'It's kind of like weaning. I had to wean myself off of wine': Navigating no- and low-alcohol drinks as potential harm reduction tools and relapse triggers by women in recovery in the UK

INTRODUCTION

Concerns have been raised that consumption of no- and low-alcohol drinks by those who are in recovery could lead to a relapse to past drinking behaviours. However, little is known regarding how individuals use these products to substitute alcohol and support their sobriety.

METHODS

This article draws on an ethnographic study of women's experiences of recovery within online sobriety communities in which semi-structured interviews were conducted with 25 UK-based women. The dataset was analysed and coded from a pragmatist feminist standpoint using a grounded theoretical approach to specifically address the research question: 'How do women in recovery navigate the protective and risk factors associated with no- and low-alcohol drinks through practices of consumption?'

RESULTS

Women in recovery navigate no- and low-alcohol drinks as potential harm-reduction tools and relapse triggers by engaging in nuanced practices of substitution. Contrasting examples include direct substitution and temporary avoidance in early recovery.

DISCUSSION AND CONCLUSIONS

Substitution practices are informed by the temporality of participants' recovery journeys, the social situation, and the products. Participants selectively replicate and resist their former drinking practices to balance their perceived harm-reduction benefits and relapse triggers of no- and low-alcohol drinks. Important considerations are raised for those in recovery who may want to use no- and low-alcohol drinks as a harm reduction tool, and for recovery modalities that promote them. It concludes with calls for more clarity regarding the definition and labelling of no- and low-alcohol drinks, and for a greater understanding of their use across different recovery cultures.

The impact of a complex school nutrition intervention on double burden of malnutrition among Thai primary school children: a 2-year quasi-experiment

OBJECTIVE

This study assessed the impacts of the Dekthai Kamsai programme on overweight/obesity, underweight and stunting among male and female primary school students.

STUDY DESIGN

A quasi-experiment was conducted in 16 intervention and 19 control schools across Thailand in 2018 and 2019. In total, 896 treated and 1779 control students from grades 1 to 3 were recruited. In intervention schools, a set of multifaceted intervention components were added into school routine practices. Anthropometric outcomes were measured at baseline and at the beginning and end of every school term.

METHODS

Propensity score matching with linear and Poisson difference-in-difference analyses were used to adjust for the non-randomisation and to analyse the intervention's effects over time.

RESULTS

Compared with controls, the increases in mean BMI-for-age Z-score (BAZ) and the incidence rate of overweight/obesity were lower in the intervention schools at the 3rd, 4th and 8th measurements and the 3rd measurement, respectively. The decrease in mean height-for-age Z-score (HAZ) was lower at the 4th measurement. The decrease in the incidence rate of wasting was lower at the 5th, 7th and 8th measurements. The favourable impacts on BAZ and HAZ were found in both sexes, while the favourable impact on overweight/obesity and unfavourable impact on wasting were found in girls.

CONCLUSIONS

This intervention might be effective in reducing BAZ, overweight/obesity, poor height gain, but not wasting. These findings highlight the benefits of a multifaceted school nutrition intervention and a need to incorporate tailor-made interventions for wasting to comprehensively address the double burden of malnutrition.

Padres Preparados, Jóvenes Saludables: intervention impact of a randomized controlled trial on Latino father and adolescent energy balance-related behaviors

BACKGROUND

Studies have shown associations among food and activity behaviors and body weight of Latino fathers and adolescents. However, few Latino father-focused interventions have been designed to improve energy balance-related behaviors (EBRBs) and weight status among early adolescents. Thus, this efficacy study aims to evaluate the Padres Preparados, Jóvenes Saludables (Padres) youth obesity prevention program for positive changes in EBRBs (fruit, vegetable, sugar-sweetened beverage (SSB), sweet/salty snack, and fast-food consumption, physical activity, and screen time) and weight status among low-income Latino fathers and adolescents (10-14 years).

METHODS

A two-arm (treatment versus delayed-treatment control group) randomized controlled trial was conducted to evaluate the efficacy of 8 weekly experiential learning sessions (2.5 hours each) based on social cognitive theory. The sessions included food preparation, parenting skills, nutrition, and physical activity. The program was delivered to father-adolescent dyads (mothers were encouraged to attend) in trusted community-based settings in a Midwest metropolitan area between 2017 and 2019. In March 2020, in-person implementation was discontinued due to COVID-19 pandemic restrictions, which limited the sample size. Father/adolescent dyads were randomized to treatment or control group within each site. Surveys and measurements were completed by fathers and adolescents to assess changes in food and activity behaviors from baseline to post-intervention. Adolescents also completed 24-hour dietary recall interviews at baseline and post-intervention. Intervention effects were assessed using linear regression mixed models adjusted for covariates and accounting for clustering of participants within sites.

RESULTS

Data from 147 father/adolescent dyads who completed at least the baseline data collection were used. No significant differences were observed for baseline to post-intervention changes in adolescents' and fathers' EBRBs or weight status between treatment and control groups. Fathers' SSB and fast food intakes were not statistically significant (p = 0.067 and p = 0.090, respectively).

CONCLUSIONS

The Padres program resulted in no significant improvements in adolescent and father EBRBs and weight status. Additional Latino father-focused interventions are needed to examine intervention effects on EBRBs among Latino adolescents.

TRIAL REGISTRATION

The Padres Preparados, Jóvenes Saludables study is registered with the U.S. National Library of Medicine, ClinicalTrials.gov Identifier: NCT03469752 (19/03/2018).

Online Sobriety Communities for Women's Problematic Alcohol Use: A Mini Review of Existing Qualitative and Quantitative Research

The increase in women's drinking is one of the most prominent trends in alcohol consumption in the UK in recent history, possibly exacerbated by COVID-19 lockdown measures. Higher rates of drinking are associated with substantial economic, health, and social costs. However, women are less likely to seek treatment for Alcohol Use Disorder (AUD) than men and have less successful treatment outcomes from traditional treatment paths, such as 12-step programs and in-patient care. Female heavy drinkers may also experience particular forms of gendered stigma that affect their experiences of addiction and recovery and their desire or ability to access these more “traditional” services. This review provides an overview of existing qualitative and quantitative research regarding online sobriety communities that are predominantly utilised by women, such as non-12-step alcohol online support groups (AOSGs) and temporary abstinence initiatives (TAIs). This is a small—but expanding—body of literature emerging as “sober curiosity” and “mindful drinking” are trending in Western contexts such as the UK, particularly amongst young women who do not identify with traditional, binary recovery language such as “alcoholic” and “addict.” This review highlights the gaps in research and concludes that further research regarding these new treatment pathways, and women's experiences when utilising them, must be conducted to provide more evidence-based options for women who want to address problematic drinking. Public health bodies could also learn more effective strategies from these innovative solutions to reduce alcohol consumption generally.

Maternal diabetes and fetal cardiac output

BACKGROUND

The intrauterine environment is a key determinant for long-term health outcomes. Adverse fetal environments, such as maternal diabetes, obesity and placental insufficiency are strongly associated with long-term health risks in children. Little is known about differences in fetal cardiac output hemodynamics of diabetic mothers (DM) vs. non-diabetic mothers (NDM). Our study aims to investigate the left-sided, right-sided, and combined cardiac output (CCO) in fetuses of DM vs. NDM.

METHODS

Retrospective data were collected in fetuses of DM (N = 532) and NDM (103) at mean gestational age 24 weeks. Examination included 2D echo and pulse wave Doppler. Wilcoxon rank sum tests and Chi-square tests were used to test for distribution difference of maternal and fetal continuous and categorical measures respectively between DM and NDM. Intraclass correlation coefficients were calculated to assess intra-observer reliability of fetal cardiac measurements.

RESULTS

DM mothers had higher mean weight (89.7±22.2 kg) than NDM (76.8±19.8 kg), p <  0.0001 and higher mean BMI (33.4±7.5) than NDM (28.3±5.8), p <  0.0001. C-section delivery occurred in 66% of DM vs. 35% of NDM fetuses. Fetuses of DM mothers had significantly larger semilunar valve diameter, higher left ventricular (LV) output, higher combined cardiac output and lower right ventricle /left ventricle ratio compared to NDM.

CONCLUSION

The greater CCO (adjusted for fetal weight), left sided cardiac output in the fetuses of DM, compared to NDM, represent differences in cardiac adaptation to the diabetic environment.

A cost comparison study to review community versus acute hospital models of nursing care delivered to oncology patients

PURPOSE

Ireland's Sláintecare health plan is placing an increased focus on primary care. A community oncology nursing programme was developed to train community nurses to deliver care in the community. While the initial pilot was proven to be clinically safe, no cost evaluation was carried out. This study aims to compare the costs of providing cancer support services in a day-ward versus in the community.

METHODS

183 interventions (40 in day-ward and 143 in community) were timed and costed using healthcare professional salaries and the Human Capital method.

RESULTS

From the healthcare provider perspective, the day-ward was a significantly cheaper option by an average of €17.13 (95% CI €13.72 - €20.54, p < 0.001). From the societal perspective, the community option was cheaper by an average of €2.77 (95% CI -€3.02 - €8.55), although this was a non-significant finding. Sensitivity analyses indicate that the community service may be significantly cheaper from the societal perspective.

CONCLUSIONS

Given the demand for cost-viable options for primary care services, this programme may represent a national option for cancer care in Ireland when viewed from the societal perspective.

Positive reinforcement targeting abstinence in substance misuse (PRAISe): Study protocol for a Cluster RCT & process evaluation of contingency management

There are approximately 256,000 heroin and other opiate users in England of whom 155,000 are in treatment for heroin (or opiate) addiction. The majority of people in treatment receive opiate substitution treatment (OST) (methadone and buprenorphine). However, OST suffers from high attrition and persistent heroin use even whilst in treatment. Contingency management (CM) is a psychological intervention based on the principles of operant conditioning. It is delivered as an adjunct to existing evidence based treatments to amplify patient benefit and involves the systematic application of positive reinforcement (financial or material incentives) to promote behaviours consistent with treatment goals. With an international evidence base for CM, NICE recommended that CM be implemented in UK drug treatment settings alongside OST to target attendance and the reduction of illicit drug use. While there was a growing evidence base for CM, there had been no examination of its delivery in UK NHS addiction services. The PRAISe trial evaluates the feasibility, acceptability, clinical and cost effectiveness of CM in UK addiction services. It is a cluster randomised controlled effectiveness trial of CM (praise and financial incentives) targeted at either abstinence from opiates or attendance at treatment sessions versus no CM among individuals receiving OST. The trial includes an economic evaluation which explores the relative costs and cost effectiveness of the two CM intervention strategies compared to TAU and an embedded process evaluation to identify contextual factors and causal mechanisms associated with variations in outcome. This study will inform UK drug treatment policy and practice. Trial registration ISRCTN 01591254.

Robust analysis of stepped wedge trials using cluster-level summaries within periods

In stepped‐wedge trials (SWTs), the intervention is rolled out in a random order over more than 1 time‐period. SWTs are often analysed using mixed‐effects models that require strong assumptions and may be inappropriate when the number of clusters is small.

We propose a non‐parametric within‐period method to analyse SWTs. This method estimates the intervention effect by comparing intervention and control conditions in a given period using cluster‐level data corresponding to exposure. The within‐period intervention effects are combined with an inverse‐variance‐weighted average, and permutation tests are used. We present an example and, using simulated data, compared the method to (1) a parametric cluster‐level within‐period method, (2) the most commonly used mixed‐effects model, and (3) a more flexible mixed‐effects model. We simulated scenarios where period effects were common to all clusters, and when they varied according to a distribution informed by routinely collected health data.

The non‐parametric within‐period method provided unbiased intervention effect estimates with correct confidence‐interval coverage for all scenarios. The parametric within‐period method produced confidence intervals with low coverage for most scenarios. The mixed‐effects models' confidence intervals had low coverage when period effects varied between clusters but had greater power than the non‐parametric within‐period method when period effects were common to all clusters.

The non‐parametric within‐period method is a robust method for analysing SWT. The method could be used by trial statisticians who want to emphasise that the SWT is a randomised trial, in the common position of being uncertain about whether data will meet the assumptions necessary for mixed‐effect models.

Endobronchial valves for emphysema: an individual patient-level reanalysis of randomised controlled trials

Introduction

Endobronchial valve placement has potential as a treatment for patients with chronic obstructive pulmonary disease (COPD). However, a robust evidence base will be needed to convince commissioners of healthcare that it is a high-value treatment. We sought to develop the evidence base by performing an individual patient-level analysis of randomised controlled trials in people with heterogeneous emphysema and an absence of collateral ventilation.

Methods

A literature search (PROSPERO register CRD42016048127) identified two trials meeting these criteria, the BelieVeR-HIFi and STELVIO studies. Anonymised individual patient data were obtained from investigators and analysed. The primary outcome measure was a comparison of change in forced expiratory volume in 1 s (FEV₁) from baseline between the treatment and control groups. Secondary end points were change from baseline in 6 min walk distance (6MWD), Medical Research Council dyspnoea score and St George’s Respiratory Questionnaire (SGRQ).

Results

114 individuals were treated with 3-month to 6-month follow-up data available for 101 individuals. FEV₁ improved by 23.1 (±28.3)% in patients treated with valves with a mean (95% CI) difference in response between groups of 17.8 (26.5, 9.2)% (p<0.0001). Relative to controls valve placement was associated with a fall in residual volume of 0.64 (0.43, 0.86) L (p<0.0001), a 9.5 (3.5, 15.6) unit fall in SGRQ (p=0.0022) and a 64.2 (94.0, 34.5) m increase in 6MWD. There were three deaths in the treatment arm and the pneumothorax rate was 15%.

Conclusions

These data strengthen the evidence that endobronchial valve treatment can produce clinically meaningful improvements in appropriately selected COPD patients.

British Thoracic Society quality standards for home oxygen use in adults

Introduction

The purpose of the quality standards document is to provide healthcare professionals, commissioners, service providers and patients with a guide to standards of care that should be met for home oxygen provision in the UK, together with measurable markers of good practice. Quality statements are based on the British Thoracic Society (BTS) Guideline for Home Oxygen Use in Adults.

Methods

Development of BTS Quality Standards follows the BTS process of quality standard production based on the National Institute for Health and Care Excellence process manual for the development of quality standards.

Results

10 quality statements have been developed, each describing a key marker of high-quality, cost-effective care for home oxygen use, and each statement is supported by quality measures that aim to improve the structure, process and outcomes of healthcare.

Discussion

BTS Quality Standards for home oxygen use in adults form a key part of the range of supporting materials that the society produces to assist in the dissemination and implementation of a guideline’s recommendations.

A systematic review and meta-analysis of prospective transition from major depression to bipolar disorder

OBJECTIVE

Some people with major depressive disorder (MDD) may be at a pre-onset stage for bipolar disorder (BD), where early identification or prevention efforts may be feasible. We aimed to identify rates and characteristics predictive of transition to BD in prospective follow-up studies of people with MDD.

METHODS

Using a systematic search strategy, we identified studies with a diagnostic ascertainment of MDD and BD of an adequate standard, and where the minimum length of follow-up was 6 months. We examined the incidence and point prevalence of BD and the pooled odds ratios (OR) for baseline predictors.

RESULTS

From 5554 unique publications, 56 were included. Nearly a quarter of adults (22.5%) and adolescents with MDD followed up for a mean length of 12-18 years developed BD, with the greatest risk of transition being in the first 5 years. The meta-analysis identified that transition from MDD to BD was predicted by family history of BD (OR = 2.89, 95% CI: 2.01-4.14, N = 7), earlier age of onset of depression (g = -0.33, SE = 0.05, N = 6) and presence of psychotic symptoms (OR = 4.76, 95% CI: 1.79-12.66, N = 5).

CONCLUSIONS

Participants with the identified risk factors merit closer observation and may benefit from prevention efforts, especially if outcomes broader than BD are considered.

Endobronchial valves for patients with heterogeneous emphysema and without interlobar collateral ventilation: open label treatment following the BeLieVeR-HIFi study

Outcomes in early trials of bronchoscopic lung volume reduction using endobronchial valves for the treatment of patients with advanced emphysema were inconsistent. However improvements in patient selection with focus on excluding those with interlobar collateral ventilation and homogeneous emphysema resulted in significant benefits in the BeLieVeR-HIFi study compared with sham treated controls. In this manuscript we present data from the control patients in the BeLieVeR-HIFi study who went on to have open label endobronchial valve treatment after completion of the clinical trial (n=12), combined with data from those in the treatment arm who did not have collateral ventilation (n=19). Three months after treatment FEV₁ increased by 27.3 (36.4)%, residual volume reduced by 0.49 (0.76) L, the 6 min walk distance increased by 32.6 (68.7) m and the St George Respiratory Questionnaire for COPD score improved by 8.2 (20.2) points. These data extend the evidence for endobronchial valve placement in appropriately selected patients with COPD.

TRIAL REGISTRATION NUMBER

ISRCTN04761234; Results.

Are we giving General Practitioners what they want from Psychiatric out-patient review letters?

We aimed to assess the quality of out-patient clinic letters in relation to GPs expectations. A questionnaire was devised and sent to 65 GPs to ascertain what they felt to be important in a psychiatric out-patient clinic letter. We examined 250 out-patient clinic letters comprising both a formatted and unformatted pattern. We compared whether one particular type of letter was more successful at providing the information specifically requested by GPs. Fifty seven per cent of GPs responded to the questionnaire. Letters following a pre-determined formatted template, although slightly longer, consistently conveyed more relevant information. Conclusion: The use of formatted letters is a means of enhancing communication between psychiatrists and GPs and within secondary psychiatry services.

The Impact of Homogeneous Versus Heterogeneous Emphysema on Dynamic Hyperinflation in Patients With Severe COPD Assessed for Lung Volume Reduction

Dynamic hyperinflation (DH) is a pathophysiologic hallmark of Chronic Obstructive Pulmonary Disease (COPD). The aim of this study was to investigate the impact of emphysema distribution on DH during a maximal cardiopulmonary exercise test (CPET) in patients with severe COPD.

This was a retrospective analysis of prospectively collected data among severe COPD patients who underwent thoracic high-resolution computed tomography, full lung function measurements and maximal CPET with inspiratory manouvers as assessment for a lung volume reduction procedure. ΔIC was calculated by subtracting the end-exercise inspiratory capacity (eIC) from resting IC (rIC) and expressed as a percentage of rIC (ΔIC %). Emphysema quantification was conducted at 3 predefined levels using the syngo PULMO-CT (Siemens AG); a difference >25% between best and worse slice was defined as heterogeneous emphysema.

Fifty patients with heterogeneous (62.7% male; 60.9 ± 7.5 years old; FEV₁% = 32.4 ± 11.4) and 14 with homogeneous emphysema (61.5% male; 62.5 ± 5.9 years old; FEV₁% = 28.1 ± 10.3) fulfilled the enrolment criteria. The groups were matched for all baseline variables. ΔIC% was significantly higher in homogeneous emphysema (39.8% ± 9.8% vs.31.2% ± 13%, p = 0.031), while no other CPET parameter differed between the groups. Upper lobe predominance of emphysema correlated positively with peak oxygen pulse, peak oxygen uptake and peak respiratory rate, and negatively with ΔIC%. Homogeneous emphysema is associated with more DH during maximum exercise in COPD patients.

Bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures (the BeLieVeR-HIFi study): a randomised controlled trial

BACKGROUND

Lung volume reduction surgery improves survival in selected patients with emphysema, and has generated interest in bronchoscopic approaches that might achieve the same effect with less morbidity and mortality. Previous trials with endobronchial valves have yielded modest group benefits because when collateral ventilation is present it prevents lobar atelectasis.

METHODS

We did a single-centre, double-blind sham-controlled trial in patients with both heterogeneous emphysema and a target lobe with intact interlobar fissures on CT of the thorax. We enrolled stable outpatients with chronic obstructive pulmonary disease who had a forced expiratory volume in 1 s (FEV1) of less than 50% predicted, significant hyperinflation (total lung capacity >100% and residual volume >150%), a restricted exercise capacity (6 min walking distance <450 m), and substantial breathlessness (MRC dyspnoea score ≥3). Participants were randomised (1:1) by computer-generated sequence to receive either valves placed to achieve unilateral lobar occlusion (bronchoscopic lung volume reduction) or a bronchoscopy with sham valve placement (control). Patients and researchers were masked to treatment allocation. The study was powered to detect a 15% improvement in the primary endpoint, the FEV1 3 months after the procedure. Analysis was on an intention-to-treat basis. The trial is registered at controlled-trials.com, ISRCTN04761234.

FINDINGS

50 patients (62% male, FEV1 [% predicted] mean 31·7% [SD 10·2]) were enrolled to receive valves (n=25) or sham valve placement (control, n=25) between March 1, 2012, and Sept 30, 2013. In the bronchoscopic lung volume reduction group, FEV1 increased by a median 8·77% (IQR 2·27-35·85) versus 2·88% (0-8·51) in the control group (Mann-Whitney p=0·0326). There were two deaths in the bronchoscopic lung volume reduction group and one control patient was unable to attend for follow-up assessment because of a prolonged pneumothorax.

INTERPRETATION

Unilateral lobar occlusion with endobronchial valves in patients with heterogeneous emphysema and intact interlobar fissures produces significant improvements in lung function. There is a risk of significant complications and further trials are needed that compare valve placement with lung volume reduction surgery.

FUNDING

Efficacy and Mechanism Evaluation Programme, funded by the Medical Research Council (MRC) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.

Significance of Patent Foramen Ovale in Patients with GOLD Stage II Chronic Obstructive Pulmonary Disease (COPD)

Background: Patent foramen ovale (PFO) is a common finding in adults. A PFO is associated with right to left shunting but its importance in the aetiology of hypoxia in early COPD remains uncertain, although it has not proved possible to demonstrate a role for PFOs in the aetiology of hypoxia in patients with Global Initiative for chronic Obstructive Lung Disease (GOLD) stage III/IV disease. We compared the characteristics of GOLD stage II patients with or without a PFO and assessed its impact on exercise performance. Methods: In 22 GOLD stage II COPD patients we measured exercise performance, arterial oxygen tension and lung function and used contrast transcranial Doppler ultrasonography (TCD) to assess the presence of a PFO. Patients (n=20) underwent TCD measurements during incremental cycle ergometry with respiratory pressures measured using an esophageal balloon catheter (n=13). Results:Twelve individuals (54%) had a PFO. Patients with a PFO were more hypoxic; mean(SD) partial pressure of oxygen in arterial blood (PaO₂)10.2(1.1) kilopascals (kPa) vs. 11.7(0.9)kPa (p<0.01), but the presence of a PFO was not associated with reduced exercise performance either on cycle ergometry or a 6 Minute Walk Test (6MWT). A strong relationship was noted between the esophageal pressure swing (P_SwingEs) and the degree of shunting observed during exercise (r=0.7; p<0.001). Conclusions:The presence of a PFO in GOLD stage II COPD patients does not appear to influence exercise performance despite increased right-to-left shunting.

Bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures (the BeLieVeR-HIFi trial): study design and rationale

Although lung volume reduction surgery improves survival in selected patients with emphysema, there has been ongoing interest in developing and evaluating bronchoscopic approaches to try to reduce lung volumes with less morbidity and mortality. The placement of endobronchial valves is one such technique, and although some patients have had a significant improvement, responses have been inconsistent because collateral ventilation prevents lobar atelectasis. We describe the protocol of a trial (ISRCTN04761234) aimed to show that a responder phenotype, patients with heterogeneous emphysema and intact interlobar fissures on CT scanning, can be identified prospectively, leading to a consistent benefit in clinical practice.

Histopathology of naturally occurring and surgically induced osteoarthritis in mice

OBJECTIVE

The morphology of lesions in mouse models of osteoarthritis (OA) has not been comprehensively characterized, in part because current histological assessments of OA focus primarily on articular cartilage (AC). In the present study, sections of murine stifle joints with naturally occurring (aged animals) and surgically induced (destabilized medial meniscus, DMM) OA were examined using a newly developed histological grading scheme that includes quantitative measurements and semiquantitative grades to evaluate multiple joint tissues.

DESIGN

The data collected was analyzed using Principal Components Analysis (PCA); factor scores for each joint were generated. Individual parameters and factor scores were compared between surgical groups and among age groups. For comparison, the original Mankin Histological-Histochemical Grading System (HHGS) also was applied.

RESULTS

Overall, lesions were most severe in the medial tibial plateaus. Significant changes in AC and neighboring bone were identified in surgically induced models and in naturally occurring disease. Mean factor scores provided a comprehensive evaluation of joint changes. An important new finding was that chondrocyte cell death within the AC was a commonly identified lesion and its extent significantly increased with age. While the Mankin HHGS detected significant overall differences in OA severity between surgical groups, it was not sensitive in detecting age-related differences, nor did it provide information regarding changes in individual tissues.

CONCLUSION

These results demonstrate the utility of this newly developed murine OA grading scheme in identifying lesions in AC and in other joint tissues. Surgically induced changes were similar to those occurring naturally with aging.

An engineered solution to the maladministration of spinal injections

BACKGROUND

An overview is provided of the progress made in a Department of Health (DH) initiative to implement an engineered solution to the maladministration of spinal injections. In an effort to eliminate the possibility of misconnection errors at the spinal route, the DH is investigating the potential for dedicated spinal equipment that will be incompatible with standard Luer syringes, needles and associated devices.

METHOD

Background information on the problem of misconnection errors is provided and a systematic approach to their eradication is detailed. Research to date has entailed extensive bench-testing of prototype non-Luer connectors, a prospective hazard analysis of spinal procedures in haematology and anaesthesia and usability evaluation of prototype non-Luer devices in simulated environments.

RESULTS

The prospective hazard analysis identified two potential risks which will need to be managed as part of a successful implementation programme.

CONCLUSION

Usability testing of two prototype connection systems concluded that one design was inadequate, as the non-Luer element was provided as a separable adapter. The second connection system was modified following the first round of testing, and achieved improved satisfaction ratings from clinicians in round two. This system was selected to proceed to a pre-implementation evaluation and the research team are currently evaluating its acceptability in clinical use.

A flexible quantitative methodology for the analysis of gene-flow between conventionally bred maize populations using microsatellite markers

Previous studies of gene-flow in agriculture have used a range of physical and biochemical markers, including transgenes. However, physical and biochemical markers are not available for all commercial varieties, and transgenes are difficult to use when trying to estimate gene flow in the field where the use of transgenes is often restricted. Here, we demonstrate the use of simple sequence repeat microsatellite markers (SSRs) to study gene flow in maize. Developing the first quantitative analysis of pooled SSR samples resulted in a high sampling efficiency which minimised the use of resources and greatly enhanced the possibility of hybrid detection. We were able to quantitatively distinguish hybrids in pools of ten samples from non-hybrid parental lines in all of the 24 pair-wise combinations of commercial varieties tested. The technique was used to determine gene flow in field studies, from which a simple model describing gene flow in maize was developed.

Colorectal foreign bodies: a systematic review

AIM

To perform a systematic review of the published reports on retained colorectal foreign bodies (CFBs) to collate the features and formulate a simple management plan based on the available evidence.

METHOD

An extensive search was carried out to identify articles on CFBs. The search was carried out on electronic databases Cinahl, Embase, Medline, PubMed and PsychInfo from 1950 to January 2009. Internet journals were also scoured and a general search was carried out using the search engine 'Google'. Papers published in languages other than English were not included.

RESULTS

This review covers a total of 193 patients with 196 presentations. There were 188 men and 5 women, a ratio of approximately 37:1. The mean age at presentation was 44.1 years (SD 16.6) in the single case reports and 39.3, 40 and 60.8 years in the three case series. Household objects, such as bottles and glasses, accounted for the largest percentage (42.2%) of inserted objects. Presentation for treatment occurred most often within 24 h of insertion and the majority of objects were removed transanally using manual manipulation with or without the use of a variety of tools, or via a scope.

CONCLUSIONS

The incidence of CFBs is disproportionately higher in men. Various techniques for removal are available, including some that are minimally invasive. The appropriate technique will depend on the size and surface of the retained object and the presence of complications such as perforation or obstruction.

Very small air bubbles (10 – 70 μl) cause clinically significant variability in syringe pump fluid delivery

AIM

The goal of this study was to analyse flow disturbances resulting from the presence of small air bubbles in syringe pump delivery lines incorporating pressure-sensing discs.

METHODS

Laboratory based gravimetric measurement of syringe pump flow rate with concurrent fluid pressure monitoring.

RESULTS

Small air bubbles can become lodged in the pressure-sensing disc part of syringe pump delivery lines. This can give rise to serious disturbances in fluid delivery from minute to minute, but does not trigger pump alarms. Small air bubbles being delivered through non-horizontal sections of delivery line can also cause significant transient disturbances to fluid delivery.

CONCLUSIONS

The demonstrated disruptions to fluid delivery could be sufficient to cause adverse effects on patients, particularly in the case of a vulnerable patient receiving a potent fast-acting drug at a low flow rate. The prevalence of these effects in clinical settings would be difficult to establish, but careful efforts to remove air from syringe delivery lines before starting infusions would be recommended to minimize the risks.

Substance abuse in an Irish antenatal population

Substance abuse is prevalent in Ireland. The potential sequelae for abuser and carer are many. In pregnancy there are further problems. We assessed the prevalence of substance abuse in our antenatal population using an anonymous questionnaire and urine toxicology screening. We examined 522 women and 18 (3.4%) had positive urine toxicology. The anonymous questionnaire failed to identify all of these women. No typical patient profile emerged when the demographic features were studied. We believe that our study has underestimated the true prevalence of substance abuse in our antenatal population and many factors may have contributed to this. Substance abuse in pregnancy remains a difficult problem to quantify and for the future the main focus of attention must be on education and prevention.

Intestinal obstruction from inspissated barium (Barolith): a systematic review of all cases from 1950 to 2006

OBJECTIVE

Having encountered a case of large bowel obstruction secondary to a barolith and successfully treated it using colonoscopic dissolution, we systematically reviewed all cases of barolith obstruction to appreciate its incidence and explore its methods of treatment.

METHOD

A literature search was carried out in the databases British Nursing Index, Cinahal, Embase, Medline, and Pub Med. There was no restriction placed on language of publication in the search.

RESULTS

There were 22 reports describing a total of 31 cases. About one third of the reported cases were successfully treated with conservative measures including the use of laxatives. Significantly, surgery was performed in nearly half of the patients. Interestingly, endoscopic dissolution was attempted in only 3 cases and it was successful in all of them.

CONCLUSION

This systematic review reveals several reported cases of barolith obstruction from 1950-2006. Only three case reports described colonoscopic dissolution. In our institute, we have recently encountered a case of large bowel obstruction secondary to a barolith and we successfully treated it using colonoscopic dissolution. Given the absence of guidelines to treat barolith induced obstruction, we are of the opinion that should a barolith obstruction occur, in the absence of perforation or ischaemic bowel, endoscopic dissolution by an experienced endoscopist under general anaesthetic offers a safe, effective, and minimally invasive method of relieving the obstruction. Should this fail surgery is indicated.

Reconciling population benefits and women's individual autonomy in mammographic screening: in-depth interviews to explore women's views about ‘informed choice’

OBJECTIVE

To explore women's reactions to 'informed choice' in mammographic screening.

SETTING AND METHODS

Telephone interviews with a convenience sample of 106 women aged 45-70 years recruited from general practices in Sydney.

RESULTS

Many (42%) women preferred an active role in decision-making. Respondents had low scores for 'uncertainty' and 'factors contributing to uncertainty' in response to explicit questions about the decision to have mammographic screening. Yet respondents indicated significantly greater willingness to have a test when the benefit of a 'new' screening test for breast cancer was expressed as relative risk reduction (RRR) (88%) than either absolute risk reduction (ARR) (78%) (McNemar's test: chi(2)1=7.14, p=0.013) or all-cause mortality (53%) (McNemar's test: chi(2)1=35.1, p<0.01). Significantly more respondents considered information about ARR 'new' to them (65%) compared with RRR information (30%) (McNemar's test: chi(2)1=25.83, p<0.01).

CONCLUSIONS

As mammographic screening exposes well women to potential harms for an overall population benefit, it is challenging to ensure 'informed choice'. Our results suggest women will likely appreciate individual consultations as the context in which to share complex information that women in our study agreed they need to know about mammographic screening. Our results also demonstrate that women's willingness as individuals to participate in mammographic screening is influenced by 'framing effect'. Hence, the quantitative content of decision aids to promote 'informed choice' must be comprehensive and balanced.

What are the effects of distance management on the retention of remote area nurses in Australia?

INTRODUCTION

Australian remote area nurses (RANs) are specialist advanced practice nurses. They work in unique, challenging and sometimes dangerous environments to provide a diverse range of healthcare services to remote and predominantly Aboriginal communities. There is an emerging skills gap in the remote nursing workforce as experienced and qualified RANs leave this demanding practice. There is a shortage of new nurses interested in working in these areas, and many of those who enter remote practice leave after a short time. Distance management was examined in order to gain a better understanding of its effects on the retention of RANs in the Australian states of Northern Territory (NT), Western Australia (WA) and South Australia (SA). Distance management in this context occurs when the health service's line management team is located geographically distant from the workplace they are managing.

METHODS

The study used a mixed method design, with a combination of anonymous surveys and interviews conducted by telephone and face to face. Qualitative and quantitative data were collected. The data were thematically analysed and basic descriptive statistics were also used. All RANs who worked in government and other non-Aboriginal controlled remote health services in NT, SA and WA were included in the sample. Sixty-one RANs (anonymous survey, 55% response rate) and 26 ex-RANs (telephone interview) participated in the research. The ex-RANs were sampled using a snowball technique where interviewees recommended former colleagues for interview. Nine nursing executives with expertise in distance management of remote health services also contributed (face-to-face interview), and they are referred to as 'the experts'.

RESULTS

Respondents expressed a dichotomy in their reactions to remote area nursing. On one hand, they expressed a strong sense of pleasure and satisfaction in the nature of their work; while, on the other, they expressed dissatisfaction with aspects of infrastructure, support and management practices. Positive aspects included autonomy of practice, working in a small team, cross-cultural practice, and the beauty and isolation of the setting. Negative aspects included poor orientation, high stress, inadequate resources, poor systems, unrealistic expectations from communities and managers leading to excessive workload, and perceived lack of support from management. The greatest negative issue raised was poor handling of leave replacement, where RANs on leave were not replaced with appropriately qualified and skilled nurses. Respondents noted a frequent change in managers, and reported that the lack of stability in management contributed to lack of support for both RANs and their managers. Lack of support from managers was frequently cited as a main cause for ex-RANs leaving their employment. Despite this, almost all respondents indicated a willingness to remain in the remote workforce if possible. Experts noted that where management was dysfunctional, RAN retention rates fell. They also acknowledged the need for good communication, interpersonal skills, availability of staff development, leave, relief staff, feedback, debriefing, professional support and working conditions. Experts believed managers should make use of available and emerging technology to communicate with RANs, and work to improve RANs' understanding of the role of the management team.

CONCLUSIONS

Remote Australian Aboriginal communities are mainly served by RANs in a health system that is sometimes ill-equipped and at times poorly managed. The theme of a second-class health system being serviced by RANs who felt they were treated as second-class health practitioners appeared throughout the data. Poor distance management practices may contribute to the high turnover of staff in remote Australia. Retention of RANs may increase with better managerial practices, such as effective communication and leadership, staffing replacement and leave, prompt attention to infrastructure issues, and staff development and appraisal. These are the keys to ensuring that RANs feel supported and valued. Remote area nursing is a rewarding career and, with systemic support, RANs may stay longer in remote practice.

High-frequency chest wall oscillation in ALS: An exploratory randomized, controlled trial

OBJECTIVES

To evaluate changes in respiratory function in patients with ALS after using high-frequency chest wall oscillation (HFCWO).

METHODS

This was a 12-week randomized, controlled trial of HFCWO in patients with probable or definite ALS, an Amyotrophic Lateral Sclerosis Functional Rating Scale respiratory subscale score < or = 11 and > or = 5, and forced vital capacity (FVC) > or = 40% predicted.

RESULTS

We enrolled 46 patients (58.0 +/- 9.8 years; 21 men, 25 women); 22 used HFCWO and 24 were untreated. Thirty-five completed the trial: 19 used HFCWO and 16 untreated. HFCWO users had less breathlessness (p = 0.021) and coughed more at night (p = 0.048) at 12 weeks compared to baseline. At 12 weeks, HFCWO users reported a decline in breathlessness (p = 0.048); nonusers reported more noise when breathing (p = 0.027). There were no significant differences in FVC change, peak expiratory flow, capnography, oxygen saturation, fatigue, or transitional dyspnea index. When patients with FVC between 40 and 70% predicted were analyzed, FVC showed a significant mean decrease in untreated patients but not in HFCWO patients; HFCWO patients had significantly less increased fatigue and breathlessness. Satisfaction with HFCWO was 79%.

CONCLUSION

High-frequency chest wall oscillation was well tolerated, considered helpful by a majority of patients, and decreased symptoms of breathlessness. In patients with impaired breathing, high-frequency chest wall oscillation decreased fatigue and showed a trend toward slowing the decline of forced vital capacity.

Influence of 'framing effect' on women's support for government funding of breast cancer screening

OBJECTIVES

To explore whether Australian women's support for government funding of mammographic screening is influenced by 'framing effect'.

METHOD

Self-administered survey of 701 women in general practice to elicit their support for government funding of each of four mammographic screening programs where benefits were expressed as a relative risk reduction (RRR); absolute risk reduction (ARR); number needed to screen (NNS) and number of cases detected for additional death avoided.

RESULTS

The proportion of respondents indicating they 'definitely would support funding' was significantly greater when benefits were expressed as RRR than ARR (chi 2(1) = 148.4, p < 0.0001), NNS (chi 2(1) = 126.4, p < 0.0001) or number of cases detected for additional deaths avoided (chi 2(1) = 29.0, p < 0.0001). 55.8% of women were not influenced by 'framing effect'. Younger women and those with higher educational levels were more likely to be susceptible to 'framing effect'.

CONCLUSION

Having demonstrated its influence among these women, 'framing effect' should be acknowledged in future research.

Nucleosome positioning signals and potential H-DNA within the DNA sequence of the imprinting control region of the mouse Igf2r gene

The imprinting control region within the second intron of the mouse Igf2r gene contains a CpG island comprising direct repeats, an imprinting box and the Air antisense promoter which is blocked by the methylation imprint on the active maternal allele. We have investigated the structural features of this DNA, including a mapping of all nucleosome positioning signals within the nucleotide sequence. A discrete series of strong positioning signals distinguished the direct repeat region from the much more diverse positioning capacity of the sequence encompassing the known regulatory elements. At only a few locations did CpG methylation modulate the use of this positioning information. Direct effects upon histone-DNA interactions are therefore unlikely to contribute significantly to the means by which the imprint may establish allele-specific chromatin architecture and determine Air expression. A strand-specific obstruction to DNA polymerase was observed between the repeat and regulatory regions. The same region adopts triple-stranded H-DNA structures in supercoiled DNA, according to pH and divalent cation exposure. Methylation did not modulate the occurrence or form of this structure under the conditions tested. This finding nevertheless adds to the repertoire of potential H-DNA structures found in the vicinity of regulatory sequences-here, in an imprinting context.

Nucleosome positioning signals in the DNA sequence of the human and mouse H19 imprinting control regions

We have investigated the sequences of the mouse and human H19 imprinting control regions (ICRs) to see whether they contain nucleosome positioning information pertinent to their function as a methylation-regulated chromatin boundary. Positioning signals were identified by an in vitro approach that employs reconstituted chromatin to comprehensively describe the contribution of the DNA to the most basic, underlying level of chromatin structure. Signals in the DNA sequence of both ICRs directed nucleosomes to flank and encompass the short conserved sequences that constitute the binding sites for the zinc finger protein CTCF, an essential mediator of insulator activity. The repeat structure of the human ICR presented a conserved array of strong positioning signals that would preferentially flank these CTCF binding sites with positioned nucleosomes, a chromatin structure that would tend to maintain their accessibility. Conversely, all four CTCF binding sites in the mouse sequence were located close to the centre of positioning signals that were stronger than those in their flanks; these binding sites might therefore be expected to be more readily incorporated into positioned nucleosomes. We found that CpG methylation did not effect widespread repositioning of nucleosomes on either ICR, indicating that allelic methylation patterns were unlikely to establish allele-specific chromatin structures for H19 by operating directly upon the underlying DNA-histone interactions; instead, epigenetic modulation of ICR chromatin structure is likely to be mediated principally at higher levels of control. DNA methylation did, however, both promote and inhibit nucleosome positioning at several sites in both ICRs and substantially negated one of the strongest nucleosome positioning signals in the human sequence, observations that underline the fact that this epigenetic modification can, nevertheless, directly and decisively modulate core histone-DNA interactions within the nucleosome.