Usability and Feasibility of the Antipsychotic Medication Decision Aid in a Community Program for First-Episode Psychosis

OBJECTIVE

Although antipsychotic medications are considered first-line treatment for psychosis, rates of discontinuation and nonadherence are high, and debate persists about their use. This pilot study aimed to explore the usability, feasibility, and potential impact of a shared decision making (SDM) intervention, the Antipsychotic Medication Decision Aid (APM-DA), for decisions about use of antipsychotic medications.

METHODS

A pilot randomized controlled trial was conducted with 17 participants in a first-episode psychosis program. Nine participants received the APM-DA, and eight received usual care.

RESULTS

After their appointments, intervention group participants had less decisional conflict and greater satisfaction with decisions than control group participants had. Use of the APM-DA did not increase appointment length. Comparison of the intervention outcomes with the control outcomes was limited because of the small sample.

CONCLUSIONS

The results support the feasibility and usability of an SDM process via the use of the APM-DA in routine community psychosis care.

Synchronous oral cavity malignancy in identical twins-unusual coincidence of similarities

The multifactorial nature of head and neck squamous cell carcinoma (HNSCC) has led to increased efforts in establishing various risk factors. Well-known environmental risk factors for HNSCC include tobacco use, heavy alcohol consumption, immunosuppression, and more recently human papillomavirus infection. Familial clustering has been observed in cancers occurring at other sites, but not so much with oral squamous cell carcinoma (OSCC) without exposure to shared environmental risk factors. An unusual case of identical twins who presented with OSCC involving an identical site and exhibiting similar histological features is reported here. The two patients underwent identical surgery with curative intent, culminating in good outcomes. It appears that no other cases of identical twins with a similar presentation in time, anatomical site, and histopathology have been reported in the literature.

Evaluating the feasibility of a decision aid to promote shared decision making among young adults with first-episode psychosis: protocol for a pilot study

BACKGROUND

Young adults ages 18 to 25 with first episode psychosis (FEP) have an increased risk of discontinuation antipsychotic medications and psychiatric service disengagement that lead to symptom exacerbation and deterioration. We seek to (1) examine the feasibility, usability, and potential impact of a Shared Decision Making (SDM) Antipsychotic Medication Decision Aid (DA) on decision-making, adherence to the decision made, and service engagement among young adults with FEP and (2) understand the role of additional patient-level factors on SDM.

METHODS

A randomized controlled trial is being conducted in a coordinated specialty care community program for FEP in an urban setting. Eligible patients are randomly assigned to receive an intervention, the Antipsychotic Medication Decision Aid, or treatment as usual. Patients receive their assigned intervention before their medication appointment with the psychiatrist and complete four interviews: before the appointment (T0), after the appointment (T1), and at 3- and 6-month follow-ups (T2 and T3). The study staff and participating psychiatrists are not blinded to the intervention. The data are de-identified to maintain blinding during the analysis process. The primary aims are feasibility of intervention delivery and research procedures and preliminary impact of the intervention on SDM-related outcomes, medication adherence, and service engagement. As a secondary aim, we will explore the contribution of personality and motivation variables, clinical relationships, cognitive functioning, and mental-health-related stigma to SDM. If the sample size permits, we plan to conduct parametric tests such as independent-samples t tests at T1 to compare differences in SDM, adherence, and engagement scales. In the case of a small sample size, we will use non-parametric tests and descriptive statistics.

DISCUSSION

This protocol outlines the methodology for a feasibility pilot comparing the effect of a novel SDM Antipsychotic Medication encounter DA with treatment as usual on SDM, medication adherence, and service engagement in FEP care. SDM is endorsed as a framework for use in FEP and antipsychotic pharmacotherapy, but its impact on adherence and health outcomes is unclear. Understanding the potential contribution of an SDM Antipsychotic Medication DA compared with usual care in psychosis pharmacotherapy is critical. The study will help answer several key questions new to SDM research, including the contribution of personality and clinical relationships to SDM in mental health and psychosis in particular. The study will serve to gather feasibility data to inform future studies and scale-up.

TRIAL REGISTRATION

Ethics approval was obtained through Temple University's institutional review board (IRB) and the City of Philadelphia's Department of Public Health IRB. The study has been retrospectively registered with ClinicalTrials.gov as NCT04373590 on 29 April 2020. https://clinicaltrials.gov/ct2/show/NCT04373590?term=NCT04373590&draw=2&rank=1.

Efficacy of temporomandibular joint arthroplasty and insertion of a Matthews device as treatment for ankylosis of the joint: a case series

Temporomandibular joint (TMJ) ankylosis is a condition in which bony or fibrous adhesion of the anatomical joint components results in loss of function. This is particularly distressing and debilitating for patients who struggle to maintain good oral hygiene, which results in additional pain, oral disease, and ultimately, a poor aesthetic profile. A retrospective chart review was carried out to document the cases of three patients who attended a single centre for the management of ankylosis of the TMJ. Consent for chart review and use of photographs was gained from each one. Charts were obtained, records reviewed, and each of the cases written up for presentation in a case series. All three underwent arthroplasty of the TMJ and insertion of Matthews devices (two patients unilateral, one bilateral). All were followed up postoperatively. They experienced significant improvements in vertical mouth opening which have been maintained to the present. The Matthews device allows movement and physiotherapy postoperatively whilst maintaining the surgically created space. This prevents impingement on the tissues placed between the glenoid fossa and mandible, and appears to prevent relapse and further ankylosis. To our knowledge, few studies to date have documented the use of the Matthews device following interpositional arthroplasty of the TMJ.

Value and learning from carer involvement in a cluster randomised controlled trial and process evaluation - Organising Support for Carers of Stroke Survivors (OSCARSS)

BACKGROUND

Patient, Carer and Public Involvement (PCPI) should be embedded in health care research. Delivering PCPI can be challenging, but even when PCPI is carried out it is rarely reported resulting in lost opportunities for learning. This paper aims to describe PCPI in the OSCARSS study, a pragmatic-cluster randomised controlled trial with an embedded economic and process evaluation.

METHODS

A carer research user group (RUG) co-developed OSCARSS to evaluate how to best deliver support to caregivers of stroke survivors. The PCPI activity involved regular meetings and preparatory work, from the initial conceptualisation of the study through to dissemination. Written reports, structured group discussions and individual interviews were carried out with the RUG and researchers to capture the added value and learning. This paper was co-authored by two of the RUG members with contributions from the wider RUG and researchers.

RESULTS

The core six members of the caregiver RUG attended the majority of the meetings alongside three researchers, one of whom was the co-chief investigator. PCPI was instrumental in changing many aspects of the research protocol, design and delivery and contributed to dissemination and sharing of good practice. There were challenges due to the emotional toll when PCPI members shared their stories and the extensive time commitment. Positive experiences of learning and fulfilment were reported by the individual researchers and PCPI members. Wider organisational administrative and financial support facilitated the PCPI. The researchers' existing positive regard for PCPI and the clear focus of the group were key to the successful co-design of this research.

CONCLUSIONS

The value and learning from the PCPI collaborative work with the researchers was of benefit to the study and the individuals involved. Specific PCPI influences were a challenge to pinpoint as successful co-design meant the researchers' and carers' contributions were intertwined and decision-making shared.

Do recovery outcome measures improve clinical practice? A linguistic analysis of the impact of the Hope, Agency and Opportunity measure in community mental health teams

AIMS

Recovery approaches are identified as the overarching framework for improving mental health services for people with severe and enduring conditions. These approaches prioritise living well with long-term conditions, as evidenced by personal recovery outcomes. There is little research demonstrating how to support busy mental health teams, work in this way. This study assessed the impact of introducing a brief measure of recovery, the Hope, Agency and Opportunity (HAO), on the attitudes and behaviours of staff working in community mental health teams, to test whether routine use of such measures facilitates recovery-based practice.

METHODS

Linguistic analysis assumes that language is indicative of wider attitudes and behaviours. Anonymised clinical notes recorded by community mental health team clinicians were analysed for recovery and non-recovery language, over 30 months. This covered periods before, during and after the introduction of the recovery measure. We used a single-case design (N = 1 community mental health team) and hypothesised that clinicians would use recovery-focused language more frequently, and non-recovery-focused language less frequently, following the introduction of the measure, and that these changes would be maintained at 18-month follow-up.

RESULTS

Visual inspection of the data indicated that recovery-focused language increased following the introduction of the HAO, though this was not maintained at follow-up. This pattern was not supported by statistical analyses. No clear pattern of change was found for non-recovery-focused language.

CONCLUSIONS

The introduction of a brief measure of recovery may have influenced staff attitudes and behaviours temporarily. Any longer term impact is likely to depend on ongoing commitment to the use of the measure, without which staff language, attitudes and behaviours return to previous levels.

Structure-function analysis and therapeutic efficacy of antibodies to fungal melanin for melanoma radioimmunotherapy

Metastatic melanoma remains difficult to treat despite recent approvals of several new drugs. Recently we reported encouraging results of Phase I clinical trial of radiolabeled with 188Re murine monoclonal IgM 6D2 to melanin in patients with Stage III/IV melanoma. Subsequently we generated a novel murine IgG 8C3 to melanin. IgGs are more amenable to humanization and cGMP (current Good Manufacturing Practice) manufacturing than IgMs. We performed comparative structural analysis of melanin-binding IgM 6D2 and IgG 8C3. The therapeutic efficacy of 213Bi- and 188Re-labeled 8C3 and its comparison with anti-CTLA4 immunotherapy was performed in B16-F10 murine melanoma model. The primary structures of these antibodies revealed significant homology, with the CDRs containing a high percentage of positively charged amino acids. The 8C3 model has a negatively charged binding surface and significant number of aromatic residues in its H3 domain, suggesting that hydrophobic interactions contribute to the antibody-melanin interaction. Radiolabeled IgG 8C3 showed significant therapeutic efficacy in murine melanoma, safety towards healthy melanin-containing tissues and favorable comparison with the anti-CTLA4 antibody. We have demonstrated that antibody binding to melanin relies on both charge and hydrophobic interactions while the in vivo data supports further development of 8C3 IgG as radioimmunotherapy reagent for metastatic melanoma.

Exploring Maternal Mental Health in Syrian Refugee Women

Introduction

There has been a rapid influx of 30,000 Syrian refugees in Canada, many are women of childbearing age, and most have young children. The literature reports that refugee women are almost 5 times more likely to develop postpartum depression than Canadian-born women. However, little is known about the experiences that the Syrian refugee women have encountered pre- and post-resettlement and their perceptions of mental health issues in general, and of maternal depression in particular. Thus, there is an urgent need to understand the refugee women's experiences of having a baby in Canada from a mental health perspective.

Methods

Participants include Syrian refugee women who migrated to Saskatoon Canada in 2015–16 and who were either pregnant or up to one year postpartum. Qualitative data was collected via a focus group with thematic analysis, while depression with Edinburgh Postnatal Depression Scale (EPDS) and PTSD screening and sociodemographic descriptive data were collected from a structured questionnaire to provide context for the qualitative analysis.

Results

Twelve women participated in the focus group, despite smiling often, 58% of them screened as probable depression (EPDS > 10), 25% screened positive for depression (> 12 on EPDS), and 17% screened positive for PTSD. None of the women indicated intimate partner violence or suicidal thoughts. All participants indicated social support, mostly partner, and 25% had a history of depression. Thematic analysis will be shared.

Conclusions

Perinatal Depression is a serious problem for refugee women that deserve more in-depth study to ensure optimal outcomes and to develop services and programs.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Wnt4 antagonises Wnt3a mediated increases in growth and glucose stimulated insulin secretion in the pancreatic beta-cell line, INS-1

The Wnt signalling pathway in beta-cells has been linked to the development of type 2 diabetes. Investigating the impact of a non-canonical Wnt ligand, Wnt4, on beta-cell function we found that in INS-1 cells, Wnt4 was able to completely block Wnt3a stimulated cell growth and insulin secretion. However, despite high levels of Wnt4 protein being detected in INS-1 cells, reducing the expression of Wnt4 had no impact on cell growth or Wnt3a signalling. As such, the role of the endogenously expressed Wnt4 in beta-cells is unclear, but the data showing that Wnt4 can act as a negative regulator of canonical Wnt signalling in beta-cells suggests that this pathway could be a potential target for modulating beta-cell function.

FC11-04 - Patterns of depression and trajectories of treatment over the perinatal period

Introduction

Perinatal depression is an important problem with potentially deleterious health outcomes; however, we know little about the trajectories of depression and treatment.

Purpose

We report the patterns of maternal depression and trajectories of treatment response in early and late pregnancy and during postpartum in 649 women recruited from the general population of pregnant women in Western Canada. Women who scored ≥ 12 on the Edinburgh Postnatal Depression Scale were classified as depressed.

Findings

Fifty-two percent of participants were primiparas, 90% were partnered, 83.3% Caucasian, 67% earn more than $40,000 per year, 90% completed high school, and 77% had planned pregnancy. The unadjusted prevalence of depression in early pregnancy (17 weeks) was 14%, late pregnancy (30 weeks) 11.5%, and postpartum (4.1 weeks) was 9.8%. All of the psychosocial factors measured - history of depression, mood instability, lack of social support, relationship problems, worry, and stressors heighten depression symptoms throughout parturition. Our practice of referring women who screened positive for depression changed prevalence rates of women who were depressed and in treatment. The number of women in treatment increased from 12.2% in early pregnancy to 24.8% at postpartum. Women were significantly more likely to get symptom relief counselling in pregnancy compared to psychotropic medication use in postpartum, with the exception of those women with history of depression and treatment engagement.

Summary

Increased understanding of the patterns and nature of maternal depression and treatment response is essential to early identification of women who are depressed and lead to treatment that is more effective.

Exploring mood variability in pregnancy and postpartum women

Introduction

Emotional and moody behaviour is often normalized in childbearing women. However, increased mood variability is associated with psychiatric problems (anxiety, depression, personality disorder), which are potentially deleterious to the health of the developing fetus and mother.

Purpose

To increase understanding about mood variability in childbearing women.

Method

Depression was measured using the Edinburgh Postpartum Depression Scale (EPDS). Mood variability was calculated from twice-daily diary ratings of “depressed”, “fear”, and “irritable” mood for one week each in early pregnancy, late pregnancy, and postpartum.

Findings

We recruited 47 women. Depression, as measured by the EPDS, and fear mood variability decreased from early pregnancy to postpartum. Depressed and irritable mood variability also declined during pregnancy, but increased in post-partum. Increases in mood variability (depressed, irritable) from late pregnancy to postpartum predicted higher postpartum EPDS. Mood diaries were available from 30 non-parturient women for comparison. Pregnant and postpartum women had higher irritable but not depressed or fear mood variability.

Conclusion

Mood, particularly anxiety, is variable over the course of pregnancy into early postpartum. This may be related to diminishing concerns about the pregnancy and baby's health after birth, sleep disruptions, or hormonal changes. Depressed mood variability is correlated with, but is distinct from depression as measured by the EPDS. We present results counter to the notion that all mood is amplified in childbearing women.

Fludarabine, Cyclophosphamide and Mitoxantrone in Relapsed or Refractory Chronic Lymphocytic Leukemia and Low Grade Non-Hodgkin's Lymphoma

A regimen combining fludarabine, cyclophosphamide and mitoxantrone (FCM) was used to treat 29 patients with relapsed or refractory chronic lymphocytic leukemia (CLL, N = 24) and low-grade non-Hodgkin's lymphoma (NHL, N = 5) based on evidence suggesting synergism between the 3 drugs. Patients were treated with mitoxantrone 5mg/m2 i.v. day 1 only, fludarabine 25 mg/m2 i.v. for 3 days or 24 mg/m2 orally for 5 days, cyclophosphamide 250 mg/m2 i.v. for 3 days or 150 mg/m2 orally for 5 days inclusive. Eighteen patients had previously received fludarabine and most were heavily pretreated with 40% having >2 prior treatments. A median number of 4 FCM courses (range of 1-9) were given. The response rate was 78.5%: 32% complete remission, 25% nodular partial remission, 21.5%, partial remission. Median duration of response was 19 months and median survival was 42 months. Sixteen patients (57%) developed neutropenia to < 0.5 x 10(9)/l and 12 (43%) infectious complications. Four patients developed large cell lymphoma (Richter's syndrome) and 2 acute myeloid leukemia. FCM is a useful combination for relapsed or refractory CLL and low grade NHL with high response rates and long duration of response. The role of FCM as first line therapy deserves study as well as its combination with the monoclonal antibody Rituximab.

Bioavailability of oestradiol from the Alora TM (0.1 mg/day) oestradiol matrix transdermal delivery system compared with Estraderm (0.1 mg/day)

This open-label, randomised, two-way crossover study compared the steady-state bioavailability of oestradiol administered by way of a new oestradiol matrix transdermal delivery system (Alora 0.1 mg/day) with that of Estraderm (0.1 mg/day) in 24 subjects. Serum oestradiol, oestrone and oestrone sulphate concentrations were determined by measurement of blood samples. Mean SD pre-dosing, nonadjusted oestradiol levels for Alora (71.9 27.0 pg/ml) were substantially higher than those for Estraderm (26.7 9.7 pg/ml), while peak oestradiol concentrations were comparable. Consequently, fluctuations in steady-state levels were substantially smaller for Alora than for Estraderm; the fluctuation index values (\[C- C ])/ max min C ) were significantly lower for Alora (0.97 0.23) than av for Estraderm (1.68 0.45). Oestradiol levels remained constant over the dosing interval with Alora but decreased significantly after 48 hours with Estraderm. The bioavailability of oestradiol with Alora was 127 56% that of Estraderm. Oestrone and oestrone sulphate data showed the same qualitative and quantitative differences between the two systems. Both systems were well tolerated. In summary, Alora delivered more oestradiol to the systemic circulation with greater consistency and over a longer time than did Estraderm.

Development of a reliable self-report outcome measure for pragmatic trials of communication therapy following stroke: the Communication Outcome after Stroke (COAST) scale

OBJECTIVE

To develop and validate a clinically feasible measure of communication effectiveness for people with any type of communication problem following stroke.

DESIGN

Cross-sectional, interview-based, psychometric study, building on the development phase for construction of the Communication Outcome after Stroke (COAST) scale.

SETTING

A community sample from the northwest of England, UK.

SUBJECTS

One hundred and two people with communication problems (aphasia and/or dysarthria) following a stroke, within the previous 4-12 months.

INTERVENTIONS

Administration of the COAST scale, on two occasions, within a two-week period, and collection of demographic and other data relating to disability, degree of aphasia (where appropriate) and hospital diagnosis of aphasia/dysarthria.

MAIN MEASURES

Acceptability (missing values), reliability (internal consistency and test-retest reliability) and item analysis (item redundancy).

RESULTS

Ninety-seven (visit 1) and 98 (visit 2) respondents provided usable data for the psychometric analysis. The 29-item COAST scale showed good acceptability (few missing values, sample spread 28-100%), internal consistency and test-retest reliability for the scale (alpha = 0.95; ICC = 0.90) and its subscales (alpha = 0.65-0.93; ICC = 0.72-0.88), but possible item redundancy. A revised scale of 20 items was produced, demonstrating good internal consistency and test-retest reliability (alpha = 0.83-92; ICC = 0.72-0.88).

CONCLUSIONS

The COAST is a patient-centred, practical and reliable measure that can be used to assess self-perceived communication effectiveness for people with aphasia and/or dysarthria. Further testing on construct validity and responsiveness to change is needed before the measure can be firmly recommended for use within clinical practice and research.

Antenatal depression in socially high-risk women in Canada

BACKGROUND

Antenatal depression is potentially deleterious to the mother and baby. Canadian Aboriginal women have an increased risk for living in poverty, family violence, and substance use; however, little is known about antenatal depression in this group. The aim of this study was to determine the prevalence and correlates of depression in socially high-risk, mostly Aboriginal pregnant women.

METHODS

Women (Aboriginal and non-Aboriginal), in two prenatal outreach programmes were approached and depressive symptoms between the two groups were compared, using the Edinburgh Postnatal Depression Scale (EPDS).

RESULTS

Sixty per cent (n = 402) of potential participants were recruited for the study. The prevalence of depression was 29.5% (n = 402). Depression was associated with a history of depression, mood swings, increased stressors, current smoker, and lack of social support. Aboriginal women were more likely to be depressed, but this was not significantly higher than non-Aboriginal women; however, they did experience significantly more self-harm thoughts. Exercise was a significant mediator for depression.

CONCLUSION

The prevalence of antenatal depression confirms rates in other high-risk, ethnic minority groups of women. A previous history of depression and mood problems were associated with depression, thus prenatal care should include a careful mental health assessment. On a positive note, the present study suggests that exercise may mediate antenatal depression.

Personal and partner measures in stages of consistent condom use among African-American heterosexual crack cocaine smokers

Participants' personal condom use measures and those of their last sex partner's were examined in five stages of change for consistent condom use among 449 urban sexually active, heterosexual, African-American crack smokers. The measures included participants' personal and their last sex partner's perceived responsibility, personal and perceived negative attitudes, and participants' self-efficacy to use condoms. The relationships between the measures and the stages were examined using analyses of variance and multivariate logistic regression. Over 90% of participants did not use condoms, consistently. Two-thirds of the inconsistent users were in the precontemplation stage. The rest were equally divided between the contemplation and preparation stages. Personal responsibility outperformed other measures in initial intention to become a regular condom user; partner's perceived responsibility dominated continued intention and actual consistent condom use. Negative attitudes and self-efficacies had strong relationships to the stages of consistent condom use in univariate analyses but these relationships became substantially weaker when the responsibility, attitude, and self-efficacy concepts were entered simultaneously into multivariate analyses.

An investigation of a personal norm of condom-use responsibility among African American crack cocaine smokers

The purpose of this study was to investigate the unique contribution of a personal norm of condom-use responsibility to the formation of intentions to use male condoms during vaginal sex. Data were collected from 402 male and 157 female heterosexual African American crack cocaine smokers in Houston, Texas, US. Two structural equation models of the intention to use a condom with the last sex partner were estimated. One model included measures of condom-use attitudes, subjective norms and condom-use self-efficacy. A second model included these three measures and a fourth measure of a personal norm of condom-use responsibility. Separate models were estimated for men and women. The addition of a personal norm of condom-use responsibility provided a significantly better fit to the data than did models including only outcome expectations, subjective norms and self-efficacy. Results also showed distinctly different underlying cognitive structures of condom-use intention for men and women. A personal norm of condom-use responsibility had a strong direct effect on men's intentions to use condoms with the last sex partner. Other variables appeared to have no direct effect on men's intentions. Women's intentions were strongly influenced by a personal norm and social subjective norms. Situational self-efficacy and outcome expectations had weaker, yet significant, effects on women's intentions. Given the strong effect of personal norms on men's intentions to use condoms, further research should be undertaken.

The impact of HIV-related interventions on HIV risk behavior in a community sample of African American crack cocaine users

While there are reports of the impact of specific interventions designed to reduce HIV drug and sexual risk behaviors, there are few reports of the impact of HIV interventions in a community-based sample. We report on baseline data from a sample of African American crack smokers who were about to participate in an intervention designed to reduce HIV-related risk behaviors. The majority were male (80%), single (70%) and homeless (52%). Data indicated that 29% of the sample had been in a previous HIV intervention in the past 12 months, the majority in a correctional setting or CBO program. There were few systematic demographic differences between the two groups. Those who had been in an intervention reported using male and female condoms significantly more frequently on all measures of condom use, had positive condom use outcome expectations for male condoms and higher affective and situational condom-related self-efficacy beliefs. These data suggest that, at a community level, the spectrum of HIV risk-reduction programs does produce a significant improvement in condom use and related cognitions, although there is a need to cover a greater proportion of the population. Previous exposure to interventions must be a critical covariate in assessing the impact of future interventions.

Cognitive rehabilitation for spatial neglect following stroke

BACKGROUND

Unilateral spatial neglect causes difficulty attending to one side of space. Various rehabilitation strategies have been used but evidence of their benefit is lacking.

OBJECTIVES

To determine the persisting effects of cognitive rehabilitation specifically aimed at spatial neglect following stroke, as measured on impairment and disability level outcome assessments and on destination on discharge from hospital.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 4 July 2005), MEDLINE (1966 to July 2005), EMBASE (1980 to July 2005), CINAHL (1983 to July 2005), PsycINFO (1974 to July 2005), UK National Research Register (July 2005). We handsearched relevant journals, screened reference lists, and tracked citations using SCISEARCH.

SELECTION CRITERIA

We included randomised controlled trials of cognitive rehabilitation specifically aimed at spatial neglect. We excluded studies of general stroke rehabilitation and studies with mixed patient groups, unless more than 75% of their sample were stroke patients or separate stroke data were available.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed trial quality.

MAIN RESULTS

We included 12 RCTs with 306 participants. Only four had adequate allocation concealment, that is a low risk of selection bias. A large number of outcome measures were reported. Only six studies measured disability and two investigated whether the effects persisted. The overall effect (standardised mean difference) on disability had a wide confidence interval that included zero and was not statistically significant. For discharge destination there were clinically significant effects but in both directions and the confidence interval of the odds ratio included one. In contrast, cognitive rehabilitation did improve performance on some, but not all, standardised neglect tests. The number of cancellation errors made was reduced and the ability to find the midpoint of a line improved immediately and persisted at follow up. These effects appeared likely to generalise from the samples studied to the target population, but were based on a small number of studies.

AUTHORS' CONCLUSIONS

Several types of neglect specific approaches are now described but there is insufficient evidence to support or refute their effectiveness at reducing disability and improving independence. They can alter test performance and warrant further investigation in high quality randomised controlled trials. As we did not review whether patients with neglect benefit from rehabilitation input in general, such patients should continue to receive general stroke rehabilitation services.

A dual-task approach to the evaluation of the myokinemetric signal as an alternative to EMG

EMG is the signal widely used in neuromuscular control, biofeedback and measurement applications. Alternative physiological signals are available, but are used relatively infrequently. In the development of assistive devices, such as functional electrical stimulators, it is important to make the device as straightforward to use as possible. This is particularly relevant for patients with neurological and often associated cognitive impairments. Different physiological signals may require different degrees of attention to control, and advantage could be gained from selection of a signal that requires the least attention to control. However, relatively little work has been carried out on how to assess the demands of different physiological signals. This paper reports on the development of a novel experimental set up designed to address this problem and, in particular, to compare two different physiological signals, the EMG and the so-called MK signal. The paper presents the hardware design, including mechanical, electronic and software design, which involves data acquisition, parallel tasks and user-friendly interface. The system described could be adapted for evaluation of other physiological signals.

Immunization of pigs against chicken gonadotropin-releasing hormone-II and lamprey gonadotropin-releasing hormone-III: Effects on gonadotropin secretion and testicular function1

The objective of this experiment was to evaluate the effects of active immunization against 2 GnRH isoforms on gonadotropin secretion and testicular function in pigs. Synthetic chicken (c) GnRH-II and lamprey (l) GnRH-III peptides, with the common pGlu-His-Trp-Ser sequence at the N-terminal omitted, were conjugated to BSA. Forty-eight male piglets were randomly assigned to 1 of 4 treatments. Pigs on treatment 1 were actively immunized against cGnRH-II, whereas pigs on treatment 2 were actively immunized against lGnRH-III. Control pigs on treatment 3 were actively immunized against the carrier protein (BSA), and pigs on treatment 4 were castrated and actively immunized against BSA. The BSA conjugate was emulsified in Freund's Incomplete Adjuvant and diethylaminoethyldextran. Primary immunization was given at 13 wk of age (WOA) with booster immunizations given at 16 and 19 WOA. Body weight and plasma samples were collected weekly beginning at 11 WOA. Treatments did not affect BW during the experimental period. Antibody titers were increased in animals immunized against cGnRH-II and lGnRH-III (P < 0.001). Cross-reactivity of the antibodies to mammalian GnRH or between cGnRH-II and lGnRH-III was minimal. Concentrations of testosterone were maximal in control boars (treatment 3) and minimal in control barrows (treatment 4) and immunized pigs (treatment x week; P < 0.01). Immunized animals had concentrations of LH (P < 0.001) and FSH (treatment x week; P < 0.03) that were less than control barrows and similar to control boars. At the end of the experiment, intact (noncastrated) pigs were exsanguinated. Testes were removed immediately; Leydig cells were isolated and treated with 0, 1, or 10 ng/mL of LH. There was an LH x GnRH treatment effect on testosterone concentrations (P < 0.03), indicating that Leydig cells were sensitive to the immunization protocol and doses of LH. Taken together, these data suggest that immunization against GnRH isoforms decreased gonadotropin secretion compared with control barrows. Additionally, immunization against cGnRH-II and lGnRH-III reduced the ability of Leydig cells to respond to LH challenges.

Infections associated with cantaloupe consumption: a public health concern

Fresh produce is an important part of a healthy diet and is consumed in greater quantity in the United States than ever before. Consumption of cantaloupe has recently been associated with several large outbreaks of infections in North America, highlighting the need for a better understanding of practices and processes that may contribute to contamination. We reviewed all cantaloupe-associated outbreaks that were reported to the Centers for Disease Control and Prevention (CDC) and published in the literature. Twenty-three outbreaks occurred between 1984 and 2002; 1434 people became ill, 42 were hospitalized, and two died in these outbreaks. Aetiological agents in the outbreaks included five serotypes of Salmonella enterica, Campylobacter jejuni, Escherichia coli O157:H7, and norovirus. We reviewed processes contributing to cantaloupe contamination, conditions affecting survival and growth of bacterial pathogens on melons, and potential methods for sanitization. For maximum safety, industry, federal, and international partners must collaborate to ensure that appropriate interventions are in place to minimize the risk of contamination and prevent the growth of pathogens during cantaloupe production, processing, storage, and preparation.

The need for randomised treatment studies in neglect research

PURPOSE

The aim was to review the methodological quality of trials to evaluate rehabilitation for spatial neglect and to determine the overall effectiveness of interventions

METHODS

A systematic literature review and meta-analysis were conducted of trials completed by 2005. Trials identified were independently assessed for methodological quality by two reviewers. Outcomes were analysed as the standardised mean difference and 95% confidence intervals with random effects models.

RESULTS

25 trials of neglect rehabilitation were identified, 12 randomised controlled trials and 13 controlled clinical trials. The methodological quality was generally poor with only 4 trials achieving an A rating, i.e. low risk of selection bias. The immediate effect of cognitive rehabilitation on disability was small, 0.26 [-0.16, 0.67] and neither this nor the persisting effect 0.61 [-0.42, 1.63] was statistically significant. The most frequently used standardised neglect test (number of single letters correctly cancelled) favoured the experimental group 0.58 [0.10, 1.05] but was not significant. When cancellation errors were measured there was a small immediate effect favouring the experimental group, of borderline statistical significance, -0.65 [-1.28, -0.01] p=0.05, and a significant persisting effect -0.76 [-1.39, -0.13] p=0.02. Cognitive rehabilitation also significantly improved immediate (p=001) and persisting (p=0.02) line bisection performance but these findings are based on only four and one study respectively.

CONCLUSIONS

The quality of trials identified was poor. Analysis of randomised controlled trials showed some evidence of an effect of intervention on measures of impairment. There was no evidence to support the effects of intervention on measures of disability. Further trials must use methods that reduce bias, have adequate statistical power, and include valid disability outcome measures.

Interventions for apraxia of speech following stroke

BACKGROUND

Apraxia of speech is a communication disorder that can affect stroke patients. Several different intervention strategies are undertaken by speech and language therapists working with this patient group.

OBJECTIVES

To assess whether therapeutic interventions improve functional speech in stroke patients with apraxia of speech and which individual therapeutic interventions are effective.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (searched May 2004). In addition, we searched the following databases: the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2003); MEDLINE (1966 to April 2004); EMBASE (1980 to April 2004); CINAHL (1982 to April 2004); PsycINFO (1974 to April 2004); the National Research Register (searched April 2004); and Current Controlled Trials Register (searched May 2004). We reviewed reference lists of relevant articles and contacted authors and researchers in an effort to identify published and unpublished trials.

SELECTION CRITERIA

We sought to include randomised controlled trials of non-drug interventions for adults with apraxia of speech following a stroke where the primary outcome was functional speech at six months follow up.

DATA COLLECTION AND ANALYSIS

One author searched the titles, abstracts and keywords. Two authors examined the abstracts that might meet the inclusion criteria. Four authors were available to assess trial quality and to extract data from eligible studies.

MAIN RESULTS

No trials were identified.

AUTHORS' CONCLUSIONS

There is no evidence from randomised trials to support or refute the effectiveness of therapeutic interventions for apraxia of speech. There is a need for high quality randomised trials to be undertaken in this area.

Cognitive rehabilitation for spatial neglect following stroke

BACKGROUND

Unilateral spatial neglect is a failure to attend to one side of space. Various strategies have been used to treat these problems but evidence of their benefit has been lacking.

OBJECTIVES

To determine the effects of cognitive rehabilitation for spatial neglect following stroke as measured on impairment and disability level assessments, and destination on discharge from hospital. To determine whether any effects persist at follow-up assessment.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched February 2001), MEDLINE (1966-December 2000), EMBASE (1980-February 2001), CINAHL (1983-January 2001), PSYCLIT and CLINPSYCH (1974-February 2001). We handsearched relevant journals, screened reference lists from relevant articles and tracked citations using SCISEARCH.

SELECTION CRITERIA

Controlled trials of cognitive rehabilitation for spatial neglect in stroke. Studies with mixed patient groups were excluded unless more than 75% of their sample were stroke patients or separate stroke data were available for stroke patients.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials, extracted data, and assessed trial quality.

MAIN RESULTS

We included 15 studies with 400 participants. A large number of different outcome measures were reported. Only six studies included a measure of disability and only four (111 participants) investigated persisting effects on any outcome. There was evidence that cognitive rehabilitation resulted in significant and persisting improvements in performance on impairment level assessments, although this varied depending on the test used. There was insufficient evidence to confirm or exclude an effect of cognitive rehabilitation at the level of disability or on destination following discharge from hospital.

REVIEWER'S CONCLUSIONS

There is some evidence that cognitive rehabilitation for spatial neglect improves performance on some impairment level tests but its effect on disability is unclear. Further well-designed RCTs are warranted as well as basic research to develop valid outcome measures.

Self-organization of alcohol-related attitudes and beliefs in a campus housing complex: an initial investigation

The self-organization of college students' alcohol-related attitudes and their beliefs about other students' attitudes were assessed within a campus housing complex. Pluralistic ignorance was widespread, in that, compared with their own self-ratings, students rated their friends and the "typical" student as being more in favor of alcohol and more lax in the number of drinks per hour that were acceptable and the number of drinks that were acceptable before driving. They also perceived typical students as more risky than their friends. Dynamic social impact theory was also supported, as students' dormitory building and floor of residence reliably predicted both their personal drinking attitudes and their beliefs about the drinking attitudes of other students.

Use of a novel contingency stimulator in Unilateral Spatial Neglect

The trial of a treatment device for Unilateral Spatial Neglect (USN) is reported. A patient who had suffered a right hemisphere stroke that resulted in left sided neglect was studied over a six month period. The study involved the use of a customized electrical device providing stimulation to the neglected hand, triggered by movement of the unaffected side. A battery of neglect measures were performed regularly throughout the study period. Though the results were difficult to interpret, there was no conclusive evidence that the device was effective. The possible reasons for this, the methodological difficulties inherent in studies of this type and suggestions for further studies are discussed.

Dual-task effects of talking while walking on velocity and balance following a stroke

BACKGROUND

Therapists and nurses often use verbal instruction in the rehabilitation of mobility following stroke. This study aimed to determine whether performing a verbal cognitive task while walking adversely affected patients' balance and velocity.

METHODS

There were two counterbalanced conditions: walking only and walking and concurrent cognitive activity. The cognitive activity used was to give one of two verbal responses to two verbal stimuli. An electronic GaitMat measured gait velocity and balance (double support time as a percentage of stride time).

RESULTS

11 people with stroke participated in the study (five women and six men, mean age 72 years, SD 9). They were on average 120 (SD 48) days post-stroke. Velocity decreased (P=0.017) and double-support time as a percentage of stride time increased (P=0.010) when the cognitive activity was added to the test.

CONCLUSIONS

Performing a verbal cognitive task while walking adversely affected stroke patients' balance and gait velocity. Susceptibility to disruption varied within the patient group, suggesting clinical heterogeneity. Further research is required before changes to clinical practice are justified.

Neuropsychological rehabilitation for traumatic brain injury: do carers benefit?

This study evaluated the effectiveness of a new rehabilitation service, compared with existing services, for carers of people with traumatic brain injury (TBI). Subjects were 96 adult carers of people consecutively admitted to two local hospitals. They were assigned to one of three groups: Early new service (pre-discharge); Late new service (post-discharge); or a Control condition (existing services only). Individual randomization was not possible and randomization by hospital site was rejected because of demographic and clinical differences between sites. Group assignment was determined by a pre-specified timetable which alternated between hospitals. Two outcomes were compared at 6 months post-injury: carers' emotional distress and how well-informed they felt about TBI and available resources. Analyses adjusting for potential confounding factors confirmed a clinically plausible superior outcome for both intervention groups compared to the control group. However, these differences did not obtain statistical significance (p > or = 0.01). Several reasons for these findings are discussed, including the novelty of the new service and methodological issues such as statistical power. Longer term follow-up studies are required as psychological sequelae and, therefore, the need for intervention is known to increase with time and may not be most apparent during the first 6 months.

Cloning and sequencing of the genes encoding the periplasmic-cytochrome B-containing selenate reductase of Thauera selenatis

The periplasmic selenate reductase (Ser) of Thauera selennatis is a component of the electron transport chain catalyzing selenate reduction with acetate as the electron donor (i.e., selenate respiration). The purified enzyme consists of three subunits (SerA, SerB and SerC). Using transposon (i.e., Tn5) mutagenesis selenate reductase mutants were isolated. Junction fragments of DNA adjacent to the integrated Tn5 were used, together with oligonucleotides derived from the N-termini of SerA and SerB, to clone from a gene bank a DNA fragment that contained the corresponding genes. After sequencing, serA, serB and serC were identified by sequence comparison with the N-termini of the three subunits. The genes are arranged in the order serA, serB, serC; a fourth open reading frame (serD) in between, but overlapping serB and serC, is also present. The serA gene product contains an apparent leader peptide with a twin-arginine motif. The remainder of the translated amino acid sequence is similar to that of a number of prokaryotic molybdenum-containing enzymes (e.g., nitrate reductases and formate dehydrogenases of Escherichia coli). The serB gene product contains four cysteine clusters and is similar to various iron-sulfur protein subunits. The serC gene product contains a putative Sec-dependent leader peptide, but there are no similarities between the remainder of the translated protein and other protein subunits. The SerC contains two histidine and four methionine residues, and these may noncovalently bind heme b--which is a component of the active selenate reductase. The serD gene product encodes a putative protein that shows no significant sequence similarities to other proteins. However, the location of the serD within the other ser genes is similar to that of narJ within the E. coli narGHJI operon (nitrate reductase A); thus suggesting that the role of SerD may be similar to that of NarJ, which is a system-specific chaperone protein.

Collaboration between community nurses and nursing faculty using substance abuse prevention focus groups

Collaboration between community nurses and nurses from a university who conducted focus groups is discussed. The focus groups explored why low-income, inner-city, white women of childbearing age did not abuse drugs. This partnership effort resulted in positive, successful outcomes for both groups of nurses and yielded culturally sensitive information that may be useful in preventing substance abuse. Methods of facilitating this collaboration and results of our joint endeavors are explored.

Parent and child mealtime behavior in families of children with cystic fibrosis

OBJECTIVES

We investigated the hypothesis that children with cystic fibrosis (CF) and their parents would show more maladaptive behaviors during dinner than children without CF and their parents.

STUDY DESIGN

Children with CF (n = 32) and their parents were compared with 29 children without CF and their parents on the rate and frequency of parent-child behaviors during a typical dinner in the families' homes by using multivariate analyses of variance.

RESULTS

When the rate of behavior, controlling for meal length, was examined, no differences were found between groups. However, parents of children with CF were found to differ from parents of control subjects in the frequency of direct and indirect commands (P <.05), coaxes (P <.01), physical prompts (P <.01), and feeding their child (P <.05). Children with CF were found to engage in more talk, spend more time away from the table, refuse food, and exhibit more noncompliance toward commands to eat than control children (P <.05 for all child variables). When behaviors were examined as a function of meal phase, parents of children with and without CF both showed an increase in commands (P <.01), coaxes (P <.05), feeds (P <.01), and physical prompts (P <.01) in the second half of the meal as compared with the first. Children with CF and the control children showed an increase in behaviors incompatible with eating during the second half of the meal compared with the first (P <.01). When faster eaters were compared with slower eaters, faster eaters consumed a higher percentage of the recommended daily allowance of energy (P <.01) than slower eaters and showed a trend to be at higher weight percentiles for age and sex (P =.08) regardless of group (CF or control).

CONCLUSIONS

Children with CF and their parents do not differ from children without CF and their parents in the rate of behaviors exhibited or types of strategies used to encourage eating. However, children with CF and their parents engage in these behaviors more frequently. Our data do not support typical parenting behaviors as effective in meeting the CF dietary requirements. Additional support in the form of child behavior management training may be needed to assist parents in meeting their child's caloric requirements.

Perceived compliance with AZT dosing among a sample of African-American drug users

The purpose of this report was to present findings from a pilot study conducted to explore the associations between sociodemographic, drug use, and health belief factors and perceived compliance with zidovudine (AZT) among African-American drug users. Data were collected in Washington, DC, USA from individuals who were African-American; were recent or current drug injectors or crack smokers; were HIV-seropositive, and were receiving treatment for HIV infection. Participants were recruited through local organizations that provide services to HIV-infected persons. Participants were interviewed using a questionnaire that solicited sociodemographic, lifetime and current drug use, current sexual behaviours, health status, HIV and drug treatment history, and health belief data. Analyses were limited to individuals currently using an illicit substance and who had received AZT during their medical treatment. Parametric (Pearson's r) and nonparametric (Spearman's rho) statistics were used to assess correlations between perceived compliance with AZT dosing and independent variables. As the study was intended to be both descriptive and exploratory, the level of statistical significance was set at 0.10, rather than the customary 0.05. Antiretroviral medications recognized and recalled by participants are presented. The most commonly recalled medication was AZT. Slightly less than one-third of participants reported being completely compliant with an AZT regimen. Perceived compliance was found to be negatively associated with 5 variables: age, homelessness, number of injections in the previous 30 days, trading sex for drugs, and the perception that AIDS is no longer a serious disease since the development of new antiretroviral medications. Intensity of feelings of joy, fear, and the belief that taking more anti-HIV medications would result in better health were found to be positively correlated. Bivariate associations between perceived compliance and sociodemographic, drug use, sexual behaviour, and health belief variables suggest further avenues of study and potential points for intervention to increase compliance with antiretroviral medications among racial/ethnic minority drug users receiving treatment for HIV infection.

The persistence of mood disorders following traumatic brain injury: a 1 year follow-up

The study investigated whether the frequency of mood disorders following traumatic brain injury (TBI) increased with time. Consecutive hospital admissions completed the Wimbledon Self-Report Scale at 6 and 12 months post-injury. Scores in the 'borderline/case' range were deemed clinically significant. Seventy-seven of those assessed at 6 months completed the 12 month follow-up. Those lost to follow-up (22) were not more likely to have been classified 'borderline/case' at 6 months. They were more likely to have been 'unoccupied' pre-injury (p=0.002). The frequency of clinically significant disorders did not change significantly, being 39% at 6 months and 35% 1 year post-injury. The majority of subjects (58) maintained the same clinical classification at both assessments. Eight of the 47 (17%) classified 'normal' at 6 months changed to 'borderline/case' at 12 months. However, 11 of the 30 (37%) classified 'borderline/case' at 6 months were 'normal' at 12 months. The direction of change was not statistically significant (p=0.5). These findings are consistent with previous research. However, the present study examined a larger sample and included a wider range of injury severity, thereby increasing the generalizability of the findings. Also, a broader spectrum of mood disorders was investigated which adds to previous work specifically on depression.

Myeloid- and lymphoid-specific breakpoint cluster regions in chromosome band 13q14 in acute leukemia

Abnormalities of chromosome band 13q14 occur in hematologic malignancies of all lineages and at all stages of differentiation. Unlike other chromosomal translocations, which are usually specific for a given lineage, the chromosomal translocation t(12;13)(p12;q14) has been observed in both B-cell and T-cell precursor acute lymphoblastic leukemia (BCP-, TCP-ALL), in differentiated and undifferentiated acute myeloblastic leukemia (AML), and in chronic myeloid leukemia (CML) at progression to blast crisis. The nature of these translocations and their pathologic consequences remain unknown. To begin to define the gene(s) involved on chromosome 13, we have performed fluorescence in situ hybridization (FISH) using a panel of YACs from the region, on a series of 10 cases of acute leukemia with t(12;13)(p12;q14) and 1 case each with "variant" translocations including t(12;13)(q21;q14), t(10;13)(q24;q14) and t(9;13)(p21;q14). In 8/13 cases/cell lines, the 13q14 break fell within a single 1.4 Mb CEPH MegaYAC. This YAC fell immediately telomeric of the forkhead (FKHR) gene, which is disrupted in the t(2;13)(q35;q14) seen in pediatric alveolar rhabdomyosarcoma. Seven of the 8 cases with breaks in this YAC were AML. In 4/13 cases, the 13q14 break fell within a 1.7-Mb YAC located about 3 Mb telomeric of the retinoblastoma (RB1) gene: all 4 cases were ALL. One case of myelodysplastic syndrome exhibited a break within 13q12, adjacent to the BRCA2 gene. These data indicate the presence of myeloid- and lymphoid-specific breakpoint cluster regions within chromosome band 13q14 in acute leukemia.