'A good decision is the one that feels right for me': Codesign with patients to inform theoretical underpinning of a decision aid website

INTRODUCTION

Patient decision aids (PtDA) complement shared decision-making with healthcare professionals and improve decision quality. However, PtDA often lack theoretical underpinning. We are codesigning a PtDA to help people with increased genetic cancer risks manage choices. The aim of an innovative workshop described here was to engage with the people who will use the PtDA regarding the theoretical underpinning and logic model outlining our hypothesis of how the PtDA would lead to more informed decision-making.

METHODS

Short presentations about psychological and behavioural theories by an expert were interspersed with facilitated, small-group discussions led by patients. Patients were asked what is important to them when they make health decisions, what theoretical constructs are most meaningful and how this should be applied to codesign of a PtDA. An artist created a visual summary. Notes from patient discussions and the artwork were analysed using reflexive thematic analysis.

RESULTS

The overarching theme was: It's personal. Contextual factors important for decision-making were varied and changed over time. There was no one 'best fit' theory to target support needs in a PtDA, suggesting an inductive, flexible framework approach to programme theory would be most effective. The PtDA logic model was revised based on patient feedback.

CONCLUSION

Meaningful codesign of PtDA including discussions about the theoretical mechanisms through which they support decision-making has the potential to lead to improved patient care through understanding the intricately personal nature of health decisions, and tailoring content and format for holistic care.

PATIENT CONTRIBUTION

Patients with lived experience were involved in codesign and coproduction of this workshop and analysis as partners and coauthors. Patient discussions were the primary data source. Facilitators provided a semi-structured guide, but they did not influence the patient discussions or provide clinical advice. The premise of this workshop was to prioritise the importance of patient lived experience: to listen, learn, then reflect together to understand and propose ideas to improve patient care through codesign of a PtDA.

Overactivation of the middle cingulate cortex and the caudate nucleus as neural correlates of the familial liability to major depressiive disorder

Introduction

Unaffected healthy 1st degree relatives of patients with major depressive disorder (MDD) are 3.6 times more liable to develop the disease themselves than the standard population without the history of the disorder. Neural correlates of this liability are of particular interest since the phenomenon does not always have behavioral manifestations and early detected can enhance quicker and better MDD prevention.

Objective

The objective of our study was to establish neuronal correlates of susceptibility MDD in unaffected healthy 1st degree relatives of patients with MDD. Inhibition of emotional information was examined in the present study.

Aims

The aim of the study was to better understand the development of MDD and the role of altered inhibition of emotional processing in it. That, in consequence, may contribute to establishing new methods of prevention and quicker detection of MDD liability.

Methods

Twenty-one unaffected healthy 1st degree relatives of patients with MDD and twenty-five matched healthy controls underwent a functional magnetic resonance imaging procedure with a task involving inhibition of emotional processing of positive, negative and neutral emotional information. 2 × 3 ANOVA was performed to establish if the two groups differed significantly in the inhibition of one of the three types of emotions.

Results

The unaffected healthy 1st degree relatives displayed an increased neural activation during the inhibition of negative emotional information in the bilateral middle cingulate cortex (MCC) and the left caudate nucleus (p< 0.05, family wise error).

Conclusions

The overactivation of the MCC and caudate nucleus can be a marker of MDD liability

Screening for asymptomatic urogenital Chlamydia trachomatis infection at a large Dublin maternity hospital: results of a pilot study

BACKGROUND

There are currently no Irish guidelines on screening for Chlamydia trachomatis infection in pregnancy. Prevalence rates in the antenatal population are not known which has prevented the development of screening recommendations for this group.

AIMS

The objective of this study was to determine the prevalence of asymptomatic urogenital C. trachomatis infection in young women attending for care at a large maternity hospital.

METHODS

All patients aged 25 years and under attending the Hospital between December 2011 and December 2013 were offered screening for urogenital C. trachomatis infection. Nucleic acid amplification testing of the C. trachomatis cryptic plasmid was performed on either endocervical swabs or first void urine samples.

RESULTS

There were 2687 women tested for C. trachomatis infection, 83.4 % (2241/2687) through the antenatal clinics, 7.1 % (193/2687) through the gynaecology clinic, and 9.4 % (253/2687) through the emergency department. The rate of a positive test result was 5.6 % (151/2687) overall. The rates in women ages 16-18, 19-21 and 22-25 years were 9.1 % (31/340), 6.5 % (50/774) and 4.4 % (69/1561), respectively. A positive test result was more likely in those who were unemployed (p = 0.04), those who were Irish (p = 0.03) and those who were unmarried (p < 0.01). There were no cases of neonatal C. trachomatis infection in babies born to mothers who were screened in early pregnancy.

CONCLUSIONS

The prevalence rate of detected C. trachomatis infection was 5.6 % in the study population. Screening of antenatal patients may have a role in preventing vertical transmission of infection to the neonate.

Fertility after abdominal myomectomy

This study aimed to evaluate the morbidity and pregnancy outcome of myomectomy in infertile women with uterine fibroids. This was a cross-sectional study. Records were reviewed for 100 consecutive women in the Rotunda Hospital who underwent myomectomy in the years 1995-1996. A questionnaire regarding subsequent fertility was sent. The study was carried out in the infertility unit at the Rotunda Hospital, Dublin, Ireland. Seventy-five women responded. Multiple myomectomy was performed in 52 (70%). Mean fibroid size was 6.8 cm (range 2-14.5 cm). Nine women (12%) developed complications; five had menstrual problems, two had wound discomfort and two had abdominal discomfort. Twenty-five women (33%) became pregnant. Seven (28%) were IVF pregnancies. Overall six (24%) miscarried. In 19 of 25, pregnancy occurred where fibroids were the only identifiable cause of infertility. We conclude that abdominal myomectomy is associated with a favourable outcome in infertile women particularly if no other confounding variable is present.

Reductions in tobacco smoke pollution and increases in support for smoke-free public places following the implementation of comprehensive smoke-free workplace legislation in the Republic of Ireland: findings from the ITC Ireland/UK Survey

OBJECTIVE

To evaluate the psychosocial and behavioural impact of the first ever national level comprehensive workplace smoke-free law, implemented in Ireland in March 2004.

DESIGN

Quasi-experimental prospective cohort survey: parallel cohort telephone surveys of national representative samples of adult smokers in Ireland (n = 769) and the UK (n = 416), surveyed before the law (December 2003 to January 2004) and 8-9 months after the law (December 2004 to January 2005).

MAIN OUTCOME MEASURES

Respondents' reports of smoking in key public venues, support for total bans in those key venues, and behavioural changes due to the law.

RESULTS

The Irish law led to dramatic declines in reported smoking in all venues, including workplaces (62% to 14%), restaurants (85% to 3%), and bars/pubs (98% to 5%). Support for total bans among Irish smokers increased in all venues, including workplaces (43% to 67%), restaurants (45% to 77%), and bars/pubs (13% to 46%). Overall, 83% of Irish smokers reported that the smoke-free law was a "good" or "very good" thing. The proportion of Irish homes with smoking bans also increased. Approximately 46% of Irish smokers reported that the law had made them more likely to quit. Among Irish smokers who had quit at post-legislation, 80% reported that the law had helped them quit and 88% reported that the law helped them stay quit.

CONCLUSION

The Ireland smoke-free law stands as a positive example of how a population-level policy intervention can achieve its public health goals while achieving a high level of acceptance among smokers. These findings support initiatives in many countries toward implementing smoke-free legislation, particularly those who have ratified the Framework Convention on Tobacco Control, which calls for legislation to reduce tobacco smoke pollution.

Stage- and CA125-related survival in patients with epithelial ovarian cancer treated at a cancer center

Current accepted prognostic indicators in ovarian cancer include performance status, surgical (FIGO) staging, and residual disease after operation. Here we present data from a prospective analysis of patients with ovarian cancer treated at the Christie Hospital. We confirm the independent prognostic effects of FIGO staging, performance status, and residual disease in our group of patients and furthermore show that CA125 levels at presentation to the oncology service are of independent prognostic significance (P= 0.02). We present survival data and show that the 3-year, cancer-specific survival for stage I disease is 90%. We postulate that this good survival may in part be due to the use of computed tomography scanning at presentation to allow accurate staging. Further clinical trials are needed to test whether combinations of surgical, histologic, biochemical, and radiologic parameters can be used to identify a population with such a good prognosis that adjuvant therapy is not required.

Stage- and CA125–related survival in patients with epithelial ovarian cancer treated at a cancer center

Current accepted prognostic indicators in ovarian cancer include performance status, surgical (FIGO) staging, and residual disease after operation. Here we present data from a prospective analysis of patients with ovarian cancer treated at the Christie Hospital. We confirm the independent prognostic effects of FIGO staging, performance status, and residual disease in our group of patients and furthermore show that CA125 levels at presentation to the oncology service are of independent prognostic significance (P= 0.02). We present survival data and show that the 3-year, cancer-specific survival for stage I disease is 90%. We postulate that this good survival may in part be due to the use of computed tomography scanning at presentation to allow accurate staging. Further clinical trials are needed to test whether combinations of surgical, histologic, biochemical, and radiologic parameters can be used to identify a population with such a good prognosis that adjuvant therapy is not required.

Birth-weight trends in primiparous women in the twentieth century

We investigated the trend in birth-weights in the Rotunda hospital in primiparous women over the 20th century. There was a significant increase in birth-weight particularly in the latter third of the century. In light of these findings we believe that new approaches to the management of labour in primiparous mothers be developed.

The caesarean section rate in the Republic of Ireland in 1998

The Caesarean section (CS) rate has risen dramatically in the United Kingdom and North America over the past 20 years. There are no recent data in the Republic of Ireland on CS rates. Our aim was to ascertain the national CS rate for the year 1998. In addition, we sought to determine instrumental delivery rates and epidural rates. Twenty-two of 24 units replied to a questionnaire giving a response rate of 92%. The CS rate was 17.8% (12.8-26.7%), 7.5% were elective and 10.3% were emergency. The size or type of the maternity unit did not influence the CS rate. The cause for the rise in the CS rate is multifactorial. Review of the current literature would suggest that a further rise in the CS rate in Ireland is likely.

The case for fire safe cigarettes made through industry documents

OBJECTIVES

To examine the extensive research undertaken by the tobacco industry over the past 25 years toward development of a fire safe cigarette.

METHODS

Research was conducted through a web based search of internal tobacco industry documents made publicly available through the 1998 Master Settlement Agreement.

RESULTS

The documents reveal that the tobacco industry produced a fire safe cigarette years ago, but failed to put it on the market. These findings contradict public industry claims that denied the technical feasibility and commercial acceptability of fire safe cigarettes. Internal documents also reveal a decades long, coordinated political strategy used to block proposed legislation and obfuscate the fire safe issue.

CONCLUSIONS

Federal legislation mandating fire safe cigarettes is needed.

Inspiratory flow limitation during sleep in pre-eclampsia: comparison with normal pregnant and nonpregnant women

Self-reported snoring is common in pregnancy, particularly in females with pre-eclampsia. The prevalence of inspiratory flow limitation during sleep in preeclamptic females was objectively assessed and compared with normal pregnant and nonpregnant females. Fifteen females with pre-eclampsia were compared to 15 females from each of the three trimesters of pregnancy, as well as to 15 matched nonpregnant control females (total study population, 75 subjects). All subjects had overnight monitoring of respiration, oxygen saturation, and blood pressure (BP). No group had evidence of a clinically significant sleep apnoea syndrome, but patients with pre-eclampsia spent substantially more time (31+/-8.4% of sleep period time, mean+/-SD) with evidence of inspiratory flow limitation compared to 15.5+/-2.3% in third trimester subjects and <5% in the other three groups (p=0.001). In the majority of preeclamptics, the pattern of flow limitation was of prolonged episodes lasting several minutes without associated oxygen desaturation. As expected, systolic and diastolic BPs were significantly higher in the pre-eclamptic group (p<0.001), but all groups showed a significant fall (p< or =0.05) in BP during sleep. Inspiratory flow limitation is common during sleep in patients with pre-eclampsia, which may have implications for the pathophysiology and treatment of this disorder.

The HELLP syndrome, a prospective study

OBJECTIVE

We undertook this study to evaluate the incidence and outcome of HELLP in Irish patients. In addition, duration and trends of the abnormal laboratory results were studied.

STUDY DESIGN

This prospective observational study screened 12068 pregnant women between January 1995 and March 1997. Any pregnant woman with hypertension, proteinuria, thrombocytopenia or anemia was monitored for hemolysis and elevated liver transaminases, from the time of recruitment till six weeks postpartum or resolution.

RESULTS

Thirteen of 12068 pregnant women (0.11%) developed HELLP. All had hypertension and 84.6% had proteinuria. Delivery was the only factor found to terminate the syndrome. Acute renal dysfunction was noted in 53.8% but none required dialysis. Laboratory parameters stabilized by the sixth postpartum day. Fetal mortality was 1 out of 14. There were no maternal deaths.

CONCLUSIONS

HELLP syndrome is a rare but potentially serious complication of pregnancy. Correlation with laboratory data and early intervention are vital in achieving a favorable outcome for both mother and fetus.

A five year review of scar dehiscence in the Rotunda Hospital, Dublin

The aims of this study were to identify risk factors for scar dehiscence in labour, to illustrate the clinical presentations of patients with scar dehiscence and to quantify the risk posed by the use of oxytocin in labour. This was a case controlled, 5 year retrospective study. Patients with scar dehiscence were identified from labour ward records with matched controls and chart review of case and control patients were performed. Our results showed that the vaginal delivery rate for trial of scar was 76.9%. The incidence of scar dehiscence was 0.043%. Oxytocic labour augmentation was a risk factor (OR 4.5, 95% CI 0.9313-42.8, p=0.065) but induction of labour using oxytocin was not (p=0.222). The commonest symptom of scar dehiscence was fetal distress (OR 12.3, 95% CI 1.9-81). There was no maternal or fetal mortality. We concluded that trial of labour after one caesarean section is acceptable practice with a good success rate and a low incidence of serious morbidity. The use of oxytocin to augment labour is associated with scar dehiscence.

Attitude to home birth in an antenatal population at the Rotunda Hospital

195 Women attending the antenatal clinics at the hospital were interviewed, about their attitudes to home birth using a standardised questionnaire. One hundred and seventy one women (88%) said that they would not favour a home birth in a subsequent delivery, 19 (9.5%) said that they would consider a home birth in a subsequent pregnancy and the remaining 5 (2.5%) were unsure. Although the majority of women attending the Rotunda Hospital would not consider a home birth, approximately 10% of the sample population would consider this in their next pregnancy. This pilot study indicates that there may be a demand for home birth in patients attending our hospital and further evaluation of this need is warranted.

The effect of strength training on the apparent inhibition of eccentric force production in voluntarily activated human quadriceps

Ten male and ten female young adults trained the knee extensors of one leg eccentrically and those of the other concentrically for 6 weeks, using a gymnasium leg-extension machine. Before and after training, both legs of each subject were tested isometrically for maximum voluntary knee-extensor force, and in both eccentric and concentric isokinetic modes at 30-250 degrees x s(-1) All limbs showed improvements in mean eccentric force (ranging from 18% in the concentrically trained legs of the females to 31% in the eccentrically trained legs of the males, P < 0.01-0.001). Upward trends in isometric and concentric forces were smaller and less- or nonsignificant. In three of the four groups, mean eccentric forces after training were significantly greater than mean isometric forces, a difference that was not evident before training. Ten further subjects of each gender, not trained but tested isometrically and isokinetically three times in 2 weeks, showed no significant improvement over the series of tests. The explanation suggested is that the increased percentage activation ("decreased inhibition"), often regarded as the main mechanism of strength gain in the early weeks of training, had been displayed particularly in the subjects' eccentric performance. This implies that the activation-shortfall, which is reduced by the initial phase of strength training, is largely or completely the same as that responsible for the fact that untrained, voluntary eccentric force is less than that of isolated muscle.

Pregnancy in Irish renal transplant recipients in the cyclosporine era

BACKGROUND

The effect of renal transplantation on pregnancy in Irish women not receiving CyA has been reported previously.

AIM

To examine all pregnancies occurring in Irish female renal transplant recipients since the introduction of CyA.

METHODS

Using a community based approach, we identified 29 pregnancies in 19 women, aged between 16 and 45, mean age 30.3 years.

RESULTS

These pregnancies ended in four miscarriages (13%), two intra-uterine deaths (6.9%) and 23 live births (79.3%). Of these live births, 73.9% were premature (< or = 36 weeks) and 65.2% were of low birth weight (< 2500 g). Admission to the neonatal intensive care was necessary in 61%, and two babies (8.7%) died in the neonatal period. Mean gestational age was 34 weeks, and mean birth weight was 2190 g. There was no change in graft function during pregnancy, with a small rise in serum creatinine post-partum (+9.64 mumol/L). The renal graft failed in three women (15.8%) by the end of the follow-up period. Compared with the precyclosporine era, the live birth rate was higher (79.3% versus 58%) with a trend towards lower birth weight and shorter gestation.

CONCLUSION

Renal transplantation with CyA use is not a contraindication to pregnancy, but it is associated with increased risk, especially when the serum creatinine is > 175 mumol/L.

Designing an effective statewide tobacco control program--Massachusetts

Smoking-related illnesses kill > 10,000 Massachusetts residents each year and cost hundreds of millions of dollars of public and private expenditures for health care. To combat this public health problem, in 1992 Massachusetts voters approved a referendum question calling for an increased excise tax on tobacco products, with the revenue supporting a Health Protection Fund. Approximately 40% of the fund is used to finance the Massachusetts Tobacco Control Program (MTCP), administered by the Massachusetts Department of Public Health. During the first 3 fiscal years (FY), the MTCP budget has averaged just over $40 million annually, declining during that period from approximately $43 million in FY 1995 to < $37 million in FY 1997.

Teenage pregnancy in the Rotunda Hospital

The primary aim of this study was to investigate obstetric outcomes in teenagers delivered in the Rotunda Hospital and to identify whether younger teenagers have a poorer obstetric outcome. Delivery record details were recorded from the years 1992-96. These included the number of teenage mothers, maternal age, parity, gestation, mode of delivery, birth weight and Apgar scores. Teenagers were classified into those aged under 17 years and those aged 17 and over. Overall 2,228 teenage mothers were delivered in the Rotunda hospital, representing 17.2% of the total teenage population delivered in Ireland during the study period. Ten percent of mothers were under 17 years; 10.6% were multiparous with 2.6% of these under 17 years. There was a significant difference in the preterm delivery rate when the teenagers were compared as a whole with matched controls aged 20-24 years (p = 0.0411). However this did not translate into a poorer neonatal outcome as on average only 5% of babies were low birth weight and only 3% had Apgar scores < 3. Overall 70.2% of deliveries were spontaneous, 20.2% were instrumental. Less than 10% of deliveries were by caesarean section. However the rate of caesarean section increased with age from 14 (5.7%) to 19 (13.5%) years and this trend was statistically significant (p = 0.013). In conclusion, this study does not support the view that younger teenage mothers have a poorer obstetric and neonatal outcome. It has also been shown that there has been a large increase in the number of multiparous patients in this teenage population.

The association between parental smoking and the diet quality of low-income children

OBJECTIVE

To assess the association between parental smoking and the diet quality of children residing in low-income housholds in the United States. MTHODS: Data from 515 low-income children (less than or equal to 185% of the poverty line), ages 2 to 17, who participated in the 1989 and 1990 United States Department of Agriculture Continuing Survey of Food Intakes of Individuals were examined. Diet quality was assessed by examining the average daily amount of nutrients consumed per 1000 kcal for protein, fiber, and 14 essential vitamins and minerals as well as total energy, percent of energy from total fat and saturated fat, and cholesterol and sodium intakes using the 3-day average of one 24-hour recall and 2 days of diet records. Parental smoking was categorized as four levels (nonsmoker; 1 to 10, 11 to 20, and more than 20) on the basis of the average number of cigarettes smoked per day by the sample child's parents. Analysis of covariance examined differences in the children's nutrient intake among the four smoking categories while controling for race, mother's age and occupation, child age, and sex.

RESULTS

Low-income children with parents who smoked (n = 235) were more likely to be white (P <.001), had younger mothers (P <.05) and were more likely to have mothers employed in blue-collar occupations (P <.001) than children whose parents were nonsmokers (N = 280). Children whose parents smoked more than 20 cigarettes per day had a higher level of energy from saturated fat, and children whose parents smoked 11 to 20 cigarettes per day had the highest cholesterol intakes in comparison with the rest of the sample. Parental smoking was also related to total fiber intake per 1000 kcal, with children of smokers having lower fiber intakes than children of nonsmokers.

CONCLUSIONS

On average, low-income children of smokers had a poorer diet quality than low-income children of nonsmokers, thus increasing their future risk of chronic disease.

Gynaecological audit in a general hospital setting

In contrast to the long tradition of audit in Obstetrics in Dublin audit in Gynaecology is a new concept. Analysis of data collected during the years 1991-1993 is presented. This has addressed the number and type of patients seen in the Gynaecology Unit, procedures performed and complications ensuing. The figures presented are similar to Gynaecology Units in Britain. Deficiencies, such as auditing for outpatient and inpatient waiting lists have been highlighted. These issues are currently being addressed.

A longitudinal study of New Zealand children's experience with alcohol

A longitudinal study assessed the use of alcohol and related measures among New Zealand children aged 9, 11, 13 and 15 years. The proportion of children who were abstainers was at a similar level to the adult population by age 15 years. Those remaining abstainers were more likely to have infrequently drinking parents and to have been warned of the bad effects of alcohol by their parents. In terms of amount consumed and frequency of drinking, there was an increase with age and a marked increase between the ages of 13 and 15 years. Frequency of drinking was positively associated with the frequency of drinking by the mother and father. Girls drank less than boys until the age of 15 years, when they drank slightly more and a difference in terms of socio-economic status (SES) emerged at age 15 years with lower SES groups drinking more.

Derivatives of dicyclopentadiene in ground water

Dicyclopentadiene, a waste product of manufacturing at the Rocky Mountain Arsenal near Denver Colorado, has been detected in ground water at this facility. Ground water extracts were analysed by gas chromatography-mass spectrometry (GC/MS) to determine if derivatives of dicyclopentadiene were present in addition to dicyclopentadiene and other chemical wastes. The derivatives thus identified were characterized by GC high resolution MS, deuterium exchange for active hydrogen in the chemical ionization source of the mass spectrometer, and GC/MS following on-column base catalyzed deuteration of enolizable hydrogen. Two ketone derivatives of dicyclopentadiene were identified by comparison with synthetic standards. Ground water derivatives of dicyclopentadiene were compared with mammalian enzymatic metabolites produced in vitro by incubation with immobilized rabbit liver cytochromes P-450. The metabolites were analysed by GC/MS and by GC/MS following derivatization and deuterium labelling. Although not found in ground water samples, the two metabolites were identified as monoepoxides of dicyclopentadiene by comparison with compounds synthesized in the laboratory.

The reversibility of leukoplakia caused by smokeless tobacco

This case describes an instance of reversibility of bilateral mucosal leukoplakic lesions caused by the long-term use of smokeless tobacco. The dentist should recognize the lesion, advise the patient to stop the tobacco usage, observe the reversibility of the lesion, and assist the patient in stopping the tobacco habit permanently.

Biological effects of the Sudan dyes. Role of the Ah cytosolic receptor

The hepatic induction of two cytochrome P1-450-mediated activities [aryl hydrocarbon hydroxylase (AHH) and ethoxyresorufin O-deethylase (ETR)] was studied following the administration of the azo dyes Sudan I, II, III, and IV. When using Ah-responsive C57BL/6J mice, Sudan dye II proved to be quite potent as an inducer causing almost maximal induction at doses as low as 40 mg/kg (1.4 mumoles/kg body weight); Sudan dyes I, III and IV caused one-half the maximal induction at four times that dose. In contrast, none of these compounds caused induction of AHH or ETR in the Ah-nonresponsive DBA/2J animals. When the dyes were given to B6D2F1 X D2 backcross progeny, a strict correlation with the presence of the Ahb allele and the inducibility of AHH and ETR was observed. When these compounds were examined as agonists for the Ah cytosolic receptor by their capacity to replace [3H]2,3,7,8-tetrachlorodibenzo-p-dioxin binding, Sudan dye II was substantially more effective than Sudan dyes I, III and IV. When four repeated doses of Sudan dye II were administered intraperitoneally to Ah-responsive C57BL/6J mice and Ah-nonresponsive DBA/2J mice, Sudan dye II-induced immunotoxicity was markedly greater in C57BL/6J compared to DBA/2J mice.