Applying a Social Ecological Model to Medical Legal Partnerships Practice and Research

The social ecological model (SEM) is a conceptual framework that recognizes individuals function within multiple interactive systems and contextual environments that influence their health. Medical Legal Partnerships (MLPs) address the social determinants of health through partnerships between health providers and civil legal services. This paper explores how the conceptual framework of SEM can be applied to the MLP model, which also uses a multidimensional approach to address an individual's social determinants of health.

Selection for increased cranial capacity in small mammals during a century of urbanization

Urbanization is a selective force that is known to drive changes in the population dynamics of wildlife. How animals adapt to changing environmental conditions is crucial to their survival in these environments. Relative brain size, or cranial capacity, is a known proxy of behavioral flexibility, and can be used to assess how well a species has adapted to a particular environment. We examined changes in cranial capacity in a time series of small mammal skulls collected from urban and rural populations in southwestern Pennsylvania. Skulls from urban populations were collected from Allegheny County, an area that experienced rapid urbanization over the past century, and skulls of rural populations from the Powdermill Nature Reserve of the Carnegie Museum, which has remained relatively unchanged forest over the same period. Our results show that Peromyscus leucopus and Microtus pennsylvanicus from urban populations had significantly greater cranial capacity than their rural counterparts, but the opposite was true for Eptesicus fuscus. We found no difference in relative cranial capacity across time in any of the small mammal species. Our results suggest that a larger cranial capacity is selected for in an urban environment and reinforces the hypothesis that behavioral flexibility is important for animals to adapt to novel environments.

Patient empowerment: Its implementation and systems within hospitals in England and Greece

Introduction

International health policies recognise patient empowerment, resulting in diverse empowerment models and systems. Research on organisational systems for implementing patient empowerment between countries or from organisational stakeholders’ perspective, however, is limited. Aims and methodology: This paper explores and compares organisational systems and structures for patient empowerment implementation in six acute public hospitals in England and Greece (three in each country), their cross-case and cross-national similarities and differences. It uses a comparative, qualitative, explanatory embedded case study design. Semi-structured interviews with a representative sample of stakeholders (n = 33) and documentary sources (n = 79) were analysed with framework.

Results

Two main patient empowerment themes were identified: (1) organisational leadership, systems, structures; (2) operational structures, services, mechanisms and activities. Generic organisational systems and structures for patient empowerment varied across-cases, but with common organisation of empowerment roles in England and common leadership in Greece. Operational structures, services and mechanisms supporting empowerment varied across-cases and cross-nationally, but with similarities in the main services.

Conclusion

Implementation of patient empowerment was weaker in Greece than in England, attributable to differing approaches to strategic and operational leadership, limited development of strategies and influential organisational structures. Overall, patient empowerment is well-embedded in organisations with a highly visible patient empowerment profile; commitment to policies and strategy implementation at different levels; strategic and operational leadership investing in dedicated roles with clear authority for patient empowerment, influential empowerment structures and mechanisms.

Underdetection of comorbid drug use at acute psychiatric admission

Aims and Method

The ability of routine clinical practice to detect drug use at acute psychiatric admission was assessed by comparing the results of urinalysis with information on drug use extracted from patient records (n=112).

Results

Urinalysis detected drug use in 23% of the sample. Cannabis was the drug most frequently found. Of the cases of drug use positively identified by urinalysis, 54% were not identified in the notes. Some information on drug use proximal to admission was found in 40% of patient records. Patients asked about proximal drug use were younger than those not asked.

Clinical Implications

All patients should be asked about drug use.

Do High Fidelity Wraparound Services for Youth with Serious Emotional Disturbances Save Money in the Long-Term?

BACKGROUND

Treating youth with serious emotional disturbances (SED) is expensive often requiring institutional care. A significant amount of recent federal and state funding has been dedicated to expanding home and community-based services for these youth as an alternative to institutional care. High Fidelity Wraparound (Wrap) is an evolving, evidence-informed practice to help sustain community-based placements for youth with an SED through the use of intensive, customized care coordination among parents, multiple child-serving agencies, and providers. While there is growing evidence on the benefits of Wrap, few studies have examined health care spending associated with Wrap participation and none have examined spending patterns after the completion of Wrap. Merging health care spending data from multiple agencies and programs allows for a more complete picture of the health care costs of treating these youth in a system-of-care framework.

AIMS OF STUDY

(i) To compare overall health care spending for youth who transitioned from institutional care into Wrap (the treatment group) versus youth not receiving Wrap (the control group) and (ii) to compare changes in health care spending, overall and by category, for both groups before (the pre-period) and after (the post-period) Wrap participation.

METHODS

The treatment group (N=161) is matched to the control group (N=324) temporally based on the month the youth entered institutional care. Both total health care spending and spending by category are compared for each group pre- and post-Wrap participation. The post-period includes the time in which the youth was receiving Wrap services and one year afterwards to capture long-term cost impacts.

RESULTS

In the year before Wrap participation, the treatment group averaged USD 8,433 in monthly health care spending versus USD 4,599 for the control group. Wrap participation led to an additional reduction of USD 1,130 in monthly health care spending as compared to the control group in the post-period. For youth participating in Wrap, these spending reductions were the result of decreases in mental health inpatient spending and general outpatient spending.

DISCUSSION

Youth participating in Wrap had much higher average monthly costs than youth in the control group for the year prior to entering Wrap, suggesting that the intervention targeted youth with the highest mental health utilization and likely more complex needs. While both groups experienced reductions in spending, the treatment group experienced larger absolute reductions, but smaller relative reductions associated with participation. These differences were driven mainly by reductions in mental health inpatient spending. Larger reductions in general outpatient spending for the treatment group suggest spillover benefits in terms of physical health care spending. Further analysis is needed to assess how these spending changes impacted health outcomes.

IMPLICATIONS FOR HEALTH POLICIES

Wrap or similar programs may lead to reductions in health care spending. This is the first study to find evidence of longer-term spending reductions for up to a year after Wrap participation.

IMPLICATIONS FOR FURTHER RESEARCH

Randomized trials or some other source of plausibly exogenous variation in Wrap participation is needed to further assess the causal impact of Wrap on health care spending, outcomes, or broader system-of-care spending.

Interprofessional Medical-Legal Education of Medical Students: Assessing the Benefits for Addressing Social Determinants of Health

PROBLEM

Screening tools exist to help identify patient issues related to social determinants of health (SDH), but solutions to many of these problems remain elusive to health care providers as they require legal solutions. Interprofessional medical-legal education is essential to optimizing health care delivery.

APPROACH

In 2011, the authors implemented a four-session didactic interprofessional curriculum on medical-legal practice for third-year medical students at Morehouse School of Medicine. This program, also attended by law students, focused on interprofessional collaboration to address client/patient SDH issues and health-harming legal needs. In 2011-2014, the medical students participated in pre- and postintervention surveys designed to determine their awareness of SDH's impact on health as well as their attitudes toward screening for SDH issues and incorporating resources, including a legal resource, to address them. Mean ratings were compared between pre- and postintervention respondent cohorts using independent-sample t tests.

OUTCOMES

Of the 222 medical students who participated in the program, 102 (46%) completed the preintervention survey and 100 (45%) completed the postintervention survey. Postintervention survey results indicated that students self-reported an increased likelihood to screen patients for SDH issues and an increased likelihood to refer patients to a legal resource (P < .001).

NEXT STEPS

Incorporating interprofessional medical-legal education into undergraduate medical education may result in an increased likelihood to screen patients for SDH and to refer patients with legal needs to a legal resource. In the future, an additional evaluation to assess the curriculum's long-term impact will be administered prior to graduation.

Empowerment in nurse leader groups in middle management: a quantitative comparative investigation

AIMS AND OBJECTIVES

The aim was to investigate structural empowerment in nurse leaders in middle management positions. Objectives were to determine levels of empowerment of nurse leaders and to compare levels of empowerment between nurse leader groups.

BACKGROUND

Access to formal and informal power, opportunity, resources, information and support are determinants of structural empowerment. Empowerment of nurse leaders in middle management positions is vital given their roles in enabling nursing teams to deliver high-quality care, benefitting both patient and workforce outcomes.

DESIGN

Quantitative component of a mixed methods study using survey principles.

METHODS

The Conditions of Work Effectiveness Questionnaire II was distributed to the total population (n = 517) of nurse leaders in an NHS Foundation Trust in England. Nurse leader groups comprised unit leaders (sisters, matrons) and senior staff nurses. Quantitative data entered on spss v 17/18, were analysed using descriptive and inferential statistics.

RESULTS

Overall, the unit response rate was 44·1% (n = 228). Levels of total and global empowerment were moderate and moderate to high respectively. Groups did not differ significantly on these parameters or on five elements of total empowerment, but significantly higher scores were found for unit leaders' access to information. Significantly higher scores were found for senior staff nurses on selected aspects of informal power and access to resources, but scores were significantly lower than unit leaders for components of support.

CONCLUSIONS

A moderately empowered population of nurse leaders differed in relation to access to information, aspects of support, resources and informal power, reflecting differences in roles, spheres of responsibility, hierarchical position and the constraints on empowerment imposed on unit leaders by financial and resource pressures.

RELEVANCE TO CLINICAL PRACTICE

Empowerment of nurse leaders in middle management is vital in enabling nursing teams to deliver high-quality care. Roles, spheres of responsibility, hierarchical position and constraints imposed by financial and resource pressures influence nurse leader empowerment. Administrative support is needed to sustain practice engagement.

A critical analysis of national policies, systems, and structures of patient empowerment in England and Greece

BACKGROUND

Comparison of patient empowerment (PE) policies in European countries can provide evidence for improvement and reform across different health systems. It may also influence patient and public involvement, patient experience, preference, and adherence.

OBJECTIVE

The objective of this study was to compare PE within national policies, systems, and structures in England and Greece for achieving integrated people-centered health services.

METHODS

We performed a critical search and review of policy and legislation papers in English and Greek languages. This included 1) general health policy and systems papers, 2) PE, patient and/or public involvement or patients' rights policy and legislation (1990-2015), and 3) comparative or discussion papers for England and/or Greece.

RESULTS

A total of 102 papers on PE policies, systems, and structures were identified initially; 80 papers were included, in which 46 were policy, legislative, and discussion papers about England, 21 were policy, legislation, and discussion papers about Greece, and 13 were comparative or discussion papers including both the countries. In England, National Health Service policies emphasized patient-centered services, involvement, and empowerment, with recent focus on patients' rights; while in Greece, they emphasized patients' rights and quality of services, with recent mentions on empowerment. The health ombudsman is a very important organization across countries; however, it may be more powerful in Greece, because of the nonexistence of local mediating bodies. Micro-structures at trusts/hospitals are comparable, but legislation gives more power to the local structures in Greece.

CONCLUSION

PE policies and systems have been developed and expressed differently in these countries. However, PE similarities, comparable dimensions and mechanisms, were identified. For both the countries, comparative research and these findings could be beneficial in building connections and relationships, contributing to wider European and international developments on PE, involvement, and patients' rights and further impact on patient preferences and adherence.

Partnerships for changing practice: Lessons from South Thames Evidence-based Practice project (STEP)

Partnership working is central to the rubric of contemporary health policy. This paper discusses and analyses the STEP partnership model and the issues emerging for academic and service coalitions, which were formed for the purpose of implementing evidence-based practice in nine clinical centres. Using a framework for collaboration, key themes for successful partnerships are summarised in a model as contextual factors: articulating a clear purpose, identifying the capacity to collaborate, ensuring wide organisational ownership, nurturing fragile relationships and securing collaborative, mutually beneficial outcomes. The paper focuses on the experience of setting up, managing, supporting and evaluating the STEP partnership from the perspective of academic and clinical leads and the independent evaluation.

Leading opinion and managing change in complex organizations: Findings from the South Thames Evidence-based Practice project

Opinion-leaders have been described in the research literature as credible experts, capable of supporting, facilitating or advocating change and influencing health professionals to adopt innovatory, evidence-based approaches to their practice (Lomas et al., 1991; Thomson et al., 1999). However, information is lacking on the complexity of selection and training, and of the role support that is necessary to enable opinion-leaders to function effectively. This paper focuses on the experience of using opinion-leaders to implement practice change as part of a multi-faceted approach within the South Thames Evidence-based Practice project (STEP), drawing on information integrated from a cross-case analysis and the independent evaluation. Key findings are that the opinion-leader role is complex and challenging, and requires a broad balance of research, management and leadership competences to inform selection and training.

Mind how you cross the gap! Outcomes for young people who failed to make the transition from child to adult services: the TRACK study

Aims and method The Transitions of Care from Child and Adolescent Mental Health Services to Adult Mental Health Services (TRACK) study was a multistage, multicentre study of adolescents' transitions between child and adult mental health services undertaken in England. We conducted a secondary analysis of the TRACK study data to investigate healthcare provision for young people (n = 64) with ongoing mental health needs, who were not transferred from child and adolescent mental health services (CAMHS) to adult mental health services mental health services (AMHS). Results The most common outcomes were discharge to a general practitioner (GP; n = 29) and ongoing care with CAMHS (n = 13), with little indication of use of third-sector organisations. Most of these young people had emotional/neurotic disorders (n = 31, 48.4%) and neurodevelopmental disorders (n = 15, 23.4%). Clinical implications GPs and CAMHS are left with the responsibility for the continuing care of young people for whom no adult mental health service could be identified. GPs may not be able to offer the skilled ongoing care that these young people need. Equally, the inability to move them decreases the capacity of CAMHS to respond to new referrals and may leave some young people with only minimal support.

Defining continuity of care from the perspectives of mental health service users and professionals: an exploratory, comparative study

Background

Continuity of care (COC) is central to the organization and delivery of mental health services. Traditional definitions have excluded service users, and this lack of involvement has been linked to poor conceptual clarity surrounding the term. Consequently, very little is known about the differences and similarities in the conceptualization of COC by mental health service users and professionals.

Objective

To explore and compare mental health service users’ and professionals’ definitions of COC.

Methods

Using an exploratory, qualitative design, five focus groups with 32 service users each met twice. Data were analysed thematically to generate a service user‐defined model of COC. In a cross‐sectional survey, health and social care professionals (n = 184) defined COC; responses were analysed thematically. Service user and professional definitions were conceptually mapped and compared to identify similarities and differences.

Results

There was crossover between the service user and professional derived models of COC. Both contained temporal, quality, systemic, staff, hospital and needs‐related elements of COC. Service users prioritized access, information, peer support and avoiding services; health professionals most frequently referred to staff, cross‐sectional and temporal COC. Service users alone identified service avoidance, peer support and day centres as COC elements; professionals alone identified cross‐sectional working.

Conclusions

Important similarities and differences exist in service user and professional conceptualizations of COC. Further research is necessary to explore these differences, prior to integrating service user and professional perspectives in a validated COC framework which could enable the development and evaluation of interventions to improve COC, informing policy and practice.

Examining the potential of information technology to improve public insurance application processes: enrollee assessments from a concurrent mixed method analysis

OBJECTIVE

To assess the perceived readiness of Medicaid and Children's Health Insurance Program (CHIP) enrollees to use information technologies (IT) in order to facilitate improvements in the application processes for these public insurance programs.

METHODS

We conducted a concurrent mixed method study of Medicaid and CHIP enrollees in a southern state. We conducted focus groups to identify enrollee concerns regarding the current application process and their IT proficiency. Additionally, we surveyed beneficiaries via telephone about their access to and use of the Internet, and willingness to adopt IT-enabled processes. 2013 households completed the survey. We used χ(2) analysis for comparisons across different groups of respondents.

RESULTS

A majority of enrollees will embrace IT-enabled enrollment, but a small yet significant group continues to lack access to facilitating technologies. Moreover, a segment of beneficiaries in the two programs continues to place a high value on personal interactions with program caseworkers.

DISCUSSION

IT holds the promise of improving efficiency and reducing barriers for enrollees, but state and federal agencies managing public insurance programs need to ensure access to traditional processes and make caseworkers available to those who require and value such assistance, even after implementing IT-enabled processes.

CONCLUSIONS

The use of IT-enabled processes is essential for effectively managing eligibility and enrollment determinations for public programs and private plans offered through state or federally operated exchanges. However, state and federal officials should be cognizant of the technological readiness of recipients and provide offline help to ensure broad participation in the insurance market.

Can access to a medical-legal partnership benefit patients with asthma who live in an urban community?

Approximately one in 10 children in the U.S. has a diagnosis of asthma. African American and low-income children are more likely to be diagnosed with asthma. They are more likely to suffer the worse outcomes because of low socioeconomic status and environmental exposures. A medical-legal partnership is an interdisciplinary collaboration between a medical entity such as a hospital or clinic and a legal entity such as a lawyer, law school, or legal aid society created to address barriers to health care access and limitations to well-being. Addressing the legal concerns of these patients can improve access to medical services, reduce family stress, and address legal concerns that contribute to poor health. The Health Law Partnership (HeLP) is one such medical-legal partnership that provides a holistic, interdisciplinary approach to health care. During the seven-year study period we found both financial ($501,209) and non-financial benefits attributable to interventions by the attorneys at HeLP.

The effect of organisational resources and eligibility issues on transition from child and adolescent to adult mental health services

OBJECTIVES

To investigate the organisational factors that impede or facilitate transition of young people from child and adolescent (CAMHS) to adult mental health services (AMHS).

METHODS

Thirty-four semi-structured interviews were conducted with health and social care professionals working in child and adult services in four English NHS Mental Health Trusts and voluntary organisations. Data were analysed thematically using a structured framework.

RESULTS

Findings revealed a lack of clarity on service availability and the operation of different eligibility criteria between child and adult mental health services, with variable service provision for young people with attention deficit hyperactivity disorder, autism spectrum disorders and learning disabilities. High workloads and staff shortages were perceived to influence service thresholds and eligibility criteria.

CONCLUSIONS

A mutual lack of understanding of services and structures together with restrictive eligibility criteria exacerbated by perceived lack of resources can impact negatively on the transition between CAMHS and AMHS, disrupting continuity of care for young people.

Somatic CALR mutations in myeloproliferative neoplasms with nonmutated JAK2

BACKGROUND

Somatic mutations in the Janus kinase 2 gene (JAK2) occur in many myeloproliferative neoplasms, but the molecular pathogenesis of myeloproliferative neoplasms with nonmutated JAK2 is obscure, and the diagnosis of these neoplasms remains a challenge.

METHODS

We performed exome sequencing of samples obtained from 151 patients with myeloproliferative neoplasms. The mutation status of the gene encoding calreticulin (CALR) was assessed in an additional 1345 hematologic cancers, 1517 other cancers, and 550 controls. We established phylogenetic trees using hematopoietic colonies. We assessed calreticulin subcellular localization using immunofluorescence and flow cytometry.

RESULTS

Exome sequencing identified 1498 mutations in 151 patients, with medians of 6.5, 6.5, and 13.0 mutations per patient in samples of polycythemia vera, essential thrombocythemia, and myelofibrosis, respectively. Somatic CALR mutations were found in 70 to 84% of samples of myeloproliferative neoplasms with nonmutated JAK2, in 8% of myelodysplasia samples, in occasional samples of other myeloid cancers, and in none of the other cancers. A total of 148 CALR mutations were identified with 19 distinct variants. Mutations were located in exon 9 and generated a +1 base-pair frameshift, which would result in a mutant protein with a novel C-terminal. Mutant calreticulin was observed in the endoplasmic reticulum without increased cell-surface or Golgi accumulation. Patients with myeloproliferative neoplasms carrying CALR mutations presented with higher platelet counts and lower hemoglobin levels than patients with mutated JAK2. Mutation of CALR was detected in hematopoietic stem and progenitor cells. Clonal analyses showed CALR mutations in the earliest phylogenetic node, a finding consistent with its role as an initiating mutation in some patients.

CONCLUSIONS

Somatic mutations in the endoplasmic reticulum chaperone CALR were found in a majority of patients with myeloproliferative neoplasms with nonmutated JAK2. (Funded by the Kay Kendall Leukaemia Fund and others.).

Continuity of care for carers of people with severe mental illness: results of a longitudinal study

INTRODUCTION

Continuity of care has been demonstrated to be important for service users and carer groups have voiced major concerns over disruptions of care. We aimed to assess the experienced continuity of care in carers of patients with both psychotic and non-psychotic disorders and explore its association with carer characteristics and psychological well-being.

METHODS

Friends and relatives caring for two groups of service users in the care of community mental health teams (CMHTs), 69 with psychotic and 38 with non-psychotic disorders, were assessed annually at three and two time points, respectively. CONTINUES, a measure specifically designed to assess continuity of care for carers themselves, was utilized along with assessments of psychological well-being and caregiving.

RESULTS

One hundred and seven carers participated. They reported moderately low continuity of care. Only 22 had had a carer's assessment and just under a third recorded psychological distress on the GHQ. For those caring for people with psychotic disorders, reported continuity was higher if the carer was male, employed, lived with the user and had had a carer's assessment; for those caring for people with non-psychotic disorders, it was higher if the carer was from the service user's immediate family, lived with them and had had a carer's assessment.

CONCLUSION

The vast majority of the carers had not had a carer's assessment provided by the CMHT despite this being a clear national priority and being an intervention with obvious potential to increase carers' reported low levels of continuity of care. Improving continuity of contact with carers may have an important part to play in the overall improvement of care in this patient group and deserves greater attention.

'Talking a different language': an exploration of the influence of organizational cultures and working practices on transition from child to adult mental health services

BACKGROUND

Organizational culture is manifest in patterns of behaviour underpinned by beliefs, values, attitudes and assumptions, which can influence working practices. Cultural factors and working practices have been suggested to influence the transition of young people moving from child to adult mental health services. Failure to manage and integrate transitional care effectively can lead to young people losing contact with health and social care systems, resulting in adverse effects on health, well-being and potential.

METHODS

The study aim was to identify the organisational factors which facilitate or impede transition of young people from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) from the perspective of health professionals and representatives of voluntary organisations. Specific objectives were (i) to explore organizational cultures, structures, processes and resources which influence transition from child to adult mental health services; (ii) identify factors which constitute barriers and facilitators to transition and continuity of care and (iii) make recommendations for service improvements. Within an exploratory, qualitative design thirty four semi-structured interviews were conducted with health and social care professionals working in CAMHS and AMHS in four NHS Mental Health Trusts and four voluntary organizations, in England.

RESULTS

A cultural divide appears to exist between CAMHS and AMHS, characterized by different beliefs, attitudes, mutual misperceptions and a lack of understanding of different service structures. This is exacerbated by working practices relating to communication and information transfer which could impact negatively on transition, relational, informational and cross boundary continuity of care. There is also evidence of a cultural shift, with some positive approaches to collaborative working across services and agencies, involving joint posts, parallel working, shared clinics and joint meetings.

CONCLUSIONS

Cultural factors embodied in mutual misperceptions, attitudes, beliefs exist between CAMHS and AMHS. Working practices can exert either positive or negative effects on transition and continuity of care. Implementation of shared education and training, standardised approaches to record keeping and information transfer, supported by compatible IT resources are recommended, alongside management strategies which evaluate the achievement of outcomes related to transition and continuity of care.

'Talking a different language': an exploration of the influence of organizational cultures and working practices on transition from child to adult mental health services

BACKGROUND

Organizational culture is manifest in patterns of behaviour underpinned by beliefs, values, attitudes and assumptions, which can influence working practices. Cultural factors and working practices have been suggested to influence the transition of young people moving from child to adult mental health services. Failure to manage and integrate transitional care effectively can lead to young people losing contact with health and social care systems, resulting in adverse effects on health, well-being and potential.

METHODS

The study aim was to identify the organisational factors which facilitate or impede transition of young people from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) from the perspective of health professionals and representatives of voluntary organisations. Specific objectives were (i) to explore organizational cultures, structures, processes and resources which influence transition from child to adult mental health services; (ii) identify factors which constitute barriers and facilitators to transition and continuity of care and (iii) make recommendations for service improvements. Within an exploratory, qualitative design thirty four semi-structured interviews were conducted with health and social care professionals working in CAMHS and AMHS in four NHS Mental Health Trusts and four voluntary organizations, in England.

RESULTS

A cultural divide appears to exist between CAMHS and AMHS, characterized by different beliefs, attitudes, mutual misperceptions and a lack of understanding of different service structures. This is exacerbated by working practices relating to communication and information transfer which could impact negatively on transition, relational, informational and cross boundary continuity of care. There is also evidence of a cultural shift, with some positive approaches to collaborative working across services and agencies, involving joint posts, parallel working, shared clinics and joint meetings.

CONCLUSIONS

Cultural factors embodied in mutual misperceptions, attitudes, beliefs exist between CAMHS and AMHS. Working practices can exert either positive or negative effects on transition and continuity of care. Implementation of shared education and training, standardised approaches to record keeping and information transfer, supported by compatible IT resources are recommended, alongside management strategies which evaluate the achievement of outcomes related to transition and continuity of care.

Continuity of care for people with psychotic illness: its relationship to clinical and social functioning

BACKGROUND

The relationship between continuity of care and user characteristics or outcomes has rarely been explored. The ECHO study operationalized and tested a multi-axial definition of continuity of care, producing a seven-factor model used here.

AIMS

To assess the relationship between user characteristics and established components of continuity of care, and the impact of continuity on clinical and social functioning.

METHODS

The sample comprised 180 community mental health team users with psychotic disorders who were interviewed at three annual time-points, to assess their experiences of continuity of care and clinical and social functioning. Scores on seven continuity factors were tested for association with user-level variables.

RESULTS

Improvement in quality of life was associated with better Experience & Relationship continuity scores (better user-rated continuity and therapeutic relationship) and with lower Meeting Needs continuity factor scores. Higher Meeting Needs scores were associated with a decrease in symptoms.

CONCLUSION

Continuity is a dynamic process, influenced significantly by care structures and organizational change.

Development of an assessment tool for the multidisciplinary evaluation of neurological dependency: preliminary findings

BACKGROUND

Multidisciplinary inputs are of vital importance in the comprehensive care management and rehabilitation of individuals with long-term neurological conditions. Although many ordinal measures of disability correlate with patient dependency and care, few are based on numbers of different health professionals required, or their skill-mix, for assistance associated with levels of dependency.

AIM AND OBJECTIVES

To develop an instrument to assess dependency in adult patients suffering from severe and complex neurological disability for use by multidisciplinary teams. Objectives were to establish content validity, construct validity, inter-rater reliability and internal consistency, and to demonstrate preliminary clinical utility from the perspective of professional staff.

DESIGN AND METHODS

A mixed methods design utilised qualitative and quantitative approaches. Stage I involved developmental fieldwork using focus groups (n = 3), questionnaires (n = 70), expert panel (n = 20) and direct observation (n = 12). In stage 2, intensive refinement through direct observation, construct validity and reliability testing (n = 100) of the instrument was completed. The research complied with the research governance and ethical standards set by the Department of Health (UK).

RESULTS

In the final format, an instrument was developed which comprised two sections. Section 1: an ordinal scaled basic care section, with 15 categories of dependency and level of descriptors based on numbers, grade and time taken by staff providing assistance. Factor analysis identified one dominant and four subsidiary factors which explained 67% of the total variance. Overall inter-rater agreement was 0.87 (kappa coefficient: range 0.67-1.0), and Cronbach's coefficient alpha was 0.733. Section 2: comprised a nominally measured specialist care section for inputs from nurses and therapists. The mean time taken to complete assessments was 12 minutes.

CONCLUSION

The instrument satisfied preliminary selective criteria for validity and reliability. Further research is necessary to satisfy other requirements of psychometric testing and clinical utility.

Pan-London tuberculosis services: a service evaluation

Background

London has the largest proportion of tuberculosis (TB) cases of any western European capital, with almost half of new cases drug-resistant. Prevalence varies considerably between and within boroughs with research suggesting inadequate control of TB transmission in London. Economic pressures may exacerbate the already considerable challenges for service organisation and delivery within this context. This paper presents selected findings from an evaluation of London’s TB services’ organisation, delivery, professional workforce and skill mix, intended to support development of a strategic framework for a pan-London TB service. These may also interest health service professionals and managers in TB services in the UK, other European cities and countries and in services currently delivered by multiple providers operating independently.

Methods

Objectives were: 1) To establish how London’s TB services are structured and delivered in relation to leadership, management, organisation and delivery, coordination, staffing and support; 2) To identify tools/models for calculating skill mix as a basis for identifying skill mix requirements in delivering TB services across London; 3) To inform a strategic framework for the delivery of a pan-London TB service, which may be applicable to other European cities. The multi-method service audit evaluation comprised documentary analysis, semi-structured interviews with TB service users (n = 10), lead TB health professionals and managers (n = 13) representing London’s five sectors and focus groups with TB nurses (n = 8) and non-London network professionals (n = 2).

Results

Findings showed TB services to be mainly hospital-based, with fewer community-based services. Documentary analysis and professionals’ interviews suggested difficulties with early access to services, low suspicion index amongst some GPs and restricted referral routes. Interviews indicated lack of managed accommodation for difficult to treat patients, professional workforce shortages, a need for strategic leadership, nurse-led clinics and structured career paths for TB nurses and few social care/outreach workers to support patients with complex needs.

Conclusions

This paper has identified key issues relating to London’s TB services’ organisation, delivery, professional workforce and skill mix. The majority of these present challenges which need to be addressed as part of the future development of a strategic framework for a pan-London TB service. More consistent strategic planning/co-ordination and sharing of best practice is needed, together with a review of pan-London TB workforce development strategy, encompassing changing professional roles, skills development needs and patient pathways. These findings may be relevant with the development of TB services in other European cities.

Somatic SF3B1 mutation in myelodysplasia with ring sideroblasts

BACKGROUND

Myelodysplastic syndromes are a diverse and common group of chronic hematologic cancers. The identification of new genetic lesions could facilitate new diagnostic and therapeutic strategies.

METHODS

We used massively parallel sequencing technology to identify somatically acquired point mutations across all protein-coding exons in the genome in 9 patients with low-grade myelodysplasia. Targeted resequencing of the gene encoding RNA splicing factor 3B, subunit 1 (SF3B1), was also performed in a cohort of 2087 patients with myeloid or other cancers.

RESULTS

We identified 64 point mutations in the 9 patients. Recurrent somatically acquired mutations were identified in SF3B1. Follow-up revealed SF3B1 mutations in 72 of 354 patients (20%) with myelodysplastic syndromes, with particularly high frequency among patients whose disease was characterized by ring sideroblasts (53 of 82 [65%]). The gene was also mutated in 1 to 5% of patients with a variety of other tumor types. The observed mutations were less deleterious than was expected on the basis of chance, suggesting that the mutated protein retains structural integrity with altered function. SF3B1 mutations were associated with down-regulation of key gene networks, including core mitochondrial pathways. Clinically, patients with SF3B1 mutations had fewer cytopenias and longer event-free survival than patients without SF3B1 mutations.

CONCLUSIONS

Mutations in SF3B1 implicate abnormalities of messenger RNA splicing in the pathogenesis of myelodysplastic syndromes. (Funded by the Wellcome Trust and others.).

Economic impact of a Medicaid population health management program

A population health management program was implemented to assess growth in health care expenditures for the disabled segment of Georgia's Medicaid population before and during the first year of a population health outcomes management program, and to compare those expenditures with projected costs based on various cost inflation trend assumptions. A retrospective, nonexperimental approach was used to analyze claims data from Georgia Medicaid claims files for all program-eligible persons for each relevant time period (intent-to-treat basis). These included all non-Medicare, noninstitutionalized Medicaid aged-blind-disabled adults older than 18 years of age. Comparisons of health care expenditures and utilization were made between base year (2003-2004) and performance year one (2006-2007), and of the difference between actual expenditures incurred in the performance year vs. projected expenditures based on various cost inflation assumptions. Demographic characteristics and clinical complexity of the population (as measured by the Chronic Illness and Disability Payment System risk score) actually increased from baseline to implementation. Actual expenditures were less than projected expenditures using any relevant medical inflation assumption. Actual expenditures were less than projected expenditures by $9.82 million when using a conservative US general medical inflation rate, by $43.6 million using national Medicaid cost trends, and by $106 million using Georgia Medicaid's own cost projections for the non-dually eligible disabled segment of Medicaid enrollees. Quadratic growth curve modeling also demonstrated a lower rate of increase in total expenditures. The rate of increase in expenditures was lower over the first year of program implementation compared with baseline. Weighted utilization rates were also lower in high-cost categories, such as inpatient days, despite increases in the risk profile of the population. Varying levels of cost avoidance could be inferred from differences between actual and projected expenditures using each of the health-related inflation assumptions.

Achieving continuity of care: facilitators and barriers in community mental health teams

Background

The integration of mental health and social services for people diagnosed with severe mental illness (SMI) has been a key aspect of attempts to reform mental health services in the UK and aims to minimise user and carer distress and confusion arising from service discontinuities. Community mental health teams (CMHTs) are a key component of UK policy for integrated service delivery, but implementing this policy has raised considerable organisational challenges. The aim of this study was to identify and explore facilitators and barriers perceived to influence continuity of care by health and social care professionals working in and closely associated with CMHTs.

Methods

This study employed a survey design utilising in-depth, semi-structured interviews with a proportionate, random sample of 113 health and social care professionals and representatives of voluntary organisations. Participants worked in two NHS Mental Health Trusts in greater London within eight adult CMHTs and their associated acute in-patient wards, six local general practices, and two voluntary organisations.

Results

Team leadership, decision making, and experiences of teamwork support were facilitators for cross boundary and team continuity; face-to-face communication between teams, managers, general practitioners, and the voluntary sector were facilitators for information continuity. Relational, personal, and longitudinal continuity were facilitated in some local areas by workforce stability. Barriers for cross boundary and team continuity were specific leadership styles and models of decision making, blurred professional role boundaries, generic working, and lack of training for role development. Barriers for relational, personal, and longitudinal continuity were created by inadequate staffing levels, high caseloads, and administrative duties that could limit time spent with users. Incompatibility of information technology systems hindered information continuity. Flexible continuity was challenged by the increasingly complex needs of service users.

Conclusions

Substantive challenges exist in harnessing the benefits of integrated CMHT working to deliver continuity of care. Team support should be prioritised in terms of IT provision linked to a review of current models of administrative support. Investment in education and training for role development, leadership, workforce retention, and skills to meet service users' complex needs are recommended.

Listening to those on the frontline: service users' experiences of London tuberculosis services

AIM

To explore tuberculosis (TB) service users' experiences and satisfaction with care provision.

BACKGROUND

Thirty-nine percent of all new UK TB cases occur in London. Prevalence varies considerably between and within boroughs. Overall, research suggests inadequate control of London's TB transmission; TB has become a health care priority for all London Primary Care Trusts. Service users' experiences and satisfaction with care provision have not been explored adequately previously.

METHODS

A qualitative research design, using semi-structured face-to-face interviews was used. Ten service users, purposively selected in key risk groups across London, were interviewed. All interviews were digitally recorded with users' permission, transcribed verbatim, and analyzed thematically.

RESULTS

Participants were treated in local hospitals for 6-12 months. Treatment was administered by TB nurses to inpatients and outpatients receiving directly observed therapy in consultation with medical staff and home visits for complex cases. Two participants did not realize the importance of compliance. Overall, they were satisfied with many TB services' aspects, communication, and service organization. Early access, low suspicion index amongst some GPs, and restricted referral routes were identified as service barriers. Other improvement areas were information provision on drug side effects, diet, nutritional status, and a few health professionals' attitudes. The effects on people varied enormously from minimal impact to psychological shock; TB also affected social and personal aspects of their life. With regard to further support facilities, some positive views on managed accommodation by TB-aware professionals for those with accommodation problems were identified.

CONCLUSION

This first in-depth study of TB service users' experiences across London offers valuable insights into service users' experiences, providing information and recommendations for a strategic framework for TB service organization and delivery. Overall, further research is needed; TB services - local, national, and international - need to be more closely aligned with service users' complex needs.

Electric acoustic stimulation of the auditory system: experience and results of ten patients using MED-EL's M and FlexEAS electrodes

OBJECTIVE

To evaluate the hearing preservation rate and speech perception scores in patients with profound high frequency hearing loss and acoustically aidable low frequency hearing, managed with the MED-EL electric acoustic stimulation system referenced to the insertion depth of the electrode array.

STUDY DESIGN

Retrospective data analysis.

PARTICIPANTS AND SETTING

Ten patients implanted at the Auditory Implant Centre, Guy's and St Thomas's Hospital, London, UK.

MAIN OUTCOME MEASURES

Pure tone audiometry, speech perception tests and electrode insertion depth angle.

RESULTS

Postoperatively, functional hearing preservation allowing electric acoustic stimulation was achieved in eight patients and total preservation of residual hearing in five patients with follow-up periods of more than 12 months. Three of four (75%) patients with an insertion depth of >360 degrees had a threshold shift of >25 dB, and all four patients had a threshold shift of >10 dB. All patients with total hearing preservation had the electrode inserted up to 360 degrees at maximum. Overall, speech perception outcomes increased significantly and hearing impairment was significantly reduced after electric acoustic stimulation or electric stimulation alone as compared with the preoperative scores.

CONCLUSION

Electric acoustic stimulation provides significant benefit to individuals with profound high frequency hearing loss. Studies with larger number of patients are needed to establish the optimal electrode insertion angle as well as to further analyse the benefit of electric acoustic stimulation.

Process, outcome and experience of transition from child to adult mental healthcare: multiperspective study

BACKGROUND

Many adolescents with mental health problems experience transition of care from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS).

AIMS

As part of the TRACK study we evaluated the process, outcomes and user and carer experience of transition from CAMHS to AMHS.

METHOD

We identified a cohort of service users crossing the CAMHS/AMHS boundary over 1 year across six mental health trusts in England. We tracked their journey to determine predictors of optimal transition and conducted qualitative interviews with a subsample of users, their carers and clinicians on how transition was experienced.

RESULTS

Of 154 individuals who crossed the transition boundary in 1 year, 90 were actual referrals (i.e. they made a transition to AMHS), and 64 were potential referrals (i.e. were either not referred to AMHS or not accepted by AMHS). Individuals with a history of severe mental illness, being on medication or having been admitted were more likely to make a transition than those with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder. Optimal transition, defined as adequate transition planning, good information transfer across teams, joint working between teams and continuity of care following transition, was experienced by less than 5% of those who made a transition. Following transition, most service users stayed engaged with AMHS and reported improvement in their mental health.

CONCLUSIONS

For the vast majority of service users, transition from CAMHS to AMHS is poorly planned, poorly executed and poorly experienced. The transition process accentuates pre-existing barriers between CAMHS and AMHS.

Specialist nursing interventions for inflammatory bowel disease

BACKGROUND

The number, type and roles of specialist nurses dedicated to the care and management of patients with inflammatory bowel disease is increasing. Despite this increase, there has been little evidence to date to demonstrate the effectiveness of specialist nursing interventions. This review aims to identify and evaluate the impact of specialist nursing interventions on management of inflammatory bowel disease, access to treatment, remission, morbidity and quality of life.

OBJECTIVES

To identify and evaluate the impact of specialist nursing interventions for improving the care and management of patients with inflammatory bowel disease (IBD).

SEARCH STRATEGY

A comprehensive search of databases including the Cochrane Library, MEDLINE, and British Nursing Index was carried out to identify trials. References from relevant papers were searched and hand searching was undertaken of relevant publications including gastroenterology conference proceedings to identify additional trials (date of last search 30 September 2008).

SELECTION CRITERIA

Randomised controlled trials, controlled before and after studies and interrupted time series studies of gastroenterology and IBD specialist nurses intending to improve access and outcomes for patients with ulcerative colitis and Crohn's disease were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two investigators independently extracted data and assessed trial quality. Any discrepancies were resolved by consensus.

MAIN RESULTS

One randomised controlled trial of 100 IBD patients receiving a specialist nurse delivered counselling package (n = 50) or routine outpatient clinic follow-up (n = 50), with assessments at entry and six and 12 months, was included in this review. This study was of low methodological quality. Disease remission, patient compliance, clinical improvement, utilisation of nurse-led services, patient satisfaction, hospital admission, outpatient attendance, progression to surgery, length of hospital stay and cost effectiveness data were not reported. Pooled mean mental health scores at 6 months were higher in patients who received nurse-led counselling compared to patients who received routine follow-up. However, this difference was not statistically significant (WMD 3.67; 95% CI -0.44 to 7.77; P = 0.08). Other pooled assessments of physical and psychological well-being showed no statistically significant differences.

AUTHORS' CONCLUSIONS

Although specialist nurse counselling interventions might provide benefit for IBD patients the one included study was of low quality and the results of this study should be interpreted with caution. Higher quality trials of gastroenterology and IBD specialist nursing interventions are needed to assess the impact of specialist nursing interventions on the care and management of patients with inflammatory bowel disease.

Continuity of care in mental health: understanding and measuring a complex phenomenon

BACKGROUND

Continuity of care is considered by patients and clinicians an essential feature of good quality care in long-term disorders, yet there is general agreement that it is a complex concept. Most policies emphasize it and encourage systems to promote it. Despite this, there is no accepted definition or measure against which to test policies or interventions designed to improve continuity. We aimed to operationalize a multi-axial model of continuity of care and to use factor analysis to determine its validity for severe mental illness.

METHOD

A multi-axial model of continuity of care comprising eight facets was operationalized for quantitative data collection from mental health service users using 32 variables. Of these variables, 22 were subsequently entered into a factor analysis as independent components, using data from a clinical population considered to require long-term consistent care.

RESULTS

Factor analysis produced seven independent continuity factors accounting for 62.5% of the total variance. These factors, Experience and Relationship, Regularity, Meeting Needs, Consolidation, Managed Transitions, Care Coordination and Supported Living, were close but not identical to the original theoretical model.

CONCLUSIONS

We confirmed that continuity of care is multi-factorial. Our seven factors are intuitively meaningful and appear to work in mental health. These factors should be used as a starting-point in research into the determinants and outcomes of continuity of care in long-term disorders.

Does appraisal enhance learning, improve practice and encourage continuing professional development? A survey of general practitioners' experiences of appraisal

BACKGROUND

Revalidation of the medical profession is under review and a system has been proposed to ensure doctors meet standards of practice and professionalism. The current appraisal system allows clinicians to chart their progress and identify developmental needs in order to improve performance. Appraisal is now an annual compulsory requirement for all doctors.

AIM AND OBJECTIVES

The aim of the study was to investigate the experiences of general practitioners (GPs) of the current appraisal process. The specific objectives were to consider the impact the appraisal process had exerted on their learning, practice and individual continuing professional development (CPD).

METHODS

We employed a cross-sectional design using a postal questionnaire sent to all doctors who work as GPs (n = 385) in West Kent.

MAIN RESULTS

Questionnaires were returned from 71.7% of doctors (n = 276). The key findings obtained were that 47.5% (n = 131) of doctors stated that taking part in the appraisal process had enhanced their learning, 40.2% (n = 111) felt that the appraisal process had improved their practice and 55.8% (n = 154) stated that the appraisal process had encouraged their CPD. Qualitative findings derived from thematic analysis of open questions revealed that participants viewed the role of the appraiser as respected peer to be vital and there was a need for independence in the appraiser's appointment. The time-consuming nature of the appraisal process was emphasised, with little protected time for preparation of documentation and engagement in CPD. Concerns were expressed about links between appraisal and revalidation.

CONCLUSIONS

Many doctors considered that the appraisal process had enhanced their learning, improved their practice and encouraged their CPD. A vital, independent role for the appraiser was emphasised as was a need to review the time-consuming nature of the current appraisal process, together with identifying protected time to complete this and CPD engagement. As the role of appraisal within the revalidation process changes it is recognised that ensuring the quality, consistency and nature of appraisal will be essential to maintain the confidence of patients and doctors.

Implementing a strategy to promote lifelong learning in the primary care workforce: an evaluation of leadership roles, change management approaches, interim challenges and achievements

OBJECTIVES

To identify and explore leadership roles and responsibilities for implementing the workforce development strategy; to identify approaches used to implement and disseminate the strategy; and to identify and explore challenges and achievements in the first 18 months following implementation.

DESIGN

A formative evaluation with qualitative methods was used. Documentary analysis, interviews (n = 29) and two focus groups (n = 12) were conducted with a purposive sample of individuals responsible for strategy implementation. Data were transcribed and analysed thematically using framework analysis.

SETTING

Regional health area in Kent, Surrey and Sussex: 24 primary care trusts (PCTs) and 900 general practices.

RESULTS

Primary care workforce tutors, lifelong learning advisors, GP tutors, patch associate GP deans and chairs of PCT education committees all had vital leadership roles, some existing and others newly developed. Approaches used to implement the strategy encompassed working within and across organisational boundaries, communication and dissemination of information. Challenges encountered by implementers were resistance to change - evident in some negative attitudes to uptake of training and development opportunities - and role diversity and influence. Achievements included successes in embedding appraisal and protected learning time, and changes in educational practices and services.

CONCLUSIONS

The use of key leadership roles and change-management approaches had brought about early indications of positive transition in lifelong learning cultures.

Detection of mucosal abnormalities in patients with oral cancer using a photodynamic technique: A pilot study

Patients who have had one oral cancer are at increased risk of developing a further malignant tumour, the detection of which is made difficult (and is often delayed) by the innocuous appearance of the early oral lesion. A technique that could reliably detect early cancers would be useful to both oral and dental health specialists. We describe a pilot study in which we used a compact spectroscopic instrument designed to excite and measure fluorescence in the oral cavity. The data were processed using principal components analysis, and the results suggest that the technique might be valuable for detecting early oral cancers. Further work should be performed to investigate some unusual characteristics observed within our data to ascertain if these are significant, simply due to errors made due data collection, or are due to other lifestyle factors. Such work could also verify that the data are due to detection of ALA metabolite in cancer and not some other systemic effect.

Assessing organisational readiness for change: use of diagnostic analysis prior to the implementation of a multidisciplinary assessment for acute stroke care

BACKGROUND

Achieving evidence-based practice in health care is integral to the drive for quality improvement in the National Health Service in the UK. Encapsulated within this policy agenda are challenges inherent in leading and managing organisational change. Not least of these is the need to change the behaviours of individuals and groups in order to embed new practices. Such changes are set within a context of organisational culture that can present a number of barriers and facilitators to change. Diagnostic analysis has been recommended as a precursor to the implementation of change to enable such barriers and facilitators to be identified and a targeted implementation strategy developed. Although diagnostic analysis is recommended, there is a paucity of advice on appropriate methods to use. This paper addresses the paucity and builds on previous work by recommending a mixed method approach to diagnostic analysis comprising both quantitative and qualitative data.

METHODS

Twenty staff members with strategic accountability for stroke care were purposively sampled to take part in semi-structured interviews. Six recently discharged patients were also interviewed. Focus groups were conducted with one group of registered ward-based nurses (n = 5) and three specialist registrars (n = 3) purposively selected for their interest in stroke care. All professional staff on the study wards were sent the Team Climate Inventory questionnaire (n = 206). This elicited a response rate of 72% (n = 148).

RESULTS

A number of facilitators for change were identified, including stakeholder support, organisational commitment to education, strong team climate in some teams, exemplars of past successful organisational change, and positive working environments. A number of barriers were also identified, including: unidisciplinary assessment/recording practices, varying in structure and evidence-base; weak team climate in some teams; negative exemplars of organisational change; and uncertainty created by impending organisational merger.

CONCLUSION

This study built on previous research by proposing a mixed method approach for diagnostic analysis. The combination of qualitative and quantitative data were able to capture multiple perspectives on barriers and facilitators to change. These data informed the tailoring of the implementation strategy to the specific needs of the Trust.

The DNA sequence and biological annotation of human chromosome 1

The reference sequence for each human chromosome provides the framework for understanding genome function, variation and evolution. Here we report the finished sequence and biological annotation of human chromosome 1. Chromosome 1 is gene-dense, with 3,141 genes and 991 pseudogenes, and many coding sequences overlap. Rearrangements and mutations of chromosome 1 are prevalent in cancer and many other diseases. Patterns of sequence variation reveal signals of recent selection in specific genes that may contribute to human fitness, and also in regions where no function is evident. Fine-scale recombination occurs in hotspots of varying intensity along the sequence, and is enriched near genes. These and other studies of human biology and disease encoded within chromosome 1 are made possible with the highly accurate annotated sequence, as part of the completed set of chromosome sequences that comprise the reference human genome.

Social relationships as predictors of depression and suicidal ideation in older adults

The prevalence of depression and suicidal ideation among older adults is considered to be a major mental health concern among this age group. The present study investigated the human relatedness variables of marital status, social support resources and sense of belonging as predictors of depression and suicidal ideation in older adults. A community sample of 110 older adults (M age 76.67 years, SD = 8.11) completed the Social Support Subscale of the Coping Resources Inventory, the Sense of Belonging Instrument, the Zung Depression Inventory and the Suicide Subscale of the General Health Questionnaire. Results indicated that fewer social support resources were associated with higher levels of depression and suicidal ideation. Sense of belonging to the community was not an additional predictor of mental health. The results of the present study suggest that enhancing social support resources in older adults could reduce depression and suicidal ideation.

Physical activity alone and with others as predictors of sense of belonging and mental health in retirees

A high sense of belonging to the community and physical activity are associated with improved mental health in older people. The present study tested a model incorporating physical activities performed alone and with others as predictors of sense of belonging, depression and suicide ideation. One hundred and ninety four retired adults (87 males, 107 females, mean age 68 years) completed the Yale Physical Activity Survey, the Sense of Belonging Instrument, the Suicide Subscale of the General Health Questionnaire and the Zung Depression Inventory. Within the context of the model, neither participating in physical activities alone, nor with at least one other person, predicted sense of belonging, depression or suicide ideation. Having the abilities and motivation to belong was a predictor of participating in physical activities with others and actual feelings of belonging and contributed to predicting mental health in retirees. It was concluded that simply performing activities with others was not associated with a sense of belonging or mental health. Rather, sense of belonging may need to be facilitated in order for mental health to be enhanced.

003.Expression of secreted frizzled related protein-4 (sFRP-4) and associated Wnt signalling in cancer and apoptosis

We examined the interplay between Wnt and secreted frizzled related protein-4 (sFRP4) in estradiol induced cell growth in breast cancer cells (MCF-7), and also determined the in vivo distribution of sFRP-4 in human breast cancer. MCF-7 cells were treated with estradiol, sFRP-4 conditioned media and a combination of the two. Real-time RT-PCR and Western blot analysis were used to determine the expression of the sFRP-4 and its associated Wnt signalling molecules following treatment. Immunohistochemistry was performed to examine sFRP-4 expression patterns in human breast cancers. Estradiol treatment up-regulated the expression of the Wnt signalling genes Wnt-10b, beta-catenin and fz-4 (P < 0.001 for all genes). This up-regulation was not associated with an increase in the Wnt signalling pathway as measured by the levels of active beta-catenin. sFRP-4 conditioned media reduced MCF-7 cell proliferation, down-regulated the Wnt signalling genes beta-catenin and fz-4 as well as down-regulating wnt signalling activity. sFRP-4 was able to reduce the proliferation of estradiol stimulated MCF-7 cells. Cytoplasmic sFRP-4 protein was expressed in all breast tumours examined, with intense staining evident in the lobular carcinoma in situ and the ductal carcinoma. These data demonstrate that sFRP-4 is a potent inhibitor of the Wnt signalling pathway in MCF-7 cells, acting not only to down-regulate the activity of the wnt signalling pathway, but also down-regulate the transcription of Wnt signalling genes. The results of these in vitro and immunohistochemical experiments warrant further investigation as to whether sFRP-4 expression can be indicative of prognosis in human breast cancer. In addition to breast cancer, we have also examined the role of sFRP-4 in other cancers such as ovarian and prostate.

An exploration of nutrition and eating disabilities in relation to quality of life at 6 months post-stroke

Quality of life (QoL) is increasingly recognised as an important healthcare outcome, especially for those living with enduring disability. Stroke is a major source of long-term disablement and many aspects of life after stroke have been explored. Little attention has been paid to nutritional issues despite the cultural and hedonistic importance of food and eating, and the deleterious effects of malnutrition. The present study employed an epidemiological survey to investigate the contribution of dietary and nutritional factors in relation to QoL after stroke. The participants were 206 survivors of a cohort of acute stroke patients consecutively admitted to a National Health Service trust hospital in South London, UK, between March 1998 and April 1999. They were interviewed in their homes at 6 months post-stroke. Cognitively or communication-impaired patients were precluded from interview except where a live-in carer participated as a proxy (n = 10). The participation rate for those who were eligible and could be contacted was 206 out of 218 (94%). Participants were assessed using standardised, validated tools for functional abilities in activities of daily living and eating, cognition and mood state, social support and economic indices, nutritional status, dietary intake, and QoL. Overall group scores demonstrated relatively minor degrees of physical disablement; exclusion of those with limited cognition and communication precluded assessment of a small subgroup with greater disablement at hospital discharge. Nonetheless, the overall assessment results were not dissimilar to other reported groups. Indices of poor nutritional status and substantial dietary inadequacy were revealed, linked with reduced appetite and depression. Multiple regression analyses revealed the dominant impact of mood state in relation to QoL scores; additional significant effects were identified for social support, eating-related disabilities and age. The effects of mood and social support are well-recognised, whilst nutrition-related effects have previously received little attention. Intervention in these areas might achieve improvements in survivors' perceived QoL.