Perceived opportunities and challenges of family and community members in supporting teen mothers in rural Eastern Uganda

There is tremendous need for feasible and acceptable community-based interventions to address poor nutrition and health among teen mothers in rural Eastern Uganda. To inform such interventions, we identified facilitators/opportunities and challenges for maternal/child nutrition and health at community level, as perceived by those closest to the problem. In-depth interviews were conducted among 101 teens, family and community members in Budondo sub-county using questions based on social cognitive theory constructs related to nutrition/health. Data were analyzed thematically using Atlas-ti7.5.4. Facilitators included family support for positive teen decision-making regarding healthcare and practices and opportunities included income generation training and availability of healthcare services. Challenges included poor attitude of parents towards community workers, harsh treatment, inability to obtain income generation materials, insufficient land, food or medical supplies and medical understaffing. To exploit opportunities for improved maternal/child health and progress towards global sustainable development goals, this study points to needs for local action.

Cross-sectional study of the prevalence, causes and management of hospital-onset diarrhoea

BACKGROUND

The National Health Service in England advises hospitals collect data on hospital-onset diarrhoea (HOD). Contemporaneous data on HOD are lacking.

AIM

To investigate prevalence, aetiology and management of HOD on medical, surgical and elderly-care wards.

METHODS

A cross-sectional study in a volunteer sample of UK hospitals, which collected data on one winter and one summer day in 2016. Patients admitted ≥72 h were screened for HOD (definition: ≥2 episodes of Bristol Stool Type 5-7 the day before the study, with diarrhoea onset >48 h after admission). Data on HOD aetiology and management were collected prospectively.

FINDINGS

Data were collected on 141 wards in 32 hospitals (16 acute, 16 teaching). Point-prevalence of HOD was 4.5% (230/5142 patients; 95% confidence interval (CI) 3.9-5.0%). Teaching hospital HOD prevalence (5.9%, 95% CI 5.1-6.9%) was twice that of acute hospitals (2.8%, 95% CI 2.1-3.5%; odds ratio 2.2, 95% CI 1.7-3.0). At least one potential cause was identified in 222/230 patients (97%): 107 (47%) had a relevant underlying condition, 125 (54%) were taking antimicrobials, and 195 (85%) other medication known to cause diarrhoea. Nine of 75 tested patients were Clostridium difficile toxin positive (4%). Eighty (35%) patients had a documented medical assessment of diarrhoea. Documentation of HOD in medical notes correlated with testing for C. difficile (78% of those tested vs 38% not tested, P<0.001). One-hundred and forty-four (63%) patients were not isolated following diarrhoea onset.

CONCLUSION

HOD is a prevalent symptom affecting thousands of patients across the UK health system each day. Most patients had multiple potential causes of HOD, mainly iatrogenic, but only a third had medical assessment. Most were not tested for C. difficile and were not isolated.

Needs and Barriers of Teen Mothers in Rural Eastern Uganda: Stakeholders' Perceptions Regarding Maternal/Child Nutrition and Health

For adolescent mothers in rural Eastern Uganda, nutrition and health may be compromised by many factors. Identifying individual and environmental needs and barriers at local levels is important to inform community-based interventions. This qualitative study used interviews based on constructs from social cognitive theory. 101 adolescent mothers, family members, health-related personnel and community workers in Budondo sub-county (Jinja district), eastern Uganda were interviewed. Young mothers had needs, related to going back to school, home-based small businesses; social needs, care support and belonging to their families, employment, shelter, clothing, personal land and animals, medical care and delivery materials. Barriers to meeting their needs included: lack of skills in income generation and food preparation, harsh treatment, pregnancy and childcare costs, lack of academic qualifications, lack of adequate shelter and land, lack of foods to make complementary feeds for infants, insufficient access to medicines, tailored health care and appropriate communications. Using the social cognitive framework, this study identified myriad needs of young mothers and barriers to improving maternal/child nutrition and health. Adolescent-mother-and-child-friendly environments are needed at local levels while continuing to reduce broader socio-cultural and economic barriers to health equity. Findings may help direct future interventions for improved adolescent maternal/child nutrition and health.

Evaluation of a vaccine passport to improve vaccine coverage in people living with HIV

An increased risk of vaccine-preventable infections (VPIs) is seen in people living with HIV (PLWH), and current vaccine coverage and immunity is variable. Vaccine passports have the potential to improve vaccine coverage. The objective was to assess how successful a vaccine passport was in improving vaccine coverage in PLWH. Baseline immunity to VPIs was established in PLWH attending a single HIV clinic and vaccinations required were determined based on the BHIVA Vaccination Guidelines (2015). The passport was completed and the PLWH informed about additional vaccines they should obtain from primary care. After 6-9 months the passport was reviewed including confirmation if vaccines were given. PLWH satisfaction with the system was evaluated by a survey. Seventy-three PLWH provided sufficient data for analysis. At baseline significant proportions of PLWH were not immune/unvaccinated to the main VPIs, especially human papillomavirus, pneumococcus and measles. After the passport was applied immunity improved significantly (56% overall, p < 0.01) for most VPIs; however, full coverage was not achieved. The system was popular with PLWH. The passport was successful in increasing vaccination coverage although full or near-full coverage was not achieved. A more successful service would probably be achieved by commissioning English HIV clinics to provide all vaccines.

Do Women Have a Choice? Care Providers' and Decision Makers' Perspectives on Barriers to Access of Health Services for Birth after a Previous Cesarean

BACKGROUND

Repeat cesarean delivery is the single largest contributor to the escalating cesarean rate worldwide. Approximately 80 percent of women with a past cesarean are candidates for vaginal birth after a cesarean (VBAC), but in Canada less than one-third plan VBAC. Emerging evidence suggests that these trends may be due in part to nonclinical factors, including care provider practice patterns and delays in access to surgical and anesthesia services. This study sought to explore maternity care providers' and decision makers' attitudes toward and experiences with providing and planning services for women with a previous cesarean.

METHODS

In-depth, semi-structured interviews were conducted with family physicians, midwives, obstetricians, nurses, anesthetists, and health service decision makers recruited from three rural and two urban Canadian communities. Constructivist grounded theory informed iterative data collection and analysis.

RESULTS

Analysis of interviews (n = 35) revealed that the factors influencing decisions resulted from interactions between the clinical, organizational, and policy levels of the health care system. Physicians acted as information providers of clinical risks and benefits, with limited discussion of patient preferences. Decision makers serving large hospitals revealed concerns related to liability and patient safety. These stemmed from competing access to surgical resources.

CONCLUSIONS

To facilitate women's increased access to planned VBAC, it is necessary to address the barriers perceived by care providers and decision makers. Strategies to mitigate concerns include initiating decision support immediately after the primary cesarean, addressing the social risks that influence women's preferences, and managing perceptions of patient and litigation risks through shared decision making.

Process Evaluation in the Community Intervention Trial for Smoking Cessation (COMMIT)

The reach and complexity of the multi-site Community Intervention Trial for Smoking Cessation (COMMIT) project call for an extensive, comprehensive evaluation plan. This article reports on the objectives, methods, and data sets of the part of the plan designed for process evaluation. We describe the systems developed for: monitoring progress in the sites, the quality of local intervention activities and data collection, and compliance with the trial-wide protocol; disseminating information for formative purposes; and generating and using process data for outcome evaluation. The process evaluation approach includes both quantitative and qualitative methods. We provide examples from community mobilization and intervention in different communities.

Promoting Smoking Control through Worksites in the Community Intervention Trial for Smoking Cessation (COMMIT)

This article describes the worksite intervention and assessment aspects of the COMMIT project. Following a brief review of the rationale for worksite smoking control efforts and how planning for such activities can be conducted as part of community-based interventions, we describe the COMMIT worksite protocol. All intervention communities conduct specified activities in the areas of smoking policy, motivational and incentive procedures to encourage smoking cessation, and provision of self-help materials and cessation services for employees. Assessment procedures include a computerized process objectives system, surveys of worksites in each of the 22 COMMIT communities, and work related questions on surveys of community residents. Baseline data that have informed the process objectives for the worksite channel are presented, as are examples of how intervention activities have been tailored to different communities.

Seeking control in the midst of uncertainty: Women's experiences of choosing mode of birth after caesarean

PROBLEM

Clinical practice guidelines indicate that over 80% of women with a previous caesarean should be offered a planned vaginal birth after caesarean (VBAC), however only one third of eligible women choose to plan a VBAC. To support informed choices for birth after caesarean, it is necessary to understand the factors that influence women's decision-making.

AIM

The goal of this study was to explore attitudes towards and experiences with decision-making for mode of delivery after caesarean from the perspectives of Canadian women.

METHODS

In-depth, semi-structured interviews were conducted with 23 women eligible for VBAC in three rural and two urban communities in British Columbia, Canada, during summer 2015. Constructivist grounded theory informed iterative data collection and analysis.

FINDINGS

Women's decision-making experiences were a process of "seeking control in the midst of uncertainty." Women formed early preferences for mode of delivery after their primary caesareans and engaged in careful deliberation during their inter-pregnancy interval, consisting of: reflecting on their birth, clarifying their values, becoming informed, considering the feasibility of options, deliberating with the care team, and making an actual choice. Women struggled to make trade-offs between having a healthy baby and social attributes of delivery, such as uninterrupted bonding with their newborn.

CONCLUSIONS

Women begin decision-making for birth after caesarean earlier than previously reported and their choices are influenced by personal experience and psychosocial concerns. Future interventions to support choice of mode of delivery should begin early after the primary caesarean, to reflect when women begin to form preferences.

Where's the pump? Associating sporadic enteric disease with drinking water using a geographic information system, in British Columbia, Canada, 1996-2005

We investigated whether risk of sporadic enteric disease differs by drinking water source and type using surveillance data and a geographic information system. We performed a cross-sectional analysis, at the individual level, that compared reported cases of enteric disease with drinking water source (surface or ground water) and type (municipal or private). We mapped 814 cases of campylobacteriosis, cryptosporidiosis, giardiasis, salmonellosis and verotoxigenic Escherichia coli infection, in a region of British Columbia, Canada, from 1996 to 2005, and determined the water source and type for each case's residence. Over the 10-year period, the risk of disease was 5.2 times higher for individuals living on land parcels serviced by private wells and 2.3 times higher for individuals living on land parcels serviced by the municipal surface/ground water mixed system, than the municipal ground water system. Rates of sporadic enteric disease potentially differ by drinking water source and type. Geographic information system technology and surveillance data are accessible to local public health authorities and used together are an efficient and affordable way to assess the role of drinking water in sporadic enteric disease.

Developing locally based research capacity in Uganda

AIM

To describe an educational project to enhance local research capacity within Hospice Africa Uganda, a Uganda-wide community-based palliative care organization.

BACKGROUND

This project emerged from a British Council Higher Education Links Scheme involving stakeholder British and Ugandan higher education institutions. The paper describes the project in relation to the remit of the British Council, the Ugandan context and the specifics of this exploratory project. The aim of the project was to build on the pre-existing local research capacity.

FINDINGS

The lessons learnt and the participatory approach adopted for meeting the challenges of teaching/learning that emerged from this project are described in relation to the local interprofessional, organizational, socio-economic and socio-cultural contexts.

CONCLUSION

Local knowledge gained through participatory engagement and collaborative working within Uganda is relevant and useful for current and future UK-Ugandan higher education partnerships.

A Multifaceted Intervention to Implement Guidelines Improved Treatment of Nursing Home–Acquired Pneumonia in a State Veterans Home

OBJECTIVES

To assess the feasibility of a multifaceted strategy to translate evidence-based guidelines for treating nursing home-acquired pneumonia (NHAP) into practice using a small intervention trial.

DESIGN

Pre-posttest with untreated control group.

SETTING

Two Colorado State Veterans Homes (SVHs) during two influenza seasons.

PARTICIPANTS

Eighty-six residents with two or more signs of lower respiratory tract infection.

INTERVENTION

Multifaceted, including a formative phase to modify the intervention, institutional-level change emphasizing immunization, and availability of appropriate antibiotics; interactive educational sessions for nurses; and academic detailing.

MEASUREMENTS

Subjects' SVH medical records were reviewed for guideline compliance retrospectively for the influenza season before the intervention and prospectively during the intervention. Bivariate comparisons-of-care processes between the intervention and control facility before and after the intervention were made using the Fischer exact test.

RESULTS

At the intervention facility, compliance with five of the guidelines improved: influenza vaccination, timely physician response to illness onset, x-ray for patients not being hospitalized, use of appropriate antibiotics, and timely antibiotic initiation for unstable patients. Chest x-ray and appropriate and timely antibiotics were significantly better at the intervention than at the control facility during the intervention year but not during the control year.

CONCLUSION

Multifaceted, evidence-based, NHAP guideline implementation improved care processes in a SVH. Guideline implementation should be studied in a national sample of nursing homes to determine whether it improves quality of life and functional outcomes of this debilitating illness for long-term care residents.

A comparison of physiological responses and rating of perceived exertion in two modes of aerobic exercise in men and women over 50 years of age

OBJECTIVES

To compare the physiological responses and ratings of perceived exertion to aerobic dance and walking sessions completed at a self selected pace.

METHODS

Six women and six men with a sample mean (SD) age of 68 (7) years completed aerobic dance and walking sessions in random order. A treadmill test was performed by each subject from which peak oxygen uptake (.VO(2)) and maximum heart rates (HRmax) were determined. During the aerobic dance and walking sessions, heart rate and .VO(2) were measured continuously throughout. Rate of perceived exertion (RPE) was measured every three minutes throughout the session.

RESULTS

The sample means (SD) for %peak .VO(2) were 67 (17)% for the aerobic dance sessions and 52 (10)% for the walking sessions, and the %HRmax sample means (SD) were 74 (12)% for the aerobic dance sessions and 60(8)% for walking sessions. The sample mean (SD) RPE for the aerobic dance sessions was 11(2), and for the walking sessions it was 10(2).

CONCLUSIONS

%peak .VO(2), %HRmax, and RPE were significantly higher for aerobic dance than for walking. However, both the aerobic dance and walking sessions were of adequate intensity to improve aerobic fitness in most subjects. Further investigation into the relation between RPE and %peak .VO(2) in a field setting over representative exercise time periods would be useful.

Tailoring the substrate specificity of the beta-glycosidase from the thermophilic archaeon Sulfolobus solfataricus

The substrate specificity of the thermophilic beta-glycosidase (lacS) from the archaeon Sulfolobus solfataricus (SSbetaG), a member of the glycohydrolase family 1, has been analysed at a molecular level using predictions from known protein sequences and structures and through site-directed mutagenesis. Three critical residues were identified and mutated to create catalysts with altered and broadened specificities for use in glycoside synthesis. The wild-type (WT) and mutated sequences were expressed as recombinant fusion proteins in Escherichia coli, with an added His(6)-tag to allow one-step chromatographic purification. Consistent with side-chain orientation towards OH-6, the single Met439-->Cys mutation enhances D-xylosidase specificity 4.7-fold and decreases D-fucosidase activity 2-fold without greatly altering its activity towards other D-glycoside substrates. Glu432-->Cys and Trp433-->Cys mutations directed towards OH-4 and -3, respectively, more dramatically impair glucose (Glc), galactose (Gal), fucose specificity than for other glycosides, resulting in two glycosidases with greatly broadened substrate specificities. These include the first examples of stereospecificity tailoring in glycosidases (e.g. WT-->W433C, k(cat)/K(M) (Gal):k(cat)/K(M) (mannose (Man))=29.4:1-->1.2:1). The robustness and high utility of these broad specificity SSbetaG mutants in parallel synthesis were demonstrated by the formation of libraries of beta-glycosides of Glc, Gal, xylose, Man in one-pot preparations at 50 degrees C in the presence of organic solvents, that could not be performed by SSbetaG-WT.

Nontraditional family romance

Family stories lie at the heart of psychoanalytic developmental theory and psychoanalytic clinical technique, but whose family? Increasingly, lesbian and gay families, multiparent families, and single-parent families are relying on modern reproductive technologies to form families. The contemplation of these nontraditional families and the vicissitudes of contemporary reproduction lead to an unknowing of what families are, including the ways in which psychoanalysts configure the family within developmental theory. This article focuses on the stories that families tell in order to account for their formation--stories that include narratives about parental union, parental sexuality, and conception. The author addresses three constructs that inform family stories and that require rethinking in light of the category crises posed by and for the nontraditional family: (1) normative logic, (2) family reverie and the construction of a family romance, and (3) the primal scene. These constructs are examined in tandem with detailed clinical material taken from the psychotherapy of a seven-year-old boy and his two mothers.

Problems in the interpretation of HIV-1 viral load assays using commercial reagents

During routine monitoring of human immunodeficiency virus (HIV) viral load, two problems arose. First, a number of patients, the majority being African, were found to have low viral loads by the Chiron branched-chain DNA assay in conjunction with low CD4(+) cell numbers. In order to determine whether this was due to failure of the branched-chain DNA assay to detect non-B subtypes of HIV, selected samples were subtyped and HIV RNA quantified by branched-chain DNA, NASBA, and the Roche Monitor RT-PCR assay. Twenty-eight (97%) of 29 Africans were infected with a non-B subtype of HIV and 15 (93.7%) of 16 non-Africans with subtype B. Twenty-three samples had a low viral load by branched-chain DNA, which was confirmed by the NASBA and RT-PCR assays. All three assays detected B and non-B subtypes with similar efficiency; NASBA failed to detect HIV RNA in a small number of non-B samples. Discrepancies between viral load and CD4(+) cell numbers did not appear therefore to be related to subtype. Second, while quantification of HIV RNA was being conducted using version 2 of the branched-chain DNA assay (lower detection limit 500 HIV RNA copies/ml) the manufacturers had developed a more sensitive assay and a comparative evaluation was therefore conducted. In approximately 30% of samples the viral load was up to 10 times higher with the more sensitive assay. These experiences emphasise the importance of close collaboration between the clinic and the laboratory.

Durability of tobacco control efforts in the 22 Community Intervention Trial for Smoking Cessation (COMMIT) communities 2 years after the end of intervention

Funding organizations increasingly want to know that successful interventions are continued after the end of a research project. Assessments of durability are rare and where done do not include the comparison communities. In this study we ascertain what tobacco control activities continued in intervention communities involved in the Community Intervention Trial for Smoking Cessation (COMMIT), a randomized, controlled community trial aimed at adult smokers, and also assessed level of tobacco control activities in the comparison communities. A mailed survey of key informants including paid staff and community volunteers in the 22 COMMIT communities was conducted. Approximately 79% of key informants responded to the survey. Although there was evidence that tobacco control activities were continuing in the intervention communities, there was an equal amount of tobacco control effort in the comparison communities. Within the specific tobacco control intervention areas, only the youth area showed more activity in intervention communities than comparison communities. We conclude that despite a positive trial outcome, differential durability was not achieved. More work needs to be done to assist communities in maintaining proven intervention activities. More study of methods to measure durability is also needed.

Potential risk of cross-infection during peripheral-venous access by contamination of tourniquets

We found that a high proportion of reusable tourniquets are contaminated with blood and bacterial pathogens. Their use contravenes hospital cross-infection control protocols and we therefore recommend the use of disposable tourniquets.

Rubella virus and chronic joint disease: is there an association?

Synovial fluid samples and/or biopsies from 79 patients with various chronic inflammatory joint diseases or traumatic joint injury were tested for rubella virus (RV) in order to confirm or refute results from other studies that suggested RV as a cause of chronic inflammatory joint disease. Sixty-eight of the 72 patients tested had RV antibodies. RV RNA was detected by reverse transcription-PCR in the synovial fluid cells from two patients. RV was also isolated by cell culture from the synovial fluid of one of these two patients. This patient was a 42-year-old female with common variable immune deficiency and Mycoplasma hominis arthritis, while the other was a 68-year-old female with rheumatoid arthritis. While these results fail to confirm that RV is associated with chronic inflammatory joint disease, they suggest that RV may persist within a joint and be reactivated when cell-mediated immunity is suppressed.

Comparative kinetics and dynamics of zaleplon, zolpidem, and placebo

PURPOSE

This study evaluated the relationship of dose, plasma concentration, and time to the pharmacodynamics of zaleplon and zolpidem, 2 structurally distinct benzodiazepine receptor agonists.

METHOD

Ten healthy male volunteers received single oral doses of placebo, 10 mg zaleplon, 20 mg zaleplon, 10 mg zolpidem, and 20 mg zolpidem in a double-blind, 5-condition crossover study, with 48 hours elapsing between trials. Plasma drug concentrations and pharmacodynamic effects were measured during the 8 to 24 hours after administration.

RESULTS

Kinetics of zaleplon and zolpidem were not significantly related to dose. However, zaleplon had more rapid elimination (apparent elimination half-life [t1/2] of 1 hour) and higher apparent oral clearance (approximately 4300 mL/min) than zolpidem (t1/2, 2.0 to 2.2 hours; apparent oral clearance, 340 to 380 mL/min). Active treatments produced pharmacodynamic effects consistent with benzodiazepine agonist activity: self- and observer-rated sedation, impairment of digit symbol substitution test (DSST) performance, impaired memory, and increased electroencephalographic activity in the beta frequency range. The overall order of agonist potency was as follows: placebo < 10 mg zaleplon < 20 mg zaleplon < 10 mg zolpidem < 20 mg zolpidem; on a number of measures, 20 mg zaleplon was comparable to 10 mg zolpidem. Quantitative effects of zolpidem 20 mg far exceeded those of other treatments. Dynamic effects of both drugs were significantly related to plasma concentration.

CONCLUSIONS

Benzodiazepine agonist effects of zaleplon and zolpidem were dose and concentration dependent. At the usual clinically effective hypnotic dose (10 mg of either drug), agonist effects of zolpidem exceeded those of zaleplon.

Ketoconazole inhibition of triazolam and alprazolam clearance: differential kinetic and dynamic consequences

BACKGROUND

Kinetic and dynamic consequences of metabolic inhibition were evaluated in a study of the interaction of ketoconazole, a P4503A inhibitor, with alprazolam and triazolam, two 3A substrate drugs with different kinetic profiles.

METHODS

In a double-blind, 5-way crossover study, healthy volunteers received (A) ketoconazole placebo plus 1.0 mg alprazolam orally, (B) 200 mg ketoconazole twice a day plus 1.0 mg alprazolam, (C) ketoconazole placebo plus 0.25 mg triazolam orally, (D) 200 mg ketoconazole twice a day plus 0.25 mg triazolam, and (E) 200 mg ketoconazole twice a day plus benzodiazepine placebo. Plasma concentrations and pharmacodynamic parameters were measured after each dose.

RESULTS

For trial B versus trial A, alprazolam clearance was reduced (27 versus 86 mL/min; P < .002) and apparent elimination half-life (t1/2) prolonged (59 versus 15 hours; P < .03), whereas peak plasma concentration (Cmax) was only slightly increased (16.1 versus 14.7 ng/mL). The 8-hour pharmacodynamic effect areas for electroencephalographic (EEG) beta activity were increased by a factor of 1.35, and those for digit-symbol substitution test (DSST) decrement were increased by 2.29 for trial B versus trial A. For trial D versus trial C, triazolam clearance was reduced (40 versus 444 mL/min; P < .002), t1/2 was prolonged (18.3 versus 3.0 hours; P < .01), and Cmax was increased (2.6 versus 5.4 ng/mL; P < .001). The 8-hour effect area for EEG was increased by a factor of 2.51, and that for DSST decrement was increased by 4.33. Observed in vivo clearance decrements due to ketoconazole were consistent with those anticipated on the basis of an in vitro model, together with in vivo plasma concentrations of ketoconazole.

CONCLUSION

For triazolam, an intermediate-extraction compound, impaired clearance by ketoconazole has more profound clinical consequences than those for alprazolam, a low extraction compound.

The captive market in nurse education and the displacement of nursing knowledge

This paper develops a framework of empowerment within which to examine the commissioning process for nurse education arising from market reform of the British National Health Service (NHS). The paper argues that an imbalance in this commissioning process favours theoretical products, such as the diploma-level nursing curricula (Project 2000). Also, the university setting of nurse education is seen as clinically de-skilling both nurse teachers and student nurses as well as influencing the discourses on clinical skills. The paper further argues that the effects of such trends are a captive market in nurse education contracting and a displacement of nursing knowledge. An approach to commissioning nurse education is described which may counter such trends and positively impact on NHS organizational development and quality. Further reform of the commissioning process is described in context of pragmatic health legislation.

Cross-gendered identifications and homosexual boyhood: toward a more complex theory of gender

This paper focuses on a subset of homosexual boys whose mixed gender experience moves beyond the conventional categories of masculinity and femininity, and who are often labeled as pathological due to a reluctance to recognize the reality of gender variance and cross-gendered identifications within the domain of mental health. Clinical examples are offered to highlight the need for a theory of gender that accounts for the interweaving of gender and psychic structure as they co-evolve and reflect the chaos inherent in human subjectivity.

Maternal viral load, CD4 cell count and vertical transmission of HIV-1

HIV load and CD4 cell numbers were measured among 95 HIV infected women during pregnancy in order to determine their value as prognostic markers for transmission of virus from mother to infant. Among the 94 live births, 13 children were infected with HIV, 69 were uninfected and 12 were of unknown infection status. HIV RNA levels, as measured by nucleic acid sequence based amplification, were significantly higher (P < 0.001) in women who transmitted virus than among those who did not transmit and maternal viral load was a stronger predictor of transmission than CD4 cell number. The predicted rate of transmission relative to maternal HIV RNA was 2% at 1,000 copies, 11% at 10,000 copies and 40% at 100,000 copies/ml. Little variation in viral load occurred during pregnancy and there was an association between viral load and prematurity, the mean gestation at delivery decreasing by 1.3 weeks for every 10-fold increase in maternal HIV RNA (P = 0.007). This study demonstrates that a high level of maternal HIV RNA is a risk factor for transmission of virus to the infant and maternal viral load is of more value as a prognostic marker for transmission risk than CD4 cell number. High viral load is also associated with premature delivery. Maternal viral load is therefore a useful marker on which to base management decisions during pregnancy.

Worksite characteristics and changes in worksite tobacco-control initiatives. Results from the COMMIT study

Few studies have prospectively examined the characteristics associated with worksite adoption of tobacco-control initiatives. Data were collected as part of the Community Intervention Trial (COMMIT) for Smoking Cessation, which conducted interventions in 11 communities. This smoking cessation intervention was based on community organization principles and delivered through multiple community channels, including worksites, health care providers, the media, and cessation resources. This article reports results from telephone interviews of intervention community worksites having 50 or more employees, conducted at baseline and the end of the intervention period. Among worksites that responded to both baseline and final surveys, 83% had not adopted a smoke-free policy at baseline, and 61% did not offer any cessation aid or quitting resources at baseline. By the final survey, 34% of those with no smoking ban at baseline had become smoke-free, and 36% of those offering no cessation assistance at baseline were offering cessation resources at the follow-up. The prevalence of policy adoption was higher among worksites employing more female employees and offering other health-promotion activities; manufacturing businesses were significantly less likely than businesses other than service and wholesale/retail businesses to adopt policies. Adoption of cessation programs was significantly more likely among worksites employing 100 to 249 workers, compared with those employing 50 to 99 workers; those predominantly employing men; those offering other types of health-promotion activities; and those with a higher rate of turnover. These results provide important information about the characteristics of worksites likely to engage in tobacco-control efforts. Health educators and others may choose to target those worksites most ready for adoption of tobacco control policies and programs, as indicated by these findings.

Gender, social pressure, and smoking cessations: the Community Intervention Trial for Smoking Cessation (COMMIT) at baseline

This study was undertaken to examine gender differences in the perception of social constraints against smoking and to explore the role of other sociodemographic and smoking factors that influence the perception of social pressure. Baseline data from the 20 U.S. sites in the National Cancer Institute's Community Intervention Trial for Smoking Cessation (COMMIT) were analyzed. We found that women were less likely than men to be heavy smokers and to report that smoking had affected their health, but more likely to report behavior indicating physiological addiction (timing of first cigarette). At all smoking levels, women were about twice as likely as men to report feeling pressure to quit, after adjusting for education, income, ethnic group, age, and other factors. The source of pressure, however, was different: more women report pressure from their children, whereas more men report pressure from friends and coworkers. Women were equally likely as men to make quit attempts, after adjusting for other factors, but were less likely to remain abstinent for at least 10 days. Women, regardless of education, ethnicity, and age, reported a greater tendency to ask permission before smoking in non-restricted public places. College-educated men were less likely than men without college education to smoke without asking in non-restricted places, but education did not influence whether women asked permission. For both sexes, smoking level and nicotine dependence were significant predictors of lighting up without asking in public places, after adjustment for other variables. We discuss these findings and their implications for the gender gap in smoking cessation and women's conflicting pressures to stop/continue smoking. Tobacco control efforts are discussed within the context of gender differences in social norms, roles, socialization, and communication cultures.

Durability of tobacco control activities in 11 north American communities: life after the Community Intervention Trial for Smoking Cessation (COMMIT)

Durability of tobacco control activities in the 11 intervention sites of the Community Intervention Trial for Heavy Smokers (COMMIT) was examined. Although continuation of COMMIT activities was not a major goal, all communities made plans to continue some tobacco control activity. Information was gathered at focus groups of former COMMIT volunteers and staff who were assembled in each community and asked to describe tobacco control activities in their communities during the past 12-16 months-the period after the termination of COMMIT funding. It was found that a tobacco coalition, board or other structure was still operating in nine of the 11 communities and 10 had some level of paid staff dedicated to smoking control. There was also substantial activity in three of the four channels that COMMIT used as an intervention framework: worksites, public education and cessation resources. Many communities were currently engaged in considerable smoking control activity aimed at youth, an area that was intentionally de-emphasized by COMMIT. Implications for the durability of health promotion programs by communities are discussed.

Women gain weight 1 year after smoking cessation while dietary intake temporarily increases

OBJECTIVE

To examine the relationship of dietary change to weight change in women who quit smoking and remained abstinent for 1 year.

METHODS

For 1 year, 582 women participating in smoking cessation classes were studied. Weight, diet, and physical activity were measured at baseline and at 1, 6, and 12 months after smoking cessation. Multivariate regression models were used to predict 1-year weight change for the 139 women who remained abstinent.

RESULTS

Women gained, on average, 9.9 lb over a 1-year period while increasing their intake of energy for 1 and 6 months but returning to baseline levels by 1 year. Sucrose, total carbohydrate, and fat intake increased significantly for the first month; fat and total carbohydrate intake remained at an increased level for 6 months. In unadjusted analyses, older women and those who smoked more cigarettes gained more weight than younger women and lighter smokers; lighter and heavier women gained more weight than women of intermediate weight. In adjusted analyses, age remained a significant factor and number of cigarettes remained of borderline significance. Change in energy intake was predictive of weight change only in women with the highest energy intake at baseline.

APPLICATIONS

Dietitians should acknowledge that most women who quit smoking gain weight in the short term. Although many women increase their energy intake, change in energy level is only one factor in weight change. Over the long term, women with high baseline intakes appear to be able to affect their weight change by reducing their energy intake.

Promoting worksite smoking control policies and actions: the Community Intervention Trial for Smoking Cessation (COMMIT) experience. The COMMIT Research Group

BACKGROUND

As an important aspect of the COMMIT trial, worksite smoking-control consultations and supports were provided to employers in 11 diverse, moderate-sized communities. After a 4-year intervention period (1989-1992), impacts on worksite policies, support resources for smokers, and employee perceptions were assessed in these communities and in 11 matched Comparison communities.

METHODS

Data from two surveys are reported here. In each of the 22 COMMIT communities, a sample of worksites within each of four size strata were surveyed to determine worksite policies, activities, and resources regarding smoking. Data from employees were obtained from independent community-wide surveys of community residents.

RESULTS

Overall, 44% of the worksites surveyed reported having smoke-free policies, with no differences between Intervention and Comparison communities. Thirty-seven percent of Intervention community work-sites reported offering smoking cessation resources or assistance for employees during the period of the study, compared to 31% of Comparison community worksites (P = 0.04). Employees in Intervention communities, relative to those in Comparison communities, reported greater awareness of stop-smoking resources, but equivalent increases in worksite smoking bans.

CONCLUSION

Although the level of worksite smoking-cessation activities was higher in Intervention than in Comparison communities, there remains a substantial need to increase the level of such activities and to integrate such activities with restrictive smoking policies.

Smokers' baseline characteristics in the COMMIT trial

BACKGROUND

Baseline telephone survey data from 10 COMMIT sites were submitted to statistical analyses to compare the smoking characteristics of non-Hispanic white (white), non-Hispanic black (black), Mexican-origin (Mexican), and Puerto Rican-origin (Puerto Rican) smokers.

RESULTS

White men and women were more likely to be classified as "heavy smokers" than members of other racial/ethnic groups, although black and Puerto Rican smokers were more likely than whites to increase their smoking rates on weekends. Whites were less likely to report stopping smoking in the past. White and Mexican smokers were most likely to smoke light or ultralight brands and least likely to smoke menthol cigarettes. Blacks were most likely to report smoking their first cigarette of the day within 10 min of waking.

CONCLUSION

The differences and similarities among different groups of smokers may have important implications for understanding patterns of tobacco-related disease in smokers from different racial/ethnic and sex groups.

A comparison of methods of predicting maximum oxygen uptake

The aim of this study was to compare the results from a Cooper walk run test, a multistage shuttle run test, and a submaximal cycle test with the direct measurement of maximum oxygen uptake on a treadmill. Three predictive tests of maximum oxygen uptake--linear extrapolation of heart rate of VO2 collected from a submaximal cycle ergometer test (predicted L/E), the Cooper 12 min walk, run test, and a multi-stage progressive shuttle run test (MST)--were performed by 22 young healthy males (mean(s.d.) age 22.1 (2.4) years; body mass 72.4(8.9kg)) and the values compared to those obtained by direct measurement on a maximal treadmill test. All of the subjects were regular exercisers. The mean(s.d.) from the various tests in ml.kg-1.min-1 were as follows: treadmill 60.1(8.0), Cooper 60.6(10.3), MST 55.6(8.0), and predictedL/E 52.0(8.4). The Cooper test had a correlation with the treadmill test of 0.92, while the MST and the predictedL/E had correlations of 0.86 and 0.76 respectively. Both the MST and predictedL/E showed systematic underprediction of the treadmill value. On average, the MST was 4.5 ml.kg-1.min-1 (s.e. 0.9) lower than the treadmill VO2max while the predictedL/E was 7.8 ml.kg-1. min-1 (s.e. 1.4) lower than the treadmill VO2max. These findings indicate that, for the population assessed, the Cooper walk run test is the best predictor of VO2max among the three tests.

A strategy to enhance skills. Developing intravenous therapy skills for community nursing

1. Information abounds on teaching clients, partners and relatives about home i.v. therapy, but there is a lack of training for community nurses in this area. 2. Training for IV therapy has been difficult to develop in community settings, but must involve managers, specialists, and practitioners. 3. Community-led IV therapy training requires resources across acute and community sectors, with skills development through contract learning and focusing skills to specific practice contexts. 4. Training and experience in managing central venous access developed by community nurses are transferable to all clients and to other colleagues.

Ethics and occupational therapy practice

Professional ethics are guiding principles which are intended to orient the individuals within the profession, ensure our clients best interests and to protect the profession itself and its position in the public mind. Professional ethics are the rules we use to make certain that each therapist is operating in a fashion which protects the integrity of our profession and hence the viability of all occupational therapists. Our professional ethics, in addition to our special training and acquired skills, explain our profession to the health care community and those patients whom we serve. Professional ethics are a method by which our membership defines itself and guides its members throughout their career. Professional ethics ensure a place of trust within the Canadian health care system for those who choose to practice occupational therapy.

Smoking cessation factors among African Americans and whites. COMMIT Research Group

OBJECTIVES

This study was undertaken to explore smoking patterns and attitudes that influence smoking cessation and relapse among African Americans.

METHODS

Baseline data from eight Community Intervention Trial for Smoking Cessation (COMMIT) sites were analyzed.

RESULTS

Compared with Whites, African Americans who smoke less than 25 cigarettes per day were 1.6 times more likely to smoke within 10 minutes of awakening (a behavioral indicator of nicotine dependence), adjusting for education, age, and gender (OR = 1.2 for heavier smokers). African Americans reported a stronger desire to quit smoking and reported serious quit attempts in the past year. African Americans favored tobacco restrictions (they were 1.8 times more likely than Whites to view smoking as a serious community problem, 1.7 times more likely to favor restrictions on cigarette vending machines, and 2.1 times more likely to prohibit smoking in their car). African Americans were lighter/moderate, menthol smokers.

CONCLUSIONS

African Americans find smoking socially unacceptable and are strongly motivated to quit, but their "wake-up" smoking may indicate high nicotine dependence, making abstinence difficult even for lighter smokers.

Compliance with worksite nonsmoking policies: baseline results from the COMMIT study of worksites

PURPOSE

Little is known about compliance with worksite nonsmoking policies. This study provides an examination of the relationship of policy compliance to characteristics of the organization and the manner in which the policy was implemented.

DESIGN

Data came from two separate surveys of 1) representatives of worksites that reported having a nonsmoking policy and 2) employed residents from the same communities whose worksites had nonsmoking policies.

SETTING

This study was conducted as part of the Community Intervention Trial for Smoking Cessation (COMMIT), being conducted in 11 diverse intervention communities.

SUBJECTS

Data are presented from surveys of 710 worksites (response rate = 90%) and 3,143 employed residents (response rate = 80%) of the same communities.

MEASURES

Compliance with nonsmoking policies was measured by self-report in both surveys and is compared with worksite and respondent characteristics, type of policy, and methods of policy implementation.

RESULTS

Compliance with nonsmoking policies was high; 55% of worksites with a policy restricting smoking reported that employees always adhered to the policy. Compliance was highest in worksites with more restrictive policies and where labor-management relations were reported to be good. Compliance also was high where the policy was effectively communicated to workers, as through worksite distribution channels, the absence of cigarette vending machines, and the availability of cessation assistance.

CONCLUSIONS

These findings indicate that compliance with worksite nonsmoking policies is generally high, especially in the presence of more stringent policies.

Worksite smoking control activities: prevalence and related worksite characteristics from the COMMIT Study, 1990

BACKGROUND

There is a pressing need for current information on worksite smoking policies and stop-smoking activities. To address these needs and identify worksite characteristics associated with such activities, a computer-assisted telephone interview was administered to 793 worksites having at least 50 employees.

METHODS

Within each of the 11 COMMIT intervention communities, attempts were made to survey 30 worksites within each of three size strata: 50-99 employees, 100-249 employees, and 250+ employees. Response to the survey was good, with a screening rate of 95% and a response rate of 90%.

RESULTS

Overall, 69% of responding worksites reported having written smoking policies, but only 15% banned all indoor smoking. Smaller worksites and manufacturing and wholesale/retail companies were less likely than other organizations to be smoke-free or have representatives attend smoking policy workshops. Thirty-five percent of worksites reported offering smoking cessation resources or assistance for employees, but only 20% offered both cessation resources and restrictive or smoke-free policies. Smaller worksites as well as wholesale/retail sales and manufacturing worksites were less likely to offer cessation resources or to participate in community wide stop-smoking events.

CONCLUSION

Although the level of worksite smoking control activities was higher than that reported in earlier surveys, there is still a substantial need to increase the level of such activities, especially at smaller worksites and in manufacturing and sales organizations.

Skeletal muscle metabolism in the offspring of trained rats

To determine the effects of maternal exercise training during pregnancy on skeletal muscle metabolism of the progeny, eleven female Sprague-Dawley rats were divided into an exercise and a control group. The maternal training group (6) ran on a rodent treadmill for 4 weeks prior to pregnancy and daily throughout gestation (21 days) at 26.8 m/min, 1 hour/day, 5 days per week. The measurements were taken 28 days postpartum. No differences were noted between the sedentary and trained maternal animals for succinic dehydrogenase (SDH), phosphofructokinase (PFK), and myosin ATPase activities of the soleus, plantaris and gastrocnemius muscles. Maternal gastrocnemius SDH and soleus PFK levels were significantly (p less than 0.05) lower than levels found in the offspring. The liver glycogen of trained maternal animals was significantly higher than that found in all other groups. As well it was shown that maternal exercise had no effect on any of the aforementioned physiological parameters measured in the pups. The results indicate that exercise training during pregnancy does not modify the skeletal muscle metabolism of the offspring as observed 28 days after birth.

Drinking patterns and drinking-related problems of Mexican-American husbands and wives

The present research builds on previous studies' findings of alcohol-related gender differences between Mexican-American men and women, through examination of drinking levels, norms and related problems within the context of marriage and family. A survey of husbands and wives in 206 married couples randomly selected from eligible households in East San Jose, California, was carried out. Highlights in our findings include significant gender differences in reports of drinking patterns, frequency of heavier drinking, tangible consequences of drinking and expectancies regarding alcohol. Most notably, correlations were found between husbands' and wives' quantity-frequency drinking measures, the frequency of heavier drinking, tangible consequences of drinking and expectancies regarding alcohol. Although men have higher levels of drinking and greater drinking-related problems, husbands' and wives' patterns are correlated with one another. These links between spouses' drinking-related variables have important implications for family prevention and education about alcohol use.