Perceptions of an eHealth family-based cardiovascular disease risk reduction intervention: a mixed methods study

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Department for the Economy, Northern Ireland

Introduction

Controllable cardiovascular disease (CVD) risk factors are often initiated in the family home, yet risk reduction is seldom targeted toward families. Participatory design of eHealth interventions with end-users has potential to increase acceptability and adherence of such interventions. Despite their shared risk of developing CVD, few eHealth interventions target both parents and children at CVD risk. Therein lies an evidence gap; the need for coproduction of a family-based eHealth intervention aimed at early CVD prevention.

Purpose

The aim of this study was to identify the perceptions of families towards the design, functionality and acceptability of an eHealth, family-based, CVD prevention intervention.

Methods

Thee online focus groups comprising six families were conducted between April and May 2021. Families consisted of at least one parent who met CVD risk factor criteria, and at least one child aged five to 17 years. Content analysis and narrative synthesis were used to identify categories and subcategories regarding development of and engagement with the proposed intervention. Additionally, quantitative, and demographic measures were used to determine psychosocial and health profiles.

Results

Three categories were identified from the focus groups:

1) previous experiences of using health-related apps or devices

2) expectations of a newly developed eHealth family-based CVD prevention intervention

3) motivators for engagement with the intervention

Goal setting, rewards, accountability, adaptability, recording achievements and competition were considered crucial motivators for engagement for both parents and children. Participants welcomed the intervention, and advised they would prefer a free, personalised, easy-to-use, non-time-consuming intervention, with multiple content formats, and additional information available should they seek to access it. Parents conveyed satisfactory general self-efficacy and quality of life, low anxiety and depression and high perceived social support.

Conclusions

Overall, families were constructive and forthcoming towards the idea of an eHealth, family-based CVD prevention intervention. These findings informed a prototype of a family-based eHealth intervention aimed at early CVD prevention. The prototype is currently being developed with plans for piloting via a randomised controlled trial in the home environment, by families as an early intervention for the prevention of CVD.

Health literacy and physical and mental health status in octogenarian patients with coronary artery disease - a prospective cohort multicentre study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): MTG Holding AS

Introduction

The number of octogenarians (≥80 years of age) receiving percutaneous coronary intervention (PCI) is rising. Evidence supports that PCI improves quality of life and functional status in this group. Optimal health-promoting behaviour is strongly influenced by health literacy. However, there is limited knowledge about the association between health literacy, physical and mental health status in octogenarians.

Purpose

To determine if octogenarians health literacy is associated with generic and disease-specific physical and mental health status after PCI.

Methods

A prospective cohort study recruited 3417 participants from seven Danish and Norwegian PCI centres, and was conducted from June 2017 until May 2019. Multiple linear regression analysis was used. Health literacy was assessed by four of the nine scales from the Health Literacy Questionnaire (HLQ) (were higher score are better); "Social support for health" (scale range 1-4) "Appraisal of health information", (scale range 1-4) "Ability to find good health information" (scale range 1-5) and "Understand health information well enough to know what to do" (scale range 1-5). Generic physical and mental health status was assessed with RAND-12 at baseline (scale range 0-100, were higher score are better). After two months, disease-specific physical and mental health status was assessed with Myocardial Infarction Dimensional Assessment Scale (scale range 0-100, were lower score are better). Socio-demographic (age, gender, cohabitation status, education) and clinical variables (number of comorbidities) were included as covariates.

Results

In all, 318 octogenarians with mean age 83.4 years (range 80-96) participated, of which 69% were males. Three aspects of health literacy, "Social support for health", "Ability to find good health information" and "Understand health information well enough to know what to do", were significantly associated with health status. Specifically, for a unit increase of "Social support for health", the generic mental health status increased by 3 units (B: 3.0 [0.2 to 5.8] P=0.034). Further, a unit increase of "Ability to find good health information" was associated with a significant 4.2 higher disease-specific physical health and significant 5.3 higher disease-specific mental health (B:-4.2 [-8.0 to -0.4] P=0.029, B:-5.3 [-9.0 to -1.6] P=0.005, respectively). Finally, for a unit increase of "Understand health information well enough to know what to do" the disease-specific physical health improved by 5.1 units (B:-5.1 [-9.7 to -0.5] P=0.029) and disease-specific mental health improved by 5.2 units (B:-5.2 [-9.7 to -0.7] P=0.025).

Conclusion

In this study, we found that elements of health literacy were associated with both physical and mental health status in octogenerians. These findings highlight the importance of adequate health literacy and the need to support those with lower health literacy following PCI.

ManGuard an eHealth intervention to reduce cardiovascular risk in male taxi drivers: a pilot randomised controlled trial protocol

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Department for the Economy, Northern Ireland

Background

Men are at higher risk then women of developing cardiovascular disease (CVD) and male taxi drivers are a particularly high risk group because of their typically unhealthy behaviours, such as poor eating habits, smoking and a sedentary lifestyle. However, only two studies of behavioural interventions targeting taxi drivers have been identified, one of which had a high attrition rate. Therefore, an eHealth intervention co-designed by taxi drivers may prove more user-friendly and effective.

Purpose

The aim of this study is to assess the feasibility of a randomised controlled trial (RCT) of an eHealth intervention – ManGuard – to reduce CVD risk in male taxi drivers.

Methods

A wait-list controlled trial of 30 male taxi drivers in Belfast, Northern Ireland, will be assigned randomly to an intervention or usual care group. The ManGuard Application comprises seven modules: i) introduction and goal setting, ii) being active iii) eating well, iv) managing stress, v) smoking, vi) alcohol and vii) keep accelerating, the latter to be used as a re-cap module. This trial will establish feasibility, including recruitment, engagement and retention rates, program usability and participant satisfaction, as well as preliminary efficacy of ManGuard in improving key outcomes. Primary outcome is to determine the feasibility of an eHealth intervention for reducing CVD risk in male taxi drivers by assessing the following outcome measures:

o Acceptability, recruitment, retention and engagement rates

o Usability and participant satisfaction, process evaluation and survey

The secondary outcome is to evaluate the preliminary efficacy of ManGuard compared to usual care in improving the following outcomes:

o Clinical indices: CVD biomarkers (cholesterol, glucose), blood pressure, anthropometry (BMI, waist circumference, body fat percentage)

o Physical activity

o Psychosocial status: health related quality of life, self-efficacy, social support

An in-depth qualitative process evaluation to explore acceptability of the intervention will also be conducted.

Trial registration: This trial has been registered prospectively on the ISRCTN registry on 5 January 2022

Conclusion

eHealth interventions have been shown to promote behaviour change and reduce CVD risk in men, but there is a lack of robust evidence for this in male taxi drivers, a high-risk group. This study aims to assess the feasibility of a future RCT assessing the impact of ManGuard on CVD risk in male taxi drivers. This study will inform a fully-powered trial that will provide robust evidence for eHealth interventions for this underserved population.

Patient experiences of shared decision-making are associated with implantable cardioverter defibrillator recipients" openness to discuss device deactivation at end-of-life

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): In Australia, this study received funding from a faculty grand by Australian University Faculty of Health Sciences Research grant. In the United States, the study was funded by a research professor award from University of Kentucky.

Background. Shared decision-making is important for ICD recipients to fully contemplate and rationally decide about ICD deactivation at end-of-life. Although discussions about device deactivation at end-of-life are recommended to be held before ICD implantation and throughout the illness trajectory, such discussions rarely occur in clinical practice.

Purpose. To identify whether ICD recipients’ experiences of end-of-life discussions with clinicians are associated with openness to discussing ICD deactivation at end-of-life.

Methods. This cross-sectional study included 293 ICD recipients living in the United States, Australia, and South Korea (mean age 59, 22.5% female, mean ICD implantation 10 years). Hierarchical logistic regression was used to determine whether patients’ experiences of shared decision-making were associated with openness to discuss device deactivation at end-of-life after controlling for relevant covariates (i.e. age, gender, ICD implantation years, ICD shock experience, general ICD experience, ICD knowledge, and concerns related to the ICD).

Results. About half of the participants (57.7%) were open to discussing ICD deactivation at end-of-life with clinicians. Almost one-quarter (23.5%) had no prior experience of discussing any end-of-life issues with clinicians. Patients’ past experiences of end-of-life discussions with clinicians were significantly associated with openness to discuss device deactivation at end-of-life (OR: 1.30) after adjusting for covariates.

Conclusion. Our results highlight that clinicians’ willingness to discuss sensitive end-of-life issues such as battery replacement and deactivation of defibrillation therapy empowers patients to actively engage in end-of-life discussions.

eHealth interventions for reducing cardiovascular disease risk in men: a systematic review and meta-analysis

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Department for the Economy (DfE) studentships

Background. Men remain at a higher risk of developing cardiovascular disease (CVD) than women and behavioral risk factor modification is an important preventive measure. However, engaging men in behavior change interventions is challenging. eHealth interventions have the potential to address this gap, though their effectiveness for reducing CVD risk in men is unclear.

Purpose. To conduct a systematic review and meta-analysis to evaluate the effectiveness of eHealth interventions for reducing CVD risk in men.

Methods. This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and principles laid out by the Cochrane Handbook for Systematic Reviews of Interventions. A search of published randomised controlled trials (RCTs) with no date restrictions up to July 2020 was conducted across five electronic databases: Cochrane Central register of Controlled Trials (CENTRAL), Medline, CINAHL Plus, PsycINFO and SCOPUS. Reference lists of relevant systematic reviews and meta-analyses were manually searched for additional trials not identified during the database search. Eligible studies were RCTs that focused on the use of eHealth to improve a minimum of two major CVD related risk factors in males aged 18 years or older.

Results. A total of 3168 records were retrieved from the online database search, with nine trials meeting the inclusion criteria following screening and full-text assessment. Study quality ranged from low to unclear, with one trial at a high risk of bias. Compared to those in a control group or receiving printed materials, participants randomised to an eHealth intervention had statistically significant improvements in BMI (Z=-2.75, p = 0.01), body weight (Z=-3.25, p = 0.01), waist circumference (Z=-2.30, p = 0.02) and systolic (Z=-3.57, p = 0.01) and diastolic (Z=-3.56, p = 0.01) blood pressure. Though less evident, there were also improvements in physical activity and diet in favour of the intervention group.

Conclusion. This was the first systematic review and meta-analysis conducted on the effectiveness of eHealth interventions for reducing CVD risk in men. This review suggests that eHealth interventions can reduce CVD risk in adult men through behavior change. However, we were unable to determine the association between intervention characteristics and outcomes. Also, overall, participant adherence to the intervention was poor. Both of these issues should be considered in future studies.

Family-based eHealth interventions to reduce cardiovascular disease risk: a systematic review

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Department for the Economy, Northern Ireland

Background

Family-based eHealth interventions have potential to reduce cardiovascular disease (CVD) risk and improve health of parents and children.

Purpose

To evaluate the effectiveness of family-based eHealth interventions to reduce parent and child CVD risk.

Methods

Systematic review. Five electronic databases were searched (CENTRAL; MEDLINE; CINAHL; EMBASE; PsycINFO) up to April 2020. Data extraction included: study design, setting, methodology, eHealth technology, experiment/control group constituents, risk factors, outcomes, incentivisation and limitations. Data were synthesised narratively. Cochrane methodology was used to assess risk of bias and reporting quality.

Results

In total, 2193 articles were screened and seven trials included for review. The most consistently improved CVD risk factor across parents and children was reduced alcohol use, whilst reduction in BMI the least consistently improved. Behaviour-change theoretical underpinning, extended follow-up duration, interactivity and incentivisation were identified as effective components of these interventions. Four studies were assessed as overall ‘low risk’ of bias and three studies had concerns with randomisation and intention-to-treat analysis. Conclusions: This is the first systematic review to evaluate family-based eHealth interventions to reduce CVD risk. Despite a paucity in high-quality trials, there is evidence of their potential effectiveness. Recommended, more high quality, behaviour-change-theory-based, clearly reported interventions with explicit outcomes.

Poultry processing and the application of microbiome mapping

Chicken is globally one of the most popular food animals. However, it is also one of the major reservoirs for foodborne pathogens, annually resulting in continued morbidity and mortality incidences worldwide. In an effort to reduce the threat of foodborne disease, the poultry industry has implemented a multifaceted antimicrobial program that incorporates not only chemical compounds, but also extensive amounts of water application and pathogen monitoring. Unfortunately, the pathogen detection methods currently used by the poultry industry lack speed, relying on microbiological plate methods and molecular detection systems that take time and lack precision. In many cases, the time to data acquisition can take 12 to 24 h. This is problematic if shorter-term answers are required which is becoming more likely as the public demand for chicken meat is only increasing, leading to new pressures to increase line speed. Therefore, new innovations in detection methods must occur to mitigate the risk of foodborne pathogens that could result from faster slaughter and processing speeds. Future technology will have 2 tracks: rapid methods that are meant to detect pathogens and indicator organisms within a few hours, and long-term methods that use microbiome mapping to evaluate sanitation and antimicrobial efficacy. Together, these methods will provide rapid, comprehensive data capable of being applied in both risk-assessment algorithms and used by management to safeguard the public.

The educational preparation of nurses in a developing economy and patient mortality

BACKGROUND

Most studies have reported that higher levels (baccalaureate degree) of educational attainment by nurses are associated with lower levels of patient mortality. Researchers working in developed economies (e.g. North America and Europe) have almost exclusively conducted these studies. The value of baccalaureate nurse education has not been tested in countries with a developing economy.

METHOD

A retrospective observational study conducted in seven hospitals. Patient mortality was the main outcome of interest. Anonymized data were extracted from nurses and patients from two different administrative sources and linked using the staff identification number that exists in both systems. We used bivariate logistic regression models to test the association between mortality and the educational attainment of the admitting nurse (responsible for assessment and care planning).

RESULTS

Data were extracted for 11 918 (12, 830 admissions) patients and 7415 nurses over the first 6 months of 2015. The majority of nurses were educated in South Asia and just over half were educated to at least bachelor degree level. After adjusting for confounding and clustering, nurse education was not found to be associated with mortality.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Our observations may suggest that in a developing economy, the academic level of nurses' education is not associated with a reduction in patient mortality. Findings should be interpreted with considerable caution but do challenge widely held assumptions about the value of baccalaureate-prepared nurses. Further research focused on nursing education in developing economies is required to inform health policy and planning.

Inhibition of Dipeptidyl-Peptidase IV Does Not Increase Circulating IGF-1 Concentrations in Growing Pigs

The enzyme dipeptidyl peptidase-IV (DPP-IV) inactivates a variety of bioactive peptides, including glucagon-like peptide-1 (GLP-1) and growth hormone releasing hormone (GHRH). Inhibiting DPP-IV in order to increase circulating GLP-1 is of interest as a treatment for Type II diabetes. Inactivation of DPP-IV may also increase circulating GHRH, potentially enhancing growth in domestic animals. To test the hypothesis that inhibition of DPP-IV activity will influence the growth hormone/IGF-1 axis, growing pigs (Sus scrofa domesticus, 78 kg) were treated with a DPP-IV inhibitor (Compound 1, the 2,5-difluorophenyl analog of the triazolopiperazine MK0431, sitagliptin), and plasma concentrations of IGF-1 were monitored. Pigs were administered either sterile saline (0.11 ml/kg followed by a continuous infusion at 2 ml/hr for 72 hrs, controls, n = 2), Compound 1 (2.78 mg/kg followed by a continuous infusion at 0.327 mg/kg·hr for 72 hrs, n = 4) or GHRH (0.11 ml/kg sterile saline, followed by a continuous infusion of GHRH at 2.5 μg/kg hr for 48 hrs, n = 4). Plasma concentrations of Compound 1 were maintained at 1 μM, which resulted in a 90% inhibition of circulating DPP-IV activity. Relative to the predose 24-hr period, area under the IGF-1 concentration curve (AUC) tended to be lower (P = 0.062) with Compound 1 (–79 ± 130 ng/ml hr) than controls (543 ± 330 ng/ml hr). GHRH treatment increased the IGF-1 AUC (1210 ± 160 ng/ml hr, P = 0.049 vs. controls and P = 0.001 vs. Compound 1). We conclude that inhibition of DPP-IV does not alter the circulating levels of IGF-1 in the growing pig.

How to research the mechanisms of non-pharmacological cardiac interventions

OBJECTIVE

To discuss research into the mechanisms of non-pharmacological interventions for cardiac populations.

METHODS

Overview of past research and theory.

RESULTS

Non-pharmacological interventions for cardiac patients (including: cardiac rehabilitation, heart failure disease management programs and psychosocial interventions) have never been so common or diverse, but also have never been subject to so much scrutiny and skepticism. Better understanding of outcomes of these interventions is an urgent global priority. Mechanisms are the "underlying entities, processes, or structures which operate in particular contexts to generate outcomes of interest."

PRACTICE

Research into the mechanisms of non-pharmacological interventions offers useful and robust knowledge of how and why cardiac interventions work that can be vital to explaining outcomes from interventions and inconsistencies in results.

CONCLUSIONS

Research into intervention mechanisms can inform the design and optimization of interventions.

IMPLICATIONS

We recommend that future research into the mechanisms of non-pharmacological interventions for cardiac population 1) view effectiveness as 'somewhat' patterned, 2) conceptualize mechanisms adequately, 3) assume they are hidden, 4) examine how context affects mechanisms, and 6) address what works for whom, when, and why.

Association between perinatal medical expenses and a waiver to increase Florida healthy start services within Florida medicaid programs: 1998 to 2006

To assess the association between perinatal care expenditures and a Medicaid waiver to increase Florida Healthy Start services among Florida Medicaid non-managed care organization (non-MCO) program enrollees. We assessed perinatal care expenditures from Medicaid claims and encounter data among non-MCO enrollees with increased risk pregnancies who gave birth in Florida during 1998-2006. We used a pre-post design to compare adjusted perinatal medical expenditures among women who received Healthy Start care coordination (n = 41,067) to women who were not contacted by the Healthy Start program after screening (n = 24,282). We calculated adjusted average costs and difference-in-differences using marginal estimates from multivariable linear mixed regression models. From the pre-waiver (January 1998-July 2001) to the late-post waiver (July 2004-December 2006), all prenatal medical costs increased $274 among care coordination participants and decreased $601 among women not contacted by the Healthy Start program, equaling a $875 increased cost difference between care coordination and no contact groups. During this same time period, delivery related expenditures increased $395 less among care coordination participants compared to women not contacted by Healthy Start. Additionally, infant medical care costs during days 29-365 decreased by an average of $240 less among the care coordination compared to the no contact group. The Medicaid waiver may have decreased delivery costs, but medical costs were increased following the waiver when considering all perinatal care. Further exploration of factors associated with the decreased delivery costs may help develop more efficient prenatal support programs.

Statewide estimation of racial/ethnic populations of men who have sex with men in the U.S

OBJECTIVES

Men who have sex with men (MSM) bear the greatest burden of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in every state in the U.S., but their populations are poorly defined. We estimated and compared populations of MSM in 2007 by region, state, and race/ethnicity.

METHODS

We averaged findings from two statistical models we had previously developed to estimate the total state-specific percentage and number of males who were MSM. The models were based, respectively, on state-specific rural/ suburban/urban characteristics and an index using state-specific household census data on same-sex male unmarried partners. A third model, based on racial/ethnic ratios from a nationally representative behavioral survey, partitioned these statewide numbers by race/ethnicity.

RESULTS

Of an estimated 7.1 million MSM residing in the U.S. in 2007, 71.4% (5.1 million) were white, 15.9% (1.1 million) were Hispanic, 8.9% (635,000) were black, 2.7% (191,000) were Asian, 0.4% (26,000) were American Indian/Alaska Native, 0.1% (6,000) were Native Hawaiian/other Pacific Islander, and 0.6% (41,000) were of multiple/unknown race/ethnicity. The overall U.S. percentage of males who were MSM (6.4%) varied from 3.3% in South Dakota to 13.2% in the District of Columbia, which we treated as a state. Estimated numbers of MSM ranged from 9,612 in Wyoming to 1,104,805 in California.

CONCLUSIONS

Plausible estimates of MSM populations by state and race/ethnicity can inform and guide HIV/AIDS surveillance, allocation of resources, and advocacy. They can help in the planning, implementation, and evaluation of HIV prevention programs and other services. Using MSM numbers as denominators, estimates of population-based MSM HIV incidence, prevalence, and mortality rates could help clarify national and state-level epidemic dynamics. Until corroborated by other modeling and/or empirical research, these estimates should be used with caution.

Infection control practices among hospital health and support workers in Hong Kong

A report by the Hong Kong government noted that hospital infection control standards were inadequate, requiring audit, development and implementation. In addition, hospital staff needed training in infection control measures. We investigated infection control practices among 162 hospital health workers (109 nurses, 45 doctors and 8 therapists) and 44 support workers in one acute hospital and two rehabilitation hospitals using a non-blinded, observational design. We examined compliance with isolation precautions and infection control guidelines, including proper wearing of a mask, goggles/face shield, or gown; handling patient care equipment, linen, and laundry; routine and terminal cleaning; and terminal cleaning of an isolation room. One major breakdown in compliance was use of sleeveless disposable plastic aprons instead of long-sleeved gowns during procedures likely to generate splashes or sprays of blood and body fluids. In more than half of the observed episodes, participants failed to disinfect medical devices, such as stethoscopes, before re-use. Thorough cleansing of commodes between patients was also lacking. Overall compliance with local and international infection control guidelines was satisfactory, but several aspects required improvement.

Estimating populations of men who have sex with men in the southern United States

Population estimates of men who have sex with men (MSM) by state and race/ethnicity are lacking, hampering effective HIV epidemic monitoring and targeting of outreach and prevention efforts. We created three models to estimate the proportion and number of adult males who are MSM in 17 southern states. Model A used state-specific census data stratified by rural/suburban/urban area and national estimates of the percentage MSM in corresponding areas. Model B used a national estimate of the percentage MSM and state-specific household census data. Model C partitioned the statewide estimates by race/ethnicity. Statewide Models A and B estimates of the percentages MSM were strongly correlated (r = 0.74; r-squared = 0.55; p < 0.001) and had similar means (5.82% and 5.88%, respectively) and medians (5.5% and 5.2%, respectively). The estimated percentage MSM in the South was 6.0% (range 3.6-13.2%; median, 5.4%). The combined estimated number of MSM was 2.4 million, including 1,656,500 (69%) whites, 339,400 (14%) blacks, 368,800 (15%) Hispanics, 34,600 (1.4%) Asian/Pacific Islanders, 7,700 (0.3%) American Indians/Alaska Natives, and 11,000 (0.5%) others. The estimates showed considerable variability in state-specific racial/ethnic percentages MSM. MSM population estimates enable better assessment of community vulnerability, HIV/AIDS surveillance, and allocation of resources. Data availability and computational ease of our models suggest other states could similarly estimate their MSM populations.

Cardiac rehabilitation: into the future

Cardiac rehabilitation is increasingly recognised as an integral component of comprehensive cardiac care. The evidence supporting its effectiveness in reducing morbidity and mortality and improving quality of life is compelling. Yet, despite this recognition and exhortations that its implementation should be a key priority, most cardiac patients do not receive rehabilitation. Service provision varies markedly and many programmes are focused on select populations, often operate in an inflexible manner and fail to add potential value. Issues of suboptimal referral, enrolment and completion are poorly addressed and the potential for embracing novel methods and the latest technology are rarely exploited. This paper reviews the current status of cardiac rehabilitation and proposes ways to improve access and uptake and reduce inequity to ensure that those who are likely to benefit from this complex intervention do so.

Speciation and phylogeography of giant petrels Macronectes

We examine global phylogeography of the two forms of giant petrel Macronectes spp. Although previously considered to be a single taxon, and despite debate over the status of some populations and the existence of minimal genetic data (one mitochondrial cytochrome b sequence per form), the current consensus based on morphology is that there are two species, Northern Giant Petrel M. halli and Southern Giant Petrel M. giganteus. This study examined genetic variation at cytochrome b as well as six microsatellite loci in giant petrels from 22 islands, representing most island groups at which the two species breed. Both markers support separate species status, although sequence divergence in cytochrome b was only 0.42% (corrected). Divergence was estimated to have occurred approximately 0.2mya, but with some colonies apparently separated for longer (up to 0.5 my). Three clades were found within giant petrels, which separated approximately 0.7mya, with the Southern Giant Petrel paraphyletic to a monophyletic Northern Giant Petrel. There was evidence of past fragmentation during the Pleistocene, with subsequent secondary contact within Southern Giant Petrels. The analysis also suggested a period of past population expansion that corresponded roughly to the timing of speciation and the separation of an ancestral giant petrel population from the fulmar Fulmarus clade.

Translation and validation of two Chinese health-related quality of life instruments in patients with coronary heart disease

1. The Chinese version of the 27-item MacNew health-related quality of life (HRQL) questionnaire is a valid, reliable and responsive core coronary heart disease (CHD)-specific HRQL measure. It can be used to compare the health outcomes, burdens of illness, and treatment effectiveness in pure or mixed populations of patients with myocardial infarction, angina, or heart failure in clinical trials and in routine clinical practice. 2. The Chinese version of the 35-item Myocardial Infarction Dimensional Assessment Scale (MIDAS) did not perform as well. Although four of the seven subscales, which cover the physical and psychosocial aspects of HRQL, are psychometrically sound when used to evaluate HRQL among CHD patients with different cardiac diagnostic categories, the remaining three subscales covering treatment-related aspects are not. The latter had only weak validity and responsiveness, which may be due to cultural differences. 3. To improve the overall performance of the Chinese version of the MIDAS, further effort is required to clarify the treatment-related impact of CHD on well-being from the patient's perspective.

Maternal obesity and risk of infant death based on Florida birth records for 2004

OBJECTIVE

The purpose of this study was to assess the relationship between pre-pregnancy maternal obesity and risk of infant death.

METHODS

In March 2004, maternal height and pre-pregnancy weight were added to the data collected on the Florida birth certificate. Using birth records linked to infant deaths, these data were used to assess the relationship between pre-pregnancy maternal obesity, as measured by body mass index, and infant death.

RESULTS

Pre-pregnancy maternal obesity was associated with increased odds of infant death. The increased risk was found with and without adjustments for maternal race, marital status, age, education, trimester prenatal care began, first birth, and tobacco use.

CONCLUSION

There is a substantial and significant association between pre-pregnancy maternal obesity and infant death.

An evaluation of SARS and droplet infection control practices in acute and rehabilitation hospitals in Hong Kong

1. This study has demonstrated that great efforts have been made by the Hospital Authority and the studied hospital cluster to contain and prevent infection, and that high levels of vigilance have been enforced in anticipation of future outbreaks of SARS and other droplet infections. 2. Most health care workers and support workers have good hospital infection control and isolation precaution knowledge levels. 3. Compliance with infection control guidelines is satisfactory and has increased compared with previous studies. 4. Most participants had positive perceptions of the guidelines and found the training programmes useful. 5. This study has identified several structures and infection control practice areas that need strengthening, including improving the clarity of some guidelines and minimising barriers to their implementation.

Home-based cardiac rehabilitation versus hospital-based rehabilitation: A cost effectiveness analysis

BACKGROUND

Home-based cardiac rehabilitation offers an alternative to traditional, hospital-based cardiac rehabilitation.

AIM

To compare the cost effectiveness of home-based cardiac rehabilitation and hospital-based cardiac rehabilitation.

METHODS

104 patients with an uncomplicated acute myocardial infarction and without major comorbidity were randomized to receive home-based rehabilitation (n=60) i.e. nurse facilitated, self-help package of 6 weeks' duration (the Heart Manual) or hospital-based rehabilitation for 8-10 weeks (n=44). Complete economic data were available in 80 patients (48 who received home-based rehabilitation and 32 who received hospital-based rehabilitation). Healthcare costs, patient costs, and quality of life (EQ-5D4.13) were assessed over the 9 months of the study.

RESULTS

The cost of running the home-based rehabilitation programme was slightly lower than that of the hospital-based programme (mean (95% confidence interval) difference - 30 pounds sterling (- 45 pounds sterling to - 12 pounds sterling) [-44 euro, -67 euro to -18 euro] per patient. The cost difference was largely the result of reduced personnel costs. Over the 9 months of the study, no significant difference was seen between the two groups in overall healthcare costs (78 pounds sterling, - 1102 pounds sterling to 1191 pounds sterling [-115 euro, -1631 euro to -1763 euro] per patient) or quality adjusted life-years (-0.06 (-0.15 to 0.02)). The lack of significant difference between home-based rehabilitation and hospital-based rehabilitation did not alter when different costs and different methods of analysis were used.

CONCLUSIONS

The health gain and total healthcare costs of the present hospital-based and home-based cardiac rehabilitation programmes for patients after myocardial infarction appear to be similar. These initial results require affirmation by further economic evaluations of cardiac rehabilitation in different settings.

Home-based versus hospital-based rehabilitation after myocardial infarction: A randomized trial with preference arms--Cornwall Heart Attack Rehabilitation Management Study (CHARMS)

BACKGROUND

Participation in cardiac rehabilitation after acute myocardial infarction is sub-optimal. Offering home-based rehabilitation may improve uptake. We report the first randomized study of cardiac rehabilitation to include patient preference.

AIM

To compare the clinical effectiveness of a home-based rehabilitation with hospital-based rehabilitation after myocardial infarction and to determine whether patient choice affects clinical outcomes.

DESIGN

Pragmatic randomized controlled trial with patient preference arms.

SETTING

Rural South West England.

METHODS

Patients admitted with uncomplicated myocardial infarction were offered hospital-based rehabilitation classes over 8-10 weeks or a self-help package of six weeks' duration (the Heart Manual) supported by a nurse. Primary outcomes at 9 months were mean depression and anxiety scores on the Hospital Anxiety Depression scale, quality of life after myocardial infarction (MacNew) score and serum total cholesterol.

RESULTS

Of the 230 patients who agreed to participate, 104 (45%) consented to randomization and 126 (55%) chose their rehabilitation programme. Nine month follow-up data were available for 84/104 (81%) randomized and 100/126 (79%) preference patients. At follow-up no difference was seen in the change in mean depression scores between the randomized home and hospital-based groups (mean difference: 0; 95% confidence interval, -1.12 to 1.12) nor mean anxiety score (-0.07; -1.42 to 1.28), mean global MacNew score (0.14; -0.35 to 0.62) and mean total cholesterol levels (-0.18; -0.62 to 0.27). Neither were there any significant differences in outcomes between the preference groups.

CONCLUSIONS

Home-based cardiac rehabilitation with the Heart Manual was as effective as hospital-based rehabilitation for patients after myocardial infarction. Choosing a rehabilitation programme did not significantly affect clinical outcomes.

Heart failure management programmes in Europe

BACKGROUND

The ESC guidelines recommend that an organised system of specialist heart failure (HF) care should be established to improve outcomes of HF patients. The aim of this study was therefore to identify the number and the content of HF management programmes in Europe.

METHOD

A two-phase descriptive study was conducted: an initial screening to identify the existence of HF management programmes; and a survey to describe the content in countries where at least 30% of the hospitals had a programme.

RESULTS

Of the 43 European countries approached, 26 (60%) estimated the percentage of HF management programmes. Seven countries reported that they had such programmes in more than 30% of their hospitals. Of the 673 hospitals responding to the questionnaire, 426 (63%) had a HF management programme. Half of the programmes (n = 205) were located in an outpatient clinic. In the UK a combination of hospital and home-based programmes was common (75%). The most programmes included physical examination, telephone consultation, patient education, drug titration and diagnostic testing. Most (89%) programmes involved nurses and physicians. Multi-disciplinary teams were active in 56% of the HF programmes. The most prominent differences between the 7 countries were the degree of collaboration with home care and GP's, the role in palliative care and the funding.

CONCLUSION

Only a few European countries have a large number of organised programmes for HF care and follow up. To improve outcomes of HF patients throughout Europe more effort should be taken to increase the number of these programmes in all countries.

A Chinese Mandarin translation and validation of the Myocardial Infarction Dimensional Assessment Scale (MIDAS)

AIMS

To evaluate the validity, reliability, and cultural relevance of the Chinese Mandarin version of Myocardial Infarction Dimensional Assessment Scale (MIDAS) as a disease-specific quality of life measure.

METHODS

The cultural relevance and content validity of the Chinese Mandarin version of the MIDAS (CM-MIDAS) was evaluated by an expert panel. Measurement performance was tested on 180 randomly selected Chinese MI patents. Thirty participants from the primary group completed the CM-MIDAS for test-retest reliability after 2 weeks. Reliability, validity and discriminatory power of the CM-MIDAS were calculated.

RESULTS

Two items were modified as suggested by the expert panel. The overall CM-MIDAS had acceptable internal consistency with Cronbach's alpha coefficient 0.93 for the scale and 0.71-0.94 for the seven domains. Test-retest reliability by intraclass correlations was 0.85 for the overall scale and 0.74-0.94 for the seven domains. There was acceptable concurrent validity with significant (p < 0.05) correlations between the CM-MDAS and the Chinese Version of the Short Form 36. The principal components analysis extracted seven factors that explained 67.18% of the variance with high factor loading indicating good construct validity.

CONCLUSION

Empirical data support CM-MIDAS as a valid and reliable disease-specific quality of life measure for Chinese Mandarin speaking patients with myocardial infarction.

Nurse specialists in adult congenital heart disease: the current status in Europe

AIM

Recommendations for the management of adults with congenital heart disease indicate that specialist referral centres should employ nurse specialists who are trained and educated in the care for these patients. We surveyed the involvement, education and activities of nurse specialists in the care for adults with congenital cardiac anomalies in Europe.

METHODS

The Euro Heart Survey on Adult Congenital Heart Disease has previously showed that 20 out of 48 specialist centres (42%) have nurse specialists affiliated with their programme. Fifteen of these 20 centres (75%) validly completed a web-based survey tool.

RESULTS

Specialist centres had a median number of 2 nurse specialists on staff, corresponding with 1 full-time equivalent. In most centres, the nurse specialists were also affiliated with other cardiac care programmes, in addition to congenital heart disease. The involvement of nurse specialists was not related to the caseload of inpatients and outpatient visits. Physical examination was the most prevalent activity undertaken by nurse specialists (93.3%), followed by telephone accessibility (86.7%), patient education (86.7%), co-ordination of care (73.3%), and follow-up after discharge (73.3%). Patient education covered mainly prevention and prophylaxis of endocarditis (100%), cardiovascular risk factors (92.3%), sport activities (92.3%), the type and characteristics of the heart defect (92.3%), the definition and aetiology of endocarditis (84.6%), cardiac risk in case of pregnancy (84.6%), and heredity (84.6%). Two third of the nurse specialists were involved in research.

CONCLUSION

This survey revealed gaps in the provision of care for these patients in Europe and demonstrated that there is room for improvement in order to provide adequate chronic disease management. The results of this study can be used by individual hospitals for benchmarking.

Live attenuated vaccine-based control of necrotic enteritis of broiler chickens

A vaccine for necrotic enteritis (NE) of chickens would reduce the current need to prevent or treat the disease in broiler chickens with antimicrobial drugs. The objective of this study was to understand aspects of immunity to the disease. The first experiment examined the virulence of six strains of Clostridium perfringens isolated from cases of NE in broiler chickens. Using a 5-day experimental oral infection of 2-week-old broiler chickens, four of the six strains were found to be virulent. Pulsed-field gel electrophoresis and PCR showed that virulence was not associated with a plasmid encoding the beta2 toxin gene, cpb2, since this was present in virulent and one of the two avirulent strains. In the second experiment, two virulent and one avirulent strains were tested for their ability to immunize ("infection-immunization") chickens through the oral route. The procedure used experimental infection for 5 days followed by bacitracin treatment for 9 days, and then re-challenge 2 days later with a virulent strain, CP4. Infection-immunization with the virulent isolates protected chickens from subsequent virulent challenge, whereas the infection-immunization with the avirulent isolate did not. In a third experiment, two of four alpha-toxin-negative mutants of CP4 protected birds from experimental NE after oral immunization. These two mutants were also attenuated for virulence. We conclude that it is possible to immunize chickens successfully against NE and that immunogen(s) other than alpha-toxin are important in protective immunity against oral infection.

Field efficacy of an ivermectin jetting fluid for control of the sheep body louse Bovicola (Damalinia) ovis in New Zealand

The efficacy of an ivermectin jetting fluid against the sheep body louse, Bovicola (Damalinia) ovis, in long-woolled sheep was investigated in three field trials. In all trials, louse populations in hand-jetted sheep were reduced to nondetectable numbers within 2 weeks of treatment. Bv comparison, shorn and unshorn control sheep maintained detectable infestations for the duration of the trials.

Treatment needs of patients admitted for acute chest pain

OBJECTIVE

To examine the characteristics, subsequent resource use and outcome of a consecutive cohort of admissions with acute chest pain not due to myocardial infarction.

METHODS

Subjects (N=356) identified in the course of a epidemiological study of myocardial infarction were interviewed and completed HAD, SF-36 and other self-report information in hospital and at 3 months and 1 year. Hospital casenotes were reviewed at 1 year.

RESULTS

A total of 218 subjects were given cardiac diagnoses and 138 noncardiac diagnoses. Cardiac subjects were more distressed and disabled and used more resources. Those in the noncardiac group reported distress and disability and resource use comparable to infarct admissions.

CONCLUSION

Awareness of psychosocial variables would aid in the assessment and management of those with and without ischaemic heart disease.

Development and validation of a short measure of health status for individuals with acute myocardial infarction: the myocardial infarction dimensional assessment scale (MIDAS)

The purpose of this study was to develop and validate a disease-specific health status measure for individuals with myocardial infarction (MI). The development of the myocardial infarction dimensional assessment scale (MIDAS) followed three main stages. Stage 1 consisted of in-depth, semi-structured, exploratory interviews conducted on a sample of 31 patients to identify areas of salience and concern to patients with MI. These interviews generated 48 candidate questions. In stage 2 the 48-item questionnaire was used in a postal survey to identify appropriate rephrasing/shortening, to determine acceptability and to help identify sub-scales of the instrument addressing different dimensions of MI. Finally, in stage 3 the construct validity of MIDAS subscales was examined in relation to clinical and other health outcomes. A single centre (district general hospital) in England was used for stages 1 and 3 and a national postal survey was conducted for stage 2. A total of 410 patients were recruited for the national survey (stage 2). Full data were available on 348 (85%) patients. One hundred and fifty-five patients were recruited to test construct validity (stage 3). The MIDAS contains 35 questions measuring seven areas of health status: physical activity, insecurity, emotional reaction, dependency, diet, concerns over medication and side effects. The measure has high face, internal and construct validity and is likely to prove useful in the evaluation of treatment regimes for MI.

Research information in nurses' clinical decision-making: what is useful?

AIM

To examine those sources of information which nurses find useful for reducing the uncertainty associated with their clinical decisions.

BACKGROUND

Nursing research has concentrated almost exclusively on the concept of research implementation. Few, if any, papers examine the use of research knowledge in the context of clinical decision-making. There is a need to establish how useful nurses perceive information sources are, for reducing the uncertainties they face when making clinical decisions.

DESIGN

Cross-case analysis involving qualitative interviews, observation, documentary audit and Q methodological modelling of shared subjectivities amongst nurses. The case sites were three large acute hospitals in the north of England, United Kingdom. One hundred and eight nurses were interviewed, 61 of whom were also observed for a total of 180 hours and 122 nurses were involved in the Q modelling exercise.

RESULTS

Text-based and electronic sources of research-based information yielded only small amounts of utility for practising clinicians. Despite isolating four significantly different perspectives on what sources were useful for clinical decision-making, it was human sources of information for practice that were overwhelmingly perceived as the most useful in reducing the clinical uncertainties of nurse decision-makers.

CONCLUSIONS

It is not research knowledge per se that carries little weight in the clinical decisions of nurses, but rather the medium through which it is delivered. Specifically, text-based and electronic resources are not viewed as useful by nurses engaged in making decisions in real time, in real practice, but those individuals who represent a trusted and clinically credible source are. More research needs to be carried out on the qualities of people regarded as clinically important information agents (specifically, those in clinical nurse specialist and associated roles) whose messages for practice appear so useful for clinicians.

The accessibility of research-based knowledge for nurses in United Kingdom acute care settings

BACKGROUND

The successful dissemination of the results of the National Health Service (NHS) research and development strategy and the development of evidence based approaches to health care rely on clinicians having access to the best available evidence; evidence fit for the purpose of reducing the uncertainties associated with clinical decisions.

AIM

To reveal the accessibility of those sources of information actually used by nurses, as well as those which they say they use.

DESIGN

Mixed method case site, using interview, observational, Q sort and documentary audit data in medical, surgical and coronary care units (CCUs) in three acute hospitals.

RESULTS

Three perspectives on accessibility were identified: (a) the humanist--in which human sources of information were the most accessible; (b) local information for local needs--in which locally produced resources were seen as the most accessible and (c) moving towards technology--in which information technology begins to be seen as accessible. Nurses' experience in a clinical specialty is positively associated with a perception that human sources such as clinical nurse specialists, link nurses, doctors and experienced clinical colleagues are more accessible than text based sources. Clinical specialization is associated with different approaches to accessing research knowledge. Coronary care unit nurses were more likely to perceive local guidelines, protocols and on-line databases as more accessible than their counterparts in general medical and surgical wards. Only a third of text-based resources available to nurses on the wards had any explicit research base. These, and the remainder were out of date (mean age of textbooks 11 years), and authorship hard to ascertain.

CONCLUSION

A strategy to increase the use of research evidence by nurses should harness the influence of clinical nurse specialists, link nurses and those engaged in practice development. These roles could act as 'conduits' through which research-based messages for practice, and information for clinical decision making, could flow. This role should be explored and enhanced.

The measurement of health-related quality of life in patients with coronary heart disease

This article provides an overview of the key concepts and methodological issues in the measurement of health-related quality of life in patients with coronary heart disease. It then outlines the approach adopted in a British study to develop and test a new disease-specific health-related quality of life instrument for use with individuals with myocardial infarction.

Hepatic failure as the presenting manifestation of malignant lymphoma

Fulminant hepatic failure carries a high mortality regardless of etiology. Liver transplantation may be lifesaving. Hepatic invasion by malignant lymphoma is a rare cause of liver failure, but one that is potentially responsive to treatment. Lymphoma (non-Hodgkin's or Hodgkin's) should be included in the differential diagnosis of fulminant hepatic failure so that liver transplantation is avoided and appropriate therapy can be instituted. The findings and clinical course of 4 patients with liver failure due to hepatic lymphoma, who were referred to our institution for liver transplant evaluation, are presented and discussed. Medical records, imaging studies, and histological material were examined. Review of the literature revealed less than 40 cases of lymphoma presenting as fulminant hepatic failure. The diagnosis of malignant lymphoma may be difficult. The presenting symptoms and signs are indistinguishable from other causes of fulminant hepatic failure. Early liver biopsy with adequate tissue and immunologic studies is mandatory for diagnosis. This condition may be reversible and may respond to chemotherapy if the diagnosis is made prior to multiorgan system failure. The presence of malignant lymphoma is considered a contraindication to liver transplantation, although firm data are lacking.

Health-related quality of life after myocardial infarction: an interview study

AIM

The aim of this qualitative study was to explore and gain insights into the effects of myocardial infarction on health-related quality of life.

BACKGROUND

The study was undertaken as part of a larger on-going project to develop and validate a disease-specific health-related quality of life instrument suitable for use with patients after myocardial infarction.

METHODS

A consecutive sample of 31 patients admitted to a district general hospital in the North of England was recruited and interviewed at home. Semi-structured interviews were conducted based on a guide developed from a review of the literature pertaining to quality of life and expert opinion. Interviews were audio-tape recorded and transcribed verbatim. Transcripts were subjected to latent and manifest content analysis and inter-rater reliability was confirmed by a researcher not involved with the interview process.

FINDINGS

Analysis of the data revealed seven major categories: physical activity/symptoms; insecurity; emotional reactions; dependency; lifestyle modification; concern over medication; and side-effects. Breathlessness, insecurity and feelings of over-protection were major problems, as was dissatisfaction with information and support.

CONCLUSION

Myocardial infarction resulted in a variety of health-related problems which affected quality of life. Systematic monitoring and evaluation of health status should be performed routinely. This is likely to be aided by the development and use of a health-related quality of life instrument for this patient group.

Narcotic analgesic effects on the sphincter of Oddi: a review of the data and therapeutic implications in treating pancreatitis

OBJECTIVE

Traditional teaching dictates that morphine induces "spasm" in the sphincter of Oddi (SO) and should not be used in acute pancreatitis and that meperidine is the analgesic of choice because it does not elevate SO pressures. A literature search and review was performed to evaluate this teaching examining the effect of narcotic analgesic's effects on SO.

METHODS

A Medline search was performed using keywords and phrases. The manufacturers of meperidine were contacted and their reports and studies were obtained and reviewed.

RESULTS

Initial studies measured biliary pressure after narcotic administration in animals, and postoperative and intraoperative cholecystectomy patients. All narcotics increased biliary pressure, but morphine was associated with the largest elevation. Later studies using endoscopic retrograde cholangiopancreatography with direct SO manometry demonstrated that the SO is exquisitely sensitive to all narcotics including meperidine and that a small increase in biliary sphincter pressure is seen with higher doses of morphine. All narcotics increase SO phasic wave frequency and interfere with SO peristalsis.

CONCLUSIONS

Narcotic-induced increases in phasic wave frequency interfere with SO filling and are responsible for the increase in bile duct pressure seen on the initial studies. No studies directly compare the effects of meperidine or morphine on SO manometry and no comparative studies exist in patients with acute pancreatitis. No outcome-based studies comparing these drugs have been performed in patients with acute pancreatitis. Morphine may be of more benefit than meperidine by offering longer pain relief with less risk of seizures. No studies or evidence exist to indicate morphine is contraindicated for use in acute pancreatitis.

Increased coronary artery blood flow with aortomyoplasty in chronic heart failure

BACKGROUND

We hypothesized that diastolic counter-pulsation using aortomyoplasty will increase coronary blood flow.

METHODS

In dogs (n = 6, 20 to 25 kg), the left latissimus dorsi muscle was isolated, wrapped around the descending thoracic aorta, and conditioned by chronic electrical stimulation. Heart failure was induced by rapid ventricular pacing. In a terminal study, left ventricular and aortic pressures, and blood flow in the left anterior descending coronary artery and descending aorta were measured. The endocardial-viability ratio was calculated.

RESULTS

Aortomyoplasty increased mean diastolic aortic pressure (70 +/- 5 to 75 +/- 5 mm Hg, p < 0.05) and reduced peak left ventricular pressure (86 +/- 4 to 84 +/- 4 mm Hg, p < 0.05), leading to a 16% increase in endocardial-viability ratio (1.29 +/- 0.05 to 1.49 +/- 0.05, p < 0.05). Coronary blood flow was increased by 15% (8.2 +/- 1.5 to 9.4 +/- 1.6 mL/min, p < 0.05). During muscle contraction, 2.7 +/- 0.5 mL was ejected from the wrapped aortic segment.

CONCLUSIONS

These data demonstrate that aortomyoplasty provides successful diastolic counterpulsation after muscle conditioning and heart failure.

Coping after heart transplantation: a descriptive study of heart transplant recipients' methods of coping

The purpose of the study reported in this paper was to explore the coping strategies of heart transplant recipients. Using a qualitative research approach, interviews were conducted with 42 participants (35 men and seven women). Analysis of the data revealed eight coping strategies: acceptance/optimism, denial/avoidance, setting targets, comparing oneself with others, making attributions, seeking social support, having faith and changing priorities and perceptions. These are discussed in relation to the literature and a tentative model of coping after heart transplantation is offered. The findings may provide pointers to health professionals about ways in which they can improve support for heart transplant recipients and their families.