disease registers were unchanged. The use of structured prompts was associated with improved recording of four of seven variables on diabetes and all six variables on asthma.

CONCLUSIONS

Local guidelines disseminated via practice based education improve the management of diabetes and possibly of asthma in inner city, non-training practices. The use of simple prompts may enhance this improvement.

Home visitation services for at-risk pregnant and postpartum women: a randomized trial

A randomized trial tested the psychosocial efficacy of a home visitation model for women at risk of out-of-home placement of their newborns. After an average of ten months of exposure, the experimental group reported significantly increased social support, greater access to services, and decreased psychological distress. Implications of the findings for interventions with at-risk families are discussed.

Psychosocial characteristics of pregnant women with and without a history of substance abuse

This study was undertaken to identify the psychosocial characteristics and service needs of pregnant women with substance abuse histories. Two hundred and twenty-five pregnant women defined as having high-risk pregnancies for psychosocial reasons were interviewed using a structured questionnaire when they presented for prenatal care at a large urban clinic. Women who admitted to problems with substance abuse were compared to those who denied a history of substance abuse. Women with an admitted history of substance abuse were significantly older, had more children, were more likely to live on their own or in an institutional setting, and more frequently reported that they currently smoked cigarettes. In addition, women with substance abuse problems delayed prenatal care an average of one month longer. Other differences between the two groups, as well as the implications of the findings for social work practice in health care settings, are discussed.

Clinical experience with penicillin skin testing in a large inner-city STD clinic

OBJECTIVE

To establish (1) the prevalence of positive penicillin skin tests among outpatients with well-defined but variable history of penicillin allergy and (2) the reproducibility, safety, and negative predictive value of skin testing with benzylpenicilloyl polylysine (PPL) and a minor-determinant mixture (MDM).

DESIGN

Serial consenting outpatients with current indications for penicillin therapy were skin-tested in duplicate with PPL and MDM. Subjects with negative skin tests (93% of those positive by history and 95% of those negative by history) received therapeutic courses of benzylpenicillin (81%) or ampicillin (19%). Negative predictive value of skin testing was established by 72-hour follow-up for adverse reactions to drug.

SETTING/PATIENTS

A total of 5063 consecutive, qualifying outpatients in a Baltimore, Md, sexually transmitted disease (STD) clinic. The study group was young (73% between 20 and 40 years old), 66% male, and 90% black; 25% had history of atopy. Follow-up was 94% complete.

RESULTS

Positive skin tests were observed in 7.1% of 776 individuals with previous history of penicillin allergy and in 1.7% of 4287 subjects negative by history (P << .001). Previous history of anaphylaxis or urticaria was associated with significantly higher rates of positive skin tests of 17.3% and 12.4%, respectively (P<<.001). Only 4% with history of exanthem had positive skin tests (P = .03). The coefficient of variation for duplicate skin tests was 11%. Time intervals since last penicillin treatment did not influence the rate of positive skin tests. Adverse reactions to skin tests occurred in 13 (1.2% of patients positive by history; 9.4% of those with positive skin tests). A mild anaphylactic reaction occurred in one individual whose preliminary scratch testing was inadvertently omitted; systemic pruritus or urticaria occurred in 11 subjects; one had a large local reaction. After penicillin administration to individuals with negative skin tests, acute allergic reactions occurred in 0.5% of subjects negative by history compared with 2.9% of subjects positive by history (chi 2 = 33.3; P = .0001). Reactions were generally mild and self-limited; only two cases of mild anaphylactic reaction occurred, both in patients with history of severe IgE-mediated reaction.

CONCLUSIONS

Skin testing with both major and minor penicillin determinants is safe using current recommendations, and both reagents are necessary for maximizing the identification of sensitized subjects. Routine penicillin skin testing can facilitate the safe use of penicillin in 90% of individuals with a previous history of penicillin allergy.

Evolution of the human immunodeficiency virus epidemic among patients attending sexually transmitted disease clinics: a decade of experience

Since human immunodeficiency virus (HIV) is predominantly sexually transmitted, serologic surveys for HIV infection in sexually transmitted disease (STD) clinics provide sentinel observations regarding HIV epidemiology. Over the past decade, 17,207 systematically collected sera from patients attending Baltimore STD clinics were analyzed. From 1979 through 1989, HIV seroprevalence rose from 0.23% to 5.35%, increasing significantly in both men and women (P less than .001). Due to a marked increase in HIV infection among women during the mid-1980s, the male-to-female ratio of HIV infection declined from 16:1 in 1979-1982 to 1.0 in 1988-1989. HIV seroprevalence increased significantly (P less than .001) in all age groups, with the greatest increase among teenagers, rising from 0.18% in 1979-1983 to 2.1% in 1987-1989 (P less than .001). Although HIV seroprevalence was higher among whites than blacks during the early 1980s, it increased in blacks subsequently (P less than .001), eventually resulting in a greater rate among black than white clinic patients (P less than .01). These data reflect the evolution of the HIV epidemic in US inner cities. HIV prevalence has increased greater than 20-fold, with recent increases being most marked among women, teenagers, and blacks. Additional resources will undoubtedly be required to support further intensive behavioral and educational programs targeted at adolescents and inner-city minorities.