Comparative effectiveness of digital mental healthcare models for adults with epilepsy: A study protocol of a randomized controlled trial

OBJECTIVE

Mental health complaints are prevalent among people with epilepsy, yet there are major barriers that prevent access to psychological care, including high out-of-pocket costs and a lack of accessible specialized services. The purpose of the current study is to examine the comparative efficacy, acceptability, cost-effectiveness, and long-term outcomes of a digital psychological intervention when delivered under two models of care (i.e., guided vs. unguided) in supporting the mental health and functioning of adults with epilepsy.

METHOD

Approximately 375 participants across Australia will be enrolled. Eligible participants will have a confirmed diagnosis of epilepsy, experience difficulties with their emotional health, be at least 18 years of age, and live in Australia. Participants will be randomized (2:2:1) to receive the Wellbeing Neuro Course, a 10-week internet-delivered program, with (i.e., guided) or without guidance by a mental health clinician (i.e., unguided), or be allocated to a treatment-as-usual waiting-list control group. Participants will complete online questionnaires at pre-, post-treatment, and 3- and 12-month follow-up and consent to have their data linked to their medical records to capture healthcare system resource use and costs.

ANALYSIS

Primary outcome measures will be symptoms of depression and anxiety. A cost-utility analysis will be undertaken using the Australian healthcare system perspective and according to current economic evaluation guidelines. Resource use and costs to the healthcare system during the study period will be captured via data linkage to relevant administrative datasets in Australia.

SIGNIFICANCE

The results of this trial will provide important data concerning the relative outcomes of these different models of care and will inform the integration of digital psychological interventions translation into healthcare services.

ETHICS AND DISSEMINATION

The Human Research Ethics Committee of Macquarie University approved the proposed study (Reference No: 520231325151475). The results will be disseminated through peer-reviewed publication(s).

ANZCTR TRIAL REGISTRATION NUMBER

ACTRN12623001327673.

PLAIN LANGUAGE SUMMARY

This study seeks to find out if a 10-week online psychological treatment can improve the mental health and well-being of Australian adults with epilepsy. Around 375 participants will be randomly assigned to different groups: one will receive treatment with guidance from mental health clinician (guided group), one without guidance (unguided group), and one starting later (waiting control group). All participants will fill out the same outcome measures online. The main goal of this research is to compare these groups and assess how well the treatment works in improving mental health outcomes.

Relations between provider adherence to a tailored motivational intervention protocol and competence in motivational interviewing

OBJECTIVES

To evaluate the association between provider adherence to Tailored Motivational Interviewing implementation strategy and motivational interviewing (MI) competence.

METHODS

156 youth-focused HIV providers enrolled in a parent implementation science trial completed: a) quarterly standardized patient assessments (SPI) during Baseline; b) a workshop, individual coaching sessions, and quarterly SPI plus feedback during Implementation; and c) quarterly SPI during Sustainment. Competence was measured using the MI-CRS and tracking data was used to assess adherence. We examined overall adherence as well as adherence to each implementation strategy in relation to MI competence.

RESULTS

Overall adherence was not associated with overall MI competence. MI competence significantly increased from Baseline to Implementation and Baseline to Sustainment. Some individual implementation strategies were associated with change in competence and the probability of achieving Intermediate/Advanced competence.

CONCLUSIONS

The results suggest that 100% percent adherence to all TMI implementation strategies may not be necessary. Completing some of the TMI implementation strategies yielded improvements in MI competence. The use of routine tracking data to measure adherence maybe more pragmatic than using observational coders and more objective than self-reports.

PRACTICE IMPLICATIONS

In busy HIV clinics, MI training should focus on strategies most directly associated with increased provider competence.

Understanding implementation completion of tailored motivational interviewing in multidisciplinary adolescent HIV clinics

Background

Understanding the barriers and facilitators of implementation completion is critical to determining why some implementation efforts fail and some succeed. Such studies provide the foundation for developing further strategies to support implementation completion when scaling up evidence-based practices (EBPs) such as Motivational Interviewing.

Method

This mixed-methods study utilized the Exploration, Preparation, Implementation, and Sustainment framework in an iterative analytic design to compare adolescent HIV clinics that demonstrated either high or low implementation completion in the context of a hybrid Type III trial of tailored motivational interviewing. Ten clinics were assigned to one of three completion categories (high, medium, and low) based on percentage of staff who adhered to three components of implementation strategies. Comparative analysis of staff qualitative interviews compared and contrasted the three high-completion clinics with the three low-completion clinics.

Results

Results suggested several factors that distinguished high-completion clinics compared to low-completion clinics including optimism, problem-solving barriers, leadership, and staff stress and turnover.

Conclusions

Implementation strategies targeting these factors can be added to EBP implementation packages to improve implementation success.

Plain Language Summary

While studies have begun to address adherence to intervention techniques, this is one of the first studies to address organizational adherence to implementation strategies. Youth HIV providers from different disciplines completed interviews about critical factors in both the inner and outer context that can support or hinder an organization's adherence to implementation strategies. Compared to less adherent clinics, more adherent clinics reported more optimism, problem-solving, and leadership strengths and less staff stress and turnover. Implementation strategies addressing these factors could be added to implementation packages to improve implementation success.

Determining the role and responsibilities of the community epilepsy nurse in the management of epilepsy

AIMS AND OBJECTIVES

The aim of this study is to enhance the understanding of the core elements and influencing factors on the community-based epilepsy nurse's role and responsibilities.

BACKGROUND

Internationally, epilepsy nurse specialists play a key role in providing person-centred care and management of epilepsy but there is a gap in understanding of their role in the community.

DESIGN

A national three-stage, mixed-method study was conducted.

METHODS

One-on-one, in-depth semi-structured qualitative interviews were conducted online with 12 community-based epilepsy nurses (Stage 1); retrospective analysis of data collected from the National Epilepsy Line, a nurse-led community helpline (Stage 2); and focus group conducted with four epilepsy nurses, to delve further into emerging findings (Stage 3). A thematic analysis was conducted in Stages 1 and 3, and a descriptive statistical analysis of Stage 2 data. Consolidated Criteria for Reporting Qualitative studies checklist was followed for reporting.

RESULTS

Three key themes emerged: (1) The epilepsy nurse career trajectory highlighted a lack of standardised qualifications, competencies, and career opportunities. (2) The key components of the epilepsy nurse role explored role diversity, responsibilities, and models of practice in the management of living with epilepsy, and experiences navigating complex fragmented systems and practices. (3) Shifting work practices detailed the adapting work practices, impacted by changing service demands, including COVID-19 pandemic experiences, role boundaries, funding, and resource availability.

CONCLUSION

Community epilepsy nurses play a pivotal role in providing holistic, person-centred epilepsy management They contribute to identifying and addressing service gaps through innovating and implementing change in service design and delivery.

RELEVANCE TO CLINICAL PRACTICE

Epilepsy nurses' person-centred approach to epilepsy management is influenced by the limited investment in epilepsy-specific integrated care initiatives, and their perceived value is impacted by the lack of national standardisation of their role and scope of practice.

NO PATIENT OR PUBLIC CONTRIBUTION

Only epilepsy nurses' perspectives were sought.

Online randomised factorial trial of electronic Screening and Brief Intervention for alcohol use in pregnancy: a study protocol

INTRODUCTION

Approximately 1 in 7 pregnant women in the USA report past-month alcohol use. Strong evidence connects prenatal alcohol exposure with a range of adverse perinatal outcomes, including the spectrum of conditions known as fetal alcohol spectrum disorders. Screening and Brief Intervention (SBI) has been recommended for pregnant women but has proven difficult to implement. This study will test the efficacy of single-session technology-delivered SBI (electronic SBI) for alcohol use in pregnancy, while simultaneously evaluating the possible additional benefit of tailored text messages and/or booster sessions in a 3×2 factorial trial.

METHOD AND ANALYSIS

This full factorial trial will use online advertising and clinic-based flyers to recruit pregnant women meeting criteria for unhealthy alcohol use, and randomly assign them to one of six conditions crossing three levels of brief intervention (none, single 120-minute session and single session plus two 5-minute boosters) with two levels of tailored text messaging (none vs twice weekly messages). The primary analysis will test for dose-response effects of the brief intervention on alcohol abstinence, defined as no self-report of alcohol use in the 90 days prior to 34 weeks' gestation, and negative results for ethyl glucuronide analysis of fingernail samples. Secondary analyses will examine main and interaction effects of tailored text messaging as well as intervention effects on birth outcomes.

ETHICS AND DISSEMINATION

Ethical approval was provided by the Michigan State University Biomedical and Health Institutional Review Board (STUDY00005298). Results will be presented at conferences and community forums, in addition to being published in a peer-reviewed journal. Intervention content demonstrating sufficient efficacy and safety will be made publicly available.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04332172).

Tailored Motivational Interviewing in Adolescent HIV Clinics: Primary Outcome Analysis of a Stepped Wedge Implementation Trial

BACKGROUND

Youth continue to have the poorest outcomes along the HIV prevention and care continua. Motivational Interviewing (MI) may promote behavior change and reduce perceived stigma, but providers often demonstrate inadequate MI competence. This study tested Tailored Motivational Interviewing (TMI), a set of implementation strategies designed to improve MI competence in youth HIV providers.

SETTING

Ten HIV clinics in the Adolescent Trials Network for HIV/AIDS Interventions.

METHODS

In a stepped wedge design, 10 clinics (N = 151 providers) were randomized in 5 clusters every 3 months to receive TMI for a 12-month implementation period. Sites were rerandomized within each cluster to receive communities of practice guidance with or without internal facilitator support in the sustainment period. Standard patient assessments were coded every 3 months for 36 months.

RESULTS

Nesting was addressed using mixed-effects regression models, with random effects for providers and sites. TMI resulted in significantly improved MI competence over baseline. Despite small reductions in competence in the sustainment window, competence was still significantly improved over baseline, with no difference between the 2 sustainment conditions.

CONCLUSIONS

TMI may be an important tool to capacitate the HIV HealthForce to end the HIV epidemic in young people.

Tailored Motivational Interviewing (TMI): A Pilot Implementation-Effectiveness Trial to Promote MI Competence in Adolescent HIV Clinics

This brief report describes results of piloted Tailored Motivational Interviewing (TMI). Tailoring focused on site-specific training needs, target patient behaviors, and implementation facilitators and barriers that staff anticipated. Participating staff (N = 31) at two adolescent HIV clinics completed a pre-training qualitative interview (N = 27), and MI competency assessments based on three pre- and six post-training standard patient role-plays (N = 27). Results included pre- to post-training MI competence improvement (t (153) = - 4.13, p ≤ 0.001) and change in competency category distribution (X² = (2, N = 155) = 15.72, p ≤ 0.001), providing initial support for the implementation of TMI in adolescent HIV clinic settings.

Development of the Motivational Interviewing Coach Rating Scale (MI-CRS) for health equity implementation contexts

OBJECTIVE

The field of implementation science emphasizes efficient and effective fidelity measurement for research outcomes and feedback to support quality improvement. This paper reports on such a measure for motivational interviewing (MI), developed with rigorous methodology and with diverse samples.

METHOD

Using item response theory (IRT) methods and Rasch modeling, we analyzed coded (a) recordings (n = 99) of intervention sessions in a clinical trial of African American adolescents with obesity; (b) standard patient interactions (n = 370) in an implementation science study with youth living with HIV; and (c) standard patient interactions (n = 172) in a diverse community sample.

RESULTS

These methods yielded a reliable and valid 12-item scale on several indicators using Rausch modeling including single construct dimensionality, strong item-session maps, good rating scale functionality, and item fit after revisions. However, absolute agreement was modest. The 12 items yielded thresholds for 4 categories: beginner, novice, intermediate and advanced.

CONCLUSIONS

The 12-item Motivational Interviewing Coach Rating Scale is the first efficient and effective fidelity measure appropriate with diverse ethnic groups, with interventions that are MI only or interventions that integrate MI with other interventions, and with adolescents and families as well as adults. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Barriers and facilitators to implementing a motivational interviewing-based intervention: a multi-site study of organizations caring for youth living with HIV

Understanding possible barriers and facilitators to effective implementation of evidence-based interventions to help high-risk youth prevent and manage HIV is crucial for their scale-up. This manuscript analyzes qualitative interview data collected during the early phase implementation of a motivational interviewing (MI) based intervention at 10 HIV care clinics in the United States providing services to youth. Using the Exploration-Preparation-Implementation-Sustainment (EPIS) framework to understand the implementation and the dynamic adaptation process (DAP) model to balance notions of intervention fidelity and flexibility, providers and stakeholders at each site (N = 97) were interviewed prior to implementation to gather their perspectives on organizational readiness for the intervention, as well as provider and client characteristics. The interviewers summarized their experience with rapid feedback forms (RFFs). Data extracted from the RFFs highlighted anticipated barriers to and facilitators of the proposed MI-based intervention, with the EPIS framework used to organize these findings. Study findings illustrate the inner and outer contextual factors that affect implementation and denote the points at which the MI-based intervention may be tailored to fit the unique context of a clinic while remaining faithful to the intervention's original design.

Determining the role and responsibilities of the Australian epilepsy nurse in the management of epilepsy: a study protocol

INTRODUCTION

Epilepsy is a common neurological condition affecting between 3% and 3.5% of the Australian population at some point in their lifetime. The effective management of chronic and complex conditions such as epilepsy requires person-centred and coordinated care across sectors, from primary to tertiary healthcare. Internationally, epilepsy nurse specialists are frequently identified as playing a vital role in improving the integration of epilepsy care and enhancing patient self-management. This workforce has not been the focus of research in Australia to date.

METHODS AND ANALYSIS

This multistage mixed-method study examines the role and responsibilities of epilepsy nurses, particularly in primary and community care settings, across Australia, including through the provision of a nurse helpline service. A nationwide sample of 30 epilepsy nurses will be purposively recruited via advertisements distributed by epilepsy organisations and through word-of-mouth snowball sampling. Two stages (1 and 3) consist of a demographic questionnaire and semistructured interviews (individual or group) with epilepsy nurse participants, with the thematic data analysis from this work informing the areas for focus in stage 3. Stage 2 comprises of a retrospective descriptive analysis of phone call data from Epilepsy Action Australia's National Epilepsy Line service to identify types of users, their needs and reasons for using the service, and to characterise the range of activities undertaken by the nurse call takers.

ETHICS AND DISSEMINATION

Ethics approval for this study was granted by Macquarie University (HREC: 52020668117612). Findings of the study will be published through peer-reviewed journal articles and summary reports to key stakeholders, and disseminated through public forums and academic conference presentations. Study findings will also be communicated to people living with epilepsy and families.

Quality of life and its association with comorbidities and adverse events from antiepileptic medications: Online survey of patients with epilepsy in Australia

OBJECTIVE

This study aimed to explore the quality of life (QoL) of adult patients with epilepsy (PwE) in Australia and its relationship with comorbidities and adverse events (AEs) from antiepileptic drugs (AEDs).

METHODS

Cross-sectional surveys were completed by PwE, or carer proxies, recruited via the online pharmacy application MedAdvisor and Australian PwE Facebook groups from May to August 2018. Data were collected on demographics, epilepsy severity and management, AEs, comorbidities, and QoL (using the Patient-Weighted Quality of Life in Epilepsy Inventory [QOLIE-10-P] total score). Two linear regression models were constructed to explore associations between AEs or comorbidities and QOLIE-10-P score, with possible confounders determined using stepwise selection.

RESULTS

Nine hundred and seventy-eight of 1267 responses were eligible (mean age of respondents: 44.5 years, 64% female, 52% employed). Recent AED use was reported by 97%; 47% were on AED monotherapy, 35% had ≤2 lifetime AEDs, and 55% were seizure-free for >1 year. After stepwise selection, control variables included in both models were time since diagnosis, employment status, seizure frequency, number of currently prescribed AEDs, and number of general practitioner (GP) visits per year. In the model for comorbidities, "psychiatric disorders" was associated with the largest QOLIE-10-P score decrease (-23.14, p < 0.001). In the model for AEs, which additionally controlled for depression and anxiety disorder, self-reported "memory problems" was associated with the largest decrease in QOLIE-10-P score (-14.27, p < 0.001).

CONCLUSIONS

In this survey of Australian PwE, many of whom had relatively well-controlled epilepsy, psychiatric and self-reported memory problems were common and associated with the greatest detrimental impact on QoL. Further research is needed to better understand the underlying causes of impaired QoL and thereby improve its management.

Adolescent HIV Healthcare Providers' Competencies in Motivational Interviewing Using a Standard Patient Model of Fidelity Monitoring

The goal of this project is to describe adolescent HIV care providers' competence in Motivational Interviewing (MI) using a standard patient interaction model of fidelity assessment. Providers (N = 151) at 11 clinics completed monthly MI role plays. The MI Coach Rating Scale was utilized to assess MI skill. Despite mean differences in baseline MI ability by provider type (medical providers, psychologists/social workers, other), when examined together, only clinic had a significant main effect. Aspects of the clinic environment may have a greater impact on providers' baseline MI ability than their job type. Future research should continue to explore these clinic factors.

Testing a Motivational Interviewing Implementation Intervention in Adolescent HIV Clinics: Protocol for a Type 3, Hybrid Implementation-Effectiveness Trial

Background

Motivational interviewing (MI) has been shown to effectively improve self-management for youth living with HIV (YLH) and has demonstrated success across the youth HIV care cascade—currently, the only behavioral intervention to do so. Substantial barriers prevent the effective implementation of MI in real-world settings. Thus, there is a critical need to understand how to implement evidence-based practices (EBPs), such as MI, and promote behavior change in youth HIV treatment settings as risk-taking behaviors peak during adolescence and young adulthood.

Objective

This study aims to describe the Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN) protocol of a tailored MI (TMI) implementation-effectiveness trial (ATN 146 TMI) to scale up an EBP in multidisciplinary adolescent HIV settings while balancing flexibility and fidelity. This protocol is part of the Scale It Up program described in this issue.

Methods

This study is a type 3, hybrid implementation-effectiveness trial that tests the effect of TMI on fidelity (MI competency and adherence to program requirements) while integrating findings from two other ATN protocols described in this issue—ATN 153 Exploration, Preparations, Implementation, Sustainment and ATN 154 Cascade Monitoring. ATN 153 guides the mixed methods investigation of barriers and facilitators of implementation, while ATN 154 provides effectiveness outcomes. The TMI study population consists of providers at 10 adolescent HIV care sites around the United States. These 10 clinics are randomly assigned to 5 blocks to receive the TMI implementation intervention (workshop and trigger-based coaching guided by local implementation teams) utilizing the dynamic wait-listed controlled design. After 12 months of implementation, a second randomization compares a combination of internal facilitator coaching with the encouragement of communities of practice (CoPs) to CoPs alone. Participants receive MI competency assessments on a quarterly basis during preimplementation, during the 12 months of implementation and during the sustainment period for a total of 36 months. We hypothesize that MI competency ratings will be higher among providers during the TMI implementation phase compared with the standard care phase, and successful implementation will be associated with improved cascade-related outcomes, namely undetectable viral load and a greater number of clinic visits among YLH.

Results

Participant recruitment began in August 2017 and is ongoing. As of mid-May 2018, TMI has 150 active participants.

Conclusions

This protocol describes the underlying theoretical framework, study design, measures, and lessons learned for TMI, a type 3, hybrid implementation-effectiveness trial, which has the potential to scale up MI and improve patient outcomes in adolescent HIV settings.

Trial Registration

ClinicalTrials.gov NCT03681912; https://clinicaltrials.gov/ct2/show/NCT03681912 (Archived by WebCite at http://www.webcitation.org/754oT7Khx)

International Registered Report Identifier (IRRID)

DERR1-10.2196/11200

Composition and Use of Cannabis Extracts for Childhood Epilepsy in the Australian Community

Recent surveys suggest that many parents are using illicit cannabis extracts in the hope of managing seizures in their children with epilepsy. In the current Australian study we conducted semi-structured interviews with families of children with diverse forms of epilepsy to explore their attitudes towards and experiences with using cannabis extracts. This included current or previous users of cannabis extracts to treat their child's seizures (n = 41 families), and families who had never used (n = 24 families). For those using cannabis, extracts were analysed for cannabinoid content, with specific comparison of samples rated by families as "effective" versus those rated "ineffective". Results showed that children given cannabis extracts tended to have more severe epilepsy historically and had trialled more anticonvulsants than those who had never received cannabis extracts. There was high variability in the cannabinoid content and profile of cannabis extracts rated as "effective", with no clear differences between extracts perceived as "effective" and "ineffective". Contrary to family's expectations, most samples contained low concentrations of cannabidiol, while Δ9-tetrahydrocannabinol was present in nearly every sample. These findings highlight profound variation in the illicit cannabis extracts being currently used in Australia and warrant further investigations into the therapeutic value of cannabinoids in epilepsy.

Frequency and predictors of psychological distress after a diagnosis of epilepsy: A community-based study

OBJECTIVE

The objective of the study was to determine the frequency and predictors of psychological distress after a diagnosis of epilepsy.

METHODS

The Sydney Epilepsy Incidence Study to Measure Illness Consequences (SEISMIC) was a prospective, multicenter, community-based study of people of all ages with newly diagnosed epilepsy in Sydney, Australia. Analyses involved multivariate logistic regression and multinomial logit regression to identify predictors of psychological distress, assessed using the Hospital Anxiety and Depression Scale (HADS) and the Strengths and Difficulties Questionnaire (SDQ), as part of structured interviews.

RESULTS

Psychological distress occurred in 33% (95% confidence interval [CI] 26 to 40%) and 24% (95% CI 18 to 31%) of 180 adults at baseline and 12months, respectively, and 23% (95% CI 14 to 33%) of 77 children at both time points. Thirty adults and 7 children had distress at baseline who recovered at 12months, while 15 adults and 7 children had new onset of distress during this period. History of psychiatric or behavioral disorder (for adults, odds ratio [OR] 6.82, 95% CI 3.08 to 15.10; for children, OR 28.85, 95% CI 2.88 to 288.60) and higher psychosocial disability (adults, OR 1.17, 95% CI 1.07 to 1.27) or lower family functioning (children, OR 1.80, 95% CI 1.08 to 3.02) were associated with psychological distress (C statistics 0.80 and 0.78).

CONCLUSIONS

Psychological distress is common and fluctuates in frequency after a diagnosis of epilepsy. Those with premorbid psychological, psychosocial, and family problems are at high risk of this adverse outcome.

An Australian nationwide survey on medicinal cannabis use for epilepsy: History of antiepileptic drug treatment predicts medicinal cannabis use

Epilepsy Action Australia conducted an Australian nationwide online survey seeking opinions on and experiences with the use of cannabis-based products for the treatment of epilepsy. The survey was promoted via the Epilepsy Action Australia's main website, on their Facebook page, and by word of mouth. The survey consisted of 39 questions assessing demographics, clinical factors, including diagnosis and seizure types, and experiences with and opinions towards cannabis use in epilepsy. A total of 976 responses met the inclusion criteria. Results show that 15% of adults with epilepsy and 13% of parents/guardians of children with epilepsy were currently using, or had previously used, cannabis products to treat epilepsy. Of those with a history of cannabis product use, 90% of adults and 71% of parents reported success in reducing seizure frequency after commencing cannabis products. The main reasons for medicinal cannabis use were to manage treatment-resistant epilepsy and to obtain a more favorable side-effect profile compared to standard antiepileptic drugs. The number of past antiepileptic drugs tried was a significant predictor of medicinal cannabis use in both adults and children with epilepsy. Fifty-six percent of adults with epilepsy and 62% of parents/guardians of children with epilepsy expressed willingness to participate in clinical trials of cannabinoids. This survey provides insight into the use of cannabis products for epilepsy, in particular some of the likely factors influencing use, as well as novel insights into the experiences of and attitudes towards medicinal cannabis in people with epilepsy in the Australian community. This article is part of a Special Issue entitled "Cannabinoids and Epilepsy".

Characterizing ammonia emissions from swine farms in eastern North Carolina: part 1--conventional lagoon and spray technology for waste treatment

Ammonia (NH3) fluxes from waste treatment lagoons and barns at two conventional swine farms in eastern North Carolina were measured. The waste treatment lagoon data were analyzed to elucidate the temporal (seasonal and diurnal) variability and to derive regression relationships between NH3 flux and lagoon temperature, pH and ammonium content of the lagoon, and the most relevant meteorological parameters. NH3 fluxes were measured at various sampling locations on the lagoons by a flowthrough dynamic chamber system interfaced to an environmentally controlled mobile laboratory. Two sets of open-path Fourier transform infrared (FTIR) spectrometers were also used to measure NH3 concentrations for estimating NH3 emissions from the animal housing units (barns) at the lagoon and spray technology (LST) sites. Two different types of ventilation systems were used at the two farms. Moore farm used fan ventilation, and Stokes farm used natural ventilation. The early fall and winter season intensive measurement campaigns were conducted during September 9 to October 11, 2002 (lagoon temperature ranged from 21.2 to 33.6 degrees C) and January 6 to February 2, 2003 (lagoon temperature ranged from 1.7 to 12 degrees C), respectively. Significant differences in seasonal NH3 fluxes from the waste treatment lagoons were found at both farms. Typical diurnal variation of NH3 flux with its maximum value in the afternoon was observed during both experimental periods. Exponentially increasing flux with increasing surface lagoon temperature was observed, and a linear regression relationship between logarithm of NH3 flux and lagoon surface temperature (T1) was obtained. Correlations between lagoon NH3 flux and chemical parameters, such as pH, total Kjeldahl nitrogen (TKN), and total ammoniacal nitrogen (TAN) were found to be statistically insignificant or weak. In addition to lagoon surface temperature, the difference (D) between air temperature and the lagoon surface temperature was also found to influence the NH3 flux, especially when D > 0 (i.e., air hotter than lagoon). This hot-air effect is included in the statistical-observational model obtained in this study, which was used further in the companion study (Part II), to compare the emissions from potential environmental superior technologies to evaluate the effectiveness of each technology.

Characterizing ammonia emissions from swine farms in eastern North Carolina: part 2--potential environmentally superior technologies for waste treatment

The need for developing environmentally superior and sustainable solutions for managing the animal waste at commercial swine farms in eastern North Carolina has been recognized in recent years. Program OPEN (Odor, Pathogens, and Emissions of Nitrogen), funded by the North Carolina State University Animal and Poultry Waste Management Center (APWMC), was initiated and charged with the evaluation of potential environmentally superior technologies (ESTs) that have been developed and implemented at selected swine farms or facilities. The OPEN program has demonstrated the effectiveness of a new paradigm for policy-relevant environmental research related to North Carolina's animal waste management programs. This new paradigm is based on a commitment to improve scientific understanding associated with a wide array of environmental issues (i.e., issues related to the movement of N from animal waste into air, water, and soil media; the transmission of odor and odorants; disease-transmitting vectors; and airborne pathogens). The primary focus of this paper is on emissions of ammonia (NH3) from some potential ESTs that were being evaluated at full-scale swine facilities. During 2-week-long periods in two different seasons (warm and cold), NH3 fluxes from water-holding structures and NH3 emissions from animal houses or barns were measured at six potential EST sites: (1) Barham farm--in-ground ambient temperature anaerobic digester/energy recovery/greenhouse vegetable production system; (2) BOC #93 farm--upflow biofiltration system--EKOKAN; (3) Carrolls farm--aerobic blanket system--ISSUES-ABS; (4) Corbett #1 farm--solids separation/ gasification for energy and ash recovery centralized system--BEST; (5) Corbett #2 farm--solid separation/ reciprocating water technology--ReCip; and (6) Vestal farm--Recycling of Nutrient, Energy and Water System--ISSUES-RENEW. The ESTs were compared with similar measurements made at two conventional lagoon and spray technology (LST) farms (Moore farm and Stokes farm). A flow-through dynamic chamber system and two sets of open-path Fourier transform infrared (OP-FTIR) spectrometers measured NH3 fluxes continuously from water-holding structures and emissions from housing units at the EST and conventional LST sites. A statistical-observational model for lagoon NH3 flux was developed using a multiple linear regression analysis of 15-min averaged NH3 flux data against the relevant environmental parameters measured at the two conventional farms during two different seasons of the year. This was used to compare the water-holding structures at ESTs with those from lagoons at conventional sites under similar environmental conditions. Percentage reductions in NH3 emissions from different components of each potential EST, as well as the whole farm on which the EST was located were evaluated from the estimated emissions from water-holding structures, barns, etc., all normalized by the appropriate nitrogen excretion rate at the potential EST farm, as well as from the appropriate conventional farm. This study showed that ammonia emissions were reduced by all but one potential EST for both experimental periods. However, on the basis of our evaluation results and analysis and available information in the scientific literature, the evaluated alternative technologies may require additional technical modifications to be qualified as unconditional ESTs relative to NH3 emissions reductions.

Rwanda: gods and ghosts

This paper provides a personal story. I was born in Africa and have a great empathy for its people. The perceptions I provide are through the eyes of an African born individual who has lived in Australia for many years. It is said that you can take the child out of Africa; however, you cannot take Africa out of the child. During my return to Rwanda in 1994 to 1995, I learned many lessons. Perhaps the most significant being that the Rwandan people displayed absolute stoicism and acceptance of adversity, and from the suffering they had endured, they displayed a great dignity.

Optokinetic reflex dysfunction in multiple sclerosis

The aim of this study was to further investigate optokinetic reflex function in multiple sclerosis. Gaze-holding in darkness, optokinetic nystagmus, optokinetic afternystagmus and latency to circularvection were measured using electro-oculography and a rotating optokinetic drum. Gaze-holding was not significantly different between the multiple sclerosis and control groups; however, four of 23 multiple sclerosis patients exhibited eccentric gaze-evoked nystagmus. There were no significant differences in either optokinetic nystagmus frequency or latency to circularvection. However, optokinetic nystagmus slow phase velocity during rise time and amplitude during beat time were significantly reduced in the multiple sclerosis group (p < 0.05 and p < 0.0001, respectively). The time constant of optokinetic afternystagmus was also significantly reduced in the multiple sclerosis group (p < 0.005). These results indicate that optokinetic nystagmus and optokinetic afternystagmus are significantly impaired multiple sclerosis.

Effectiveness of St John's wort in major depression: a randomized controlled trial

CONTEXT

Extracts of St John's wort are widely used to treat depression. Although more than 2 dozen clinical trials have been conducted with St John's wort, most have significant flaws in design and do not enable meaningful interpretation.

OBJECTIVE

To compare the efficacy and safety of a standardized extract of St John's wort with placebo in outpatients with major depression.

DESIGN AND SETTING

Randomized, double-blind, placebo-controlled clinical trial conducted between November 1998 and January 2000 in 11 academic medical centers in the United States.

PARTICIPANTS

Two hundred adult outpatients (mean age, 42.4 years; 67.0% female; 85.9% white) diagnosed as having major depression and having a baseline Hamilton Rating Scale for Depression (HAM-D) score of at least 20.

INTERVENTION

Participants completed a 1-week, single-blind run-in of placebo, then were randomly assigned to receive either St John's wort extract (n = 98; 900 mg/d for 4 weeks, increased to 1200 mg/d in the absence of an adequate response thereafter) or placebo (n = 102) for 8 weeks.

MAIN OUTCOME MEASURES

The primary outcome measure was rate of change on the HAM-D over the treatment period. Secondary measures included the Beck Depression Inventory (BDI), Hamilton Rating Scale for Anxiety (HAM-A), the Global Assessment of Function (GAF) scale, and the Clinical Global Impression-Severity and -Improvement scales (CGI-S and CGI-I).

RESULTS

The random coefficient analyses for the HAM-D, HAM-A, CGI-S, and CGI-I all showed significant effects for time but not for treatment or time-by-treatment interaction (for HAM-D scores, P<.001, P =.16, and P =.58, respectively). Analysis of covariance showed nonsignificant effects for BDI and GAF scores. The proportion of participants achieving an a priori definition of response did not differ between groups. The number reaching remission of illness was significantly higher with St John's wort than with placebo (P =.02), but the rates were very low in the full intention-to-treat analysis (14/98 [14.3%] vs 5/102 [4.9%], respectively). St John's wort was safe and well tolerated. Headache was the only adverse event that occurred with greater frequency with St John's wort than placebo (39/95 [41%] vs 25/100 [25%], respectively).

CONCLUSION

In this study, St John's wort was not effective for treatment of major depression.

Reconciling animal and human data in a cancer risk assessment of acrylonitrile

OBJECTIVES

Bioassays of rats exposed to acrylonitrile have consistently detected an elevated incidence of central nervous system (CNS) cancer. In contrast, epidemiologic studies have not found a statistically stable increase in CNS cancer mortality. The purpose of this paper is to examine whether or not CNS cancers predicted from the most appropriate inhalation bioassay in rats are consistent with CNS cancers observed in 3 recent, large epidemiologic studies.

METHODS

A linearized multistage model was fit to dose-response data from a rat inhalation bioassay to estimate carcinogenic potency. This potency was applied to epidemiologic studies of acrylonitrile-exposed workers. After adjustment for less than complete lifetime follow-up in the epidemiologic studies, consistency was examined between CNS cancers predicted by the model fit to the animal data for the exposure levels and sample sizes of the epidemiologicy studies and the CNS cancers observed in the epidemiologic studies.

RESULTS

The model predicted totals of 17.7, 3.6, and 7.6 CNS cancer deaths for the studies. These predictions were not far from the observed CNS cancer deaths (12, 6, and 6) and were well within their 95% confidence intervals of 6.9-22.3, 2.2-13.1, and 2.2-13.1, respectively.

CONCLUSIONS

The CNS cancer potency estimated from the best available inhalation bioassay was consistent with the observed deaths in the epidemiologic studies as long as continuous lifetime exposure was chosen as the exposure metric. The lack of observed excess in CNS cancer among the studied workers may have been due to low exposures, insufficient follow-up times, or both.

Concentrated swine feeding operations and public health: a review of occupational and community health effects

Recent industry changes in swine-management practices have resulted in a growing controversy surrounding the environmental and public health effects of modern swine production. The numerous wastes produced by intensive swine production not only pose a significant challenge to effective environmental management but also are associated with decreased air quality in confinement houses, potentially transferable antimicrobial resistance patterns, and several infectious agents that can be pathogenic to humans. Published studies have documented a variety of contaminants, microbial agents, and health effects in those occupationally exposed to swine, and these have provided the groundwork for an increasing body of research to evaluate possible community health effects. Nonetheless, several factors limit our ability to define and quantify the potential role of intensive swine-rearing facilities in occupational and community health. Our incomplete understanding and ability to detect specific exposures; the complicated nature of disease etiology; pathogenesis; and surveillance; and the inherent difficulties associated with study design all contribute to the inadequate level of knowledge that currently prevails. However; an evaluation of the published literature; and a recognition of the elements that may be compromising these studies; provides the foundation from which future studies may develop.

The needs and supportive networks of the dying: an assessment instrument and mapping procedure for hospice patients

If institutional systems that provide end-of-life care are to survive the demands of managed care, they will need to tie together methods of assessing the needs of the dying, leading to a new understanding of the functioning of a patient's existing helping networks. This paper presents the preliminary findings of a research project conducted at a Midwest hospice. The study utilized a cross sectional correlational survey of patients' needs via the Early Risk and Resiliency Inventory (ERRI), while mapping their helping networks with a Circles of Care Ecomap. It addressed the question, "What is the relationship between the needs of the dying and the formal and informal support provided?" Study findings supported the contention that higher need patients utilized the more expensive institutional services rather than relying on available natural networks; and statistical analysis of the study instrument suggested the creation of a new conceptual domain of psychospiritual need.

The Cardiac Arrhythmia Suppression Trial: Implications for nursing practice

BACKGROUND

Care of patients with ventricular arrhythmia after myocardial infarction requires careful nursing management, including assisting with arrhythmia monitoring and testing. Because ventricular premature depolarization is a known risk factor for sudden cardiac death, it was hypothesized that the suppression of asymptomatic or mildly symptomatic ventricular premature depolarization would improve survival in these patients.

OBJECTIVE

To review the Cardiac Arrhythmia Suppression Trial findings and provide implications for nursing practice for patients after myocardial infarction.

METHODS

The Cardiac Arrhythmia Suppression Trial was a multicenter, randomized, placebo-controlled trial designed to determine whether the suppression of ventricular premature depolarizations in postmyocardial infarction patients would improve survival. Three class I antiarrhythmic drugs were used: encainide, flecainide, or moricizine. Patients for whom the drug suppressed their arrhythmia 80% or more were randomly assigned to that drug and dose or its matching placebo and were followed every 4 months (main study). Patients with 1% to 79% suppression were randomly assigned to the drug or its placebo that best treated their arrhythmia and followed every 4 months.

RESULTS

Suppression of asymptomatic or mildly symptomatic ventricular premature depolarization in patients using encainide, flecainide, or moricizine failed to improve patient survival and was even harmful in some cases.

CONCLUSIONS

Our results showed that in the absence of effective antiarrhythmic drug therapy, supportive nursing care and arrhythmia monitoring is important until appropriate therapy for the management of these arrhythmias in patients who have had a myocardial infarction can be found. Clinical trials are essential to provide an evaluation of therapies and direction for further studies, as well as a basis for practicing clinicians.

The Cardiac Arrhythmia Suppression Trial: Implications for nursing practice

BACKGROUND: Care of patients with ventricular arrhythmia after myocardial infarction requires careful nursing management, including assisting with arrhythmia monitoring and testing. Because ventricular premature depolarization is a known risk factor for sudden cardiac death, it was hypothesized that the suppression of asymptomatic or mildly symptomatic ventricular premature depolarization would improve survival in these patients. OBJECTIVE: To review the Cardiac Arrhythmia Suppression Trial findings and provide implications for nursing practice for patients after myocardial infarction. METHODS: The Cardiac Arrhythmia Suppression Trial was a multicenter, randomized, placebo-controlled trial designed to determine whether the suppression of ventricular premature depolarizations in postmyocardial infarction patients would improve survival. Three class I antiarrhythmic drugs were used: encainide, flecainide, or moricizine. Patients for whom the drug suppressed their arrhythmia 80% or more were randomly assigned to that drug and dose or its matching placebo and were followed every 4 months (main study). Patients with 1% to 79% suppression were randomly assigned to the drug or its placebo that best treated their arrhythmia and followed every 4 months. RESULTS: Suppression of asymptomatic or mildly symptomatic ventricular premature depolarization in patients using encainide, flecainide, or moricizine failed to improve patient survival and was even harmful in some cases. CONCLUSIONS: Our results showed that in the absence of effective antiarrhythmic drug therapy, supportive nursing care and arrhythmia monitoring is important until appropriate therapy for the management of these arrhythmias in patients who have had a myocardial infarction can be found. Clinical trials are essential to provide an evaluation of therapies and direction for further studies, as well as a basis for practicing clinicians.

Smoking cessation and arrhythmic death: the CAST experience. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators

OBJECTIVES

This study was performed to assess the effect of cigarette smoking cessation on overall mortality and the incidence of arrhythmic death in the population of the Cardiac Arrhythmia Suppression Trial (CAST).

BACKGROUND

Cigarette smoking is a known risk factor for sudden cardiac death. Some of the adverse effects of smoking have been shown to dissipate with smoking cessation, but the time frame over which these changes occur and the population that stands to benefit have not been well delineated. CAST was a multicenter double-blind placebo-controlled study to determine whether suppression of ventricular ectopic activity by means of antiarrhythmic drugs in patients with left ventricular dysfunction after acute myocardial infarction would reduce the incidence of arrhythmic death.

METHODS

Of 2,752 patients randomized to blinded therapy, 1,026 were smoking at the time of their baseline examination and completed a 4-month follow-up visit. Of these, 517 stopped smoking by the time of this visit ("quitters") and 509 continued to smoke ("smokers").

RESULTS

Over a mean follow-up period of slightly < 16 months, there were 17 arrhythmic deaths and 32 total deaths among the quitters versus 30 and 45, respectively, among the smokers; these differences were of marginal statistical significance. Most of the fatal events occurred in a group at high risk of ongoing ischemia: the 558 patients who did not have thrombolysis or undergo revascularization after their qualifying myocardial infarction. In this high risk cohort, smoking cessation greatly reduced the incidence of arrhythmic death and was associated with a statistically significant benefit in survival.

CONCLUSIONS

Smoking cessation was accompanied by a marked reduction in arrhythmic death and overall mortality that achieved statistical significance in a high risk cohort. These data imply that smoking cessation is important in risk factor reduction in patients with advanced ischemic heart disease.

Evaluation of an infrared open-path spectrometer using an exposure chamber and a calibration cell

This study evaluated the use of a controlled exposure chamber and calibration cell to investigate the performance of open-path remote sensing instruments for workplace monitoring of pollutants. An open-path infrared spectrometer was deployed in a chamber, and a range of homogeneous air concentrations were generated using the tracer gas sulfur hexafluoride (SF6). Open-path measurements were compared with point-sample measurements taken along the beam and analyzed using an infrared (IR) and electron capture detector (ECD). A five-compartment calibration cell placed in the optical path was used to simulate heterogeneous concentrations of pollutants. Fifteen concentration patterns were created by injecting different volumes of SF6 into each compartment. Open-path spectrometer measurements were compared with compartment concentrations measured using an ECD. Results indicated that stable homogeneous and heterogeneous concentrations of SF6 were generated in the controlled exposure chamber and five-compartment calibration cell, respectively. Overall, individual open-path measurements were within 20% of point samples measured with the IR and ECDs. The open-path spectrometer measurements had a consistent positive bias of about 12%. Exposure chamber experiments uncovered remote sensing instrument design aspects that could adversely impact its use for indoor monitoring. The weight and size of the instrument make it useable only in a fixed position, thus limiting spatial coverage of the beam in a room. The instrument components were not air-tight, resulting in overestimation of some open-path concentrations. A controlled test chamber and a long calibration cell placed in the optical path are useful tools for evaluating a variety of open-path spectrometer instrument performance issues relevant to industrial hygiene monitoring.

Evaluation of optical source-detector configurations for tomographic reconstruction of chemical concentrations in indoor air

This article reports on numerical studies to evaluate and compare optical remote sensing configurations for tomographically reconstructing pollutant concentrations in indoor air. With a remote sensing/computed tomography system, two-dimensional maps of pollutant concentrations with good spatial resolution can be created for an entire room. The successful use of such a system for exposure assessment, ventilation assessment, or source monitoring depends on the remote sensing configuration. A systematic method was developed to evaluate the performance of 10 configurations. One hundred and twenty test maps were reconstructed with an algebraic reconstruction method using all 10 configurations; reconstruction quality was evaluated using 4 criteria. Reconstruction quality was related to the number and location of detectors in the room and the complexity of the test maps. Configurations using the same number of detectors placed in different locations resulted in reconstructions that differed in quality. The effect of reducing the number density of rays on reconstruction quality was studied. Based on these simulations, two configurations that used four detectors to scan the room were selected, and their performance was evaluated in the presence of various levels of measurement noise. Two configurations that used four detectors were most suited for exposure assessment. It was found that when designing a configuration, the number and independence of rays should be maximized. Results underscored the need to thoroughly test configurations through numerical studies prior to field implementation; a wide variety of concentration maps, relevant to the application, should be tested under both ideal and nonideal sampling conditions.

Evaluation of algorithms for tomographic reconstruction of chemical concentrations in indoor air

Numerical studies were performed to evaluate and compare four different algorithms for tomographically reconstructing pollutant concentrations in indoor air measured with an optical remote sensing system. With a remote sensing/computed tomography system, two-dimensional maps of air concentrations can be created for an entire room with good spatial and temporal resolution. The success of such a system for characterizing the flow of contaminants in air, exposure assessment, and leak detection depends on the choice of tomographic reconstruction algorithm. A systematic method was developed to evaluate the performance of four algorithms: ART, ART3, SIRT, and SART. One hundred and twenty test maps were reconstructed by each algorithm under ideal and nonideal sampling conditions, and image quality was evaluated using four criteria. The nonideal sampling conditions included simulation of measurement noise and reduction in the number density of rays. Performance of the algorithms was found to be intimately related to the number of peaks in the test maps. The importance of using multiple measures of image quality was underscored by the fact that for some sampling conditions simulated, performance of the algorithms was judged differently depending on the evaluation criteria. Results indicated that using numerical studies is successful for evaluating such algorithms.

Pulmonary toxicity of monocrotaline differs at critical periods of lung development

We injected 3-day-old (neonatal), 8-day-old (infant), and 8-wk-old (adult) Sprague-Dawley rats with monocrotaline to examine the effect of a toxic agent at various stages of lung development. Two and four weeks after injection the rats were killed and the heart and lungs removed: the right and left ventricles were separated and weighed, the pulmonary artery was injected with barium-gelatin, and the lung was fixed in the inflated state. Morphometric techniques were applied to assess lung volume, alveolar size and number, and arterial size, muscularity, and concentration relative to alveolar. Rats injected with monocrotaline in the neonatal period did not survive to 3 wk. After 2 wk, there was no significant right ventricular hypertrophy and pulmonary vascular changes were no worse than in the other rat groups injected with monocrotaline, but alveolar development was severely impaired; less than one-third the normal number was present. Rats injected with monocrotaline in infancy had normal alveolar development. After 2-wk, the arterial changes, i.e. extension of muscle into peripheral arteries, medial hypertrophy of muscular arteries, and decreased arterial concentration relative to alveolar were similar to those observed in adult rats. After 4 wk, there was a decrease in medial hypertrophy associated with growth in artery size and only a lack of regression of right ventricular weight. In adult rats, after 4 wk medial hypertrophy became progressively more severe, the arterial concentration relative to alveolar decreased further, and right ventricular hypertrophy developed.(ABSTRACT TRUNCATED AT 250 WORDS)

Address of the President Lord Todd, O.M. at the Anniversary Meeting, 30 November 1978: Award of Medals 1978

The Copley Medal is awarded to Professor R. B. Woodward, ForMem. R. S. Professor Woodward is universally acknowledged to be the leading organic chemist of his generation. He has constantly been attracted by the chemistry of naturally occurring substances and his work has transformed the field. He recognized at a very early stage that spectroscopy allowed a control of synthetic and degradative research that could not previously have been contemplated. He made major contributions to the structure determination of complex molecules from widely different classes of compounds, including penicillin, strych­nine, patulin, gelsemine, cevine, aureomycin, calycanthine and tetrodotoxin.