"I didn't have to look her in the eyes"-participants' experiences of the therapeutic relationship in internet-based psychodynamic therapy for adolescent depression

Objective: To explore young people's perceptions of the relationship with the therapist in internet-based psychodynamic treatment for adolescent depression.Method: As a part of a randomized controlled trial, 18 adolescents aged 15-19 were interviewed after participating in treatment. Interviews followed a semi-structured interview schedule and were analyzed using thematic analysis.Results: The findings are reported around four main themes: "a meaningful and significant relationship with someone who cared", "a helping relationship with someone who guided and motivated me through therapy"; "a relationship made safer and more open by the fact that we didn't have to meet" and "a nonsignificant relationship with someone I didn't really know and who didn't know me".Conclusion: Even when contact is entirely text-based, it is possible to form a close and significant relationship with a therapist in internet-based psychodynamic treatment. Clinicians need to monitor the relationship and seek to repair ruptures when they emerge.Trial registration: ISRCTN.org identifier: ISRCTN16206254..

Guided and unguided internet-delivered psychodynamic therapy for social anxiety disorder: A randomized controlled trial

Social Anxiety Disorder (SAD) is highly prevalent and debilitating disorder. Treatments exist but are not accessible and/or helpful for all patients, indicating a need for accessible treatment alternatives. The aim of the present trial was to evaluate internet-delivered psychodynamic therapy (IPDT) with and without therapist guidance, compared to a waitlist control condition, in the treatment of adults with SAD. In this randomized, clinical trial, we tested whether IPDT was superior to a waitlist control, and whether IPDT with therapeutic guidance was superior to unguided IPDT. Participants were recruited nationwide in Sweden. Eligible participants were ≥ 18 years old and scoring ≥ 60 on the Liebowitz Social Anxiety Scale self-report (LSAS-SR) whilst not fulfilling any of the exclusion criteria. Included participants were randomly assigned to IPDT with guidance (n = 60), IPDT without guidance (n = 61), or waitlist (n = 60). The IPDT intervention comprised eight self-help modules based on affect-focused dynamic therapy, delivered over 8 weeks on a secure online platform. The primary outcome was SAD symptoms severity measured weekly by the LSAS-SR. Primary analyses were calculated on an intention-to-treat sample including all participants randomly assigned. Secondary outcomes were depressive symptoms, generalized anxiety, quality of life, emotion regulation and defensive functioning. At post-treatment, both active treatments were superior to the waitlist condition with guided treatment exhibiting larger between group effects than unguided treatment (d = 1.07 95% CI [0.72, 1.43], p < .001 and d = 0.61, 95% CI [0.25, 0.98], p = .0018) on the LSAS-SR respectively. Guided IPDT lead to larger improvements than unguided IPDT (d = 0.46, 95% CI [0.11, 0.80], p < .01). At post-treatment, guided IPDT was superior to waitlist on all secondary outcome measures. Unguided IPDT was superior to waitlist on depressive symptoms and general anxiety, but not on emotion regulation, self-compassion or quality of life. Guided IPDT was superior to unguided PDT on depressive symptoms, with a trend towards superiority on a measure of generalized anxiety. At six and twelve month follow-up there were no significant differences between guided and unguided IPDT. In conclusion, IPDT shows promising effects in the treatment of SAD, with larger benefits from guided IPDT compared to non-guided, at least at post-treatment. This finding increases the range of accessible and effective treatment alternatives for adults suffering from SAD. The study was prospectively registered at ClinicalTrials (NCT05015166).

Real-world hepatitis C treatment outcomes and reinfections among people who inject drugs at a needle and syringe program in Stockholm, Sweden

BACKGROUND

People who inject drugs (PWID) represent a population with an increased prevalence of hepatitis C (HCV) infections. HCV treatment among PWID is essential to reach the WHO goal of eliminating HCV as a major public health threat by 2030. Despite better understanding of PWID subgroups and changes in risk behaviors over time, more knowledge about HCV treatment outcomes in different HCV prevalence populations and settings is warranted to enhance the continuum of care.

METHODS

All Stockholm Needle and Syringe Program (NSP) participants who initiated HCV treatment between October 2017 and June 2020 were HCV RNA tested at end of treatment and twelve weeks thereafter to confirm cure with a sustained virological response (SVR). All cured participants were prospectively followed from SVR to the last negative HCV RNA test or a subsequent reinfection, until October 31, 2021.

RESULTS

Overall, 409 NSP participants initiated HCV treatment, 162 at the NSP and 247 in another treatment setting. There were a total of 6.4% treatment dropouts (n = 26), 11.7% among participants treated at the NSP and 2.8% among those treated elsewhere (p < 0.001). Stimulant use (p < 0.05) and not being in an opioid agonist treatment program (p < 0.05) was associated with dropout. More participants treated outside the NSP were lost to follow-up between end of treatment and SVR (p < 0.05). During follow-up post-SVR, 43 reinfections occurred, corresponding to a reinfection rate of 9.3/100 PY (95% CI 7.0, 12.3). Factors associated with reinfection were younger age (p < 0.001), treatment while in prison (p < 0.01) and homelessness (p < 0.05).

DISCUSSION

In this high HCV prevalence NSP setting, with a majority of stimulant users, treatment success was high and the level of reinfections manageable. To reach HCV elimination, there is a need to target specific PWID subgroups for HCV treatment, in both harm reduction and adjacent healthcare settings frequented by PWID.

Therapeutic alliance is calming and curing-The interplay between alliance and emotion regulation as predictors of outcome in Internet-based treatments for adolescent depression

OBJECTIVE

Therapeutic alliance is one of the most stable predictors of outcome in psychotherapy, regardless of theoretical orientation. The alliance-outcome relationship in internet-based treatments has been investigated with mixed results. There is preliminary evidence that emotion regulation can work as a mediator for the alliance-outcome relationship. The present study aimed to investigate whether alliance predicted outcome session by session in two internet-based treatments for adolescent depression, and whether this relationship was mediated by emotion regulation.

METHOD

Two hundred and seventy-two participants aged 15-19 years and diagnosed with depression were randomized to 10 weeks of internet-based psychodynamic or cognitive behavioral treatment. Both therapists and patients rated the alliance weekly. Patients also rated depressive symptoms and emotion regulation weekly. Analyses were made using cross-lagged panel modeling.

RESULTS

Alliance, as rated by both therapist and patient, predicted depression scores the following week. Emotion regulation rated by the patient also predicted depression scores the following week. Furthermore, alliance scores predicted emotion regulation scores the following week, which in turn predicted depression scores the week after, supporting the hypothesis that alliance influences outcome partly through emotion regulation. There were no group differences in any of these relationships.

CONCLUSION

Alliance seems to play an important role in internet-based treatments, partly through emotion regulation. Clinicians working with text-based treatments should pay attention to the working alliance. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Unpacking the active ingredients of internet-based psychodynamic therapy for adolescents

Internet-based psychodynamic psychotherapy (iPDT) for adolescents has been found to be effective for treating depression, but not much is known about its active ingredients.

OBJECTIVE

To explore the techniques used in chat sessions in an iPDT program for depressed adolescents, and to investigate whether they predicted improvement in depression symptoms.

METHOD

The study uses data collected from a pilot study. The iPDT consisted of 8 modules delivered over 10 weeks that included text, video, exercises, and a weekly text-based chat session with a therapeutic support worker (TSW). The participants were 23 adolescents meeting criteria for depression. The TSWs were 9 psychology master's students. A depression inventory QIDS-A17-SR was filled weekly by the participants, and a self-rated techniques inventory (MULTI-30) was filled by the TSWs after each chat session.

RESULTS

Common factor techniques were the most widely used techniques in the chat sessions. Both common factors and psychodynamic techniques predicted improvement in depression, with psychodynamic techniques predicting improvement at the following week. CBT techniques were also used but did not predict improvement in depression.

CONCLUSION

iPDT seem to work in line with theory, where the mechanisms thought to be important for change in treatment were predictive of outcome.

"Good job!": Therapists' encouragement, affirmation, and personal address in internet-based cognitive behavior therapy for adolescents with depression

Internet-delivered interventions are generally effective for psychological problems. While the presence of a clinician guiding the client via text messages typically leads to better outcomes, the characteristics of what constitutes high-quality communication are less well investigated. This study aimed to identify how an internet therapist most effectively communicates with clients in internet-delivered cognitive behavioral therapy (ICBT). Using data from a treatment study of depressed adolescents with a focus on participants who had a positive outcome, messages from therapists were analyzed using thematic analysis. The study focused on the therapist's 1) encouragement and 2) affirmation, and how the therapists used 3) personal address. The analysis resulted in a total of twelve themes (Persistence Wins, You Are a Superhero, You Make Your Luck, You Understand, Hard Times, You Are Like Others, My View on the Matter, Time for a Change, Welcome In, Let Me Help You, You Affect Me, and I Am Human). Overall, the themes form patterns where treatment is described as hard work that requires a motivated client who is encouraged by the therapist. The findings are discussed based on the cognitive behavioral theoretical foundation of the treatment, prior research on therapist behaviors, and the fact that the treatment is provided over the internet.

Connecting over the internet: Establishing the therapeutic alliance in an internet-based treatment for depressed adolescents

Internet-based treatments have been developed for youth mental health difficulties, with promising results. However, little is known about the features of therapeutic alliance, and how it is established and maintained, in text-based interactions between adolescents and therapists in internet-based treatments. This study uses data collected during a pilot evaluation of a psychodynamic internet-based therapy for depressed adolescents. The adolescents had instant-messaging chats with their therapists once a week, over 10 weeks. The adolescents also rated the therapeutic alliance each week, using the Session Alliance Inventory. The present study uses qualitative methods to analyse transcripts of text-based communication between the young people and their therapists. The aim is to identify and describe the key features of therapeutic alliance, and reflect upon the implications for theory and clinical practice. Analysis identified three 'values' that may underpin a strong therapeutic alliance: togetherness, agency and hope. A number of therapist techniques were also found, which seemed to create a sense of these values during text-chat sessions. These findings are discussed, alongside implications for future research.

Factors associated with non-walking 4 months after hip fracture. A prospective study of 23,759 fractures

INTRODUCTION

Despite advances in new surgical techniques and improvements in medical care of the last decades a considerable number of patients will not regain their ability to walk after a hip fracture.

AIMS

To further identify risk factors associated with non-walking 4-months after a hip fracture.

MATERIAL AND METHODS

Register-based, longitudinal study with a 4-month follow-up. The collected data from the Swedish hip fracture registry, RIKSHÖFT, contained all hip fracture between 201301-01-2015-12-31 in Sweden. All patients older than 50 years with a non-pathological fracture and who were able to walk before the fracture were included. The association of sex, age, general health, dementia and type of discharge with complete loss of walking after a hip fracture were investigated using a multivariate analysis.

RESULTS

Included were 23,759 patients. At the 4-month follow-up, 10% were unable to walk. Twenty-five per cent of patients with dementia lost their ability to walk compared to 7% of those with no cognitive dysfunction. Adjusted odds ratio (OR) for factors associated with loss of walking ability were; discharge to institutionalized care rather than their own home or a rehabilitation unit (OR=1.91; 95% CI=1.67-2.18), dementia (OR=1.80; 95% CI=1.57-2.06), male gender (OR=1.59; 95% CI=1.40-1.81) and ASA score grade III-V (OR=1.37; 95% CI=1.20-1.55) but not age (OR=1.01; 95% CI=1.00-1.02).

CONCLUSIONS

An important factor associated with a complete loss of walking ability after a hip fracture is the discharge to institutionalized care. This factor might be influenced either by favouring rehabilitation units or by improving the rehabilitation protocols.

Health literacy and changes in pattern of drug use among participants at the Stockholm Needle Exchange Program during the COVID-19 pandemic

Background and aims

People who inject drugs may be particularly vulnerable to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to underlying health problems, stigma and social vulnerabilities. Harm reduction services, including needle exchange programs (NEP), have been subjected to varying degrees of disruption in the world, especially in the beginning of the coronavirus disease 2019 (COVID-19) pandemic. Compared to responses in other countries, Sweden’s initial strategy toward limiting the spread and impact of COVID-19 was less restrictive to its citizens with no imposed general societal lockdown. In this study, we investigate changes in drug use patterns, utilization of NEP associated health services, COVID-19 health literacy and the prevalence of SARS-CoV-2 antibodies among NEP clients in Stockholm during the COVID-19 pandemic.

Methods

NEP visits and services provided (needles/syringes, HIV and hepatitis C tests and treatment, naloxone distributed) and overall mortality among NEP clients between January 1 and October 31, 2020, were used for trend analyses in comparison with corresponding 2019 data. Between July 27 and October 2, 2020, NEP clients (n = 232) responded to a 27 item COVID-19 Health Literacy Questionnaire. SARS CoV-2 IgG antibody tests (n = 779) were performed between June 15 and October 31, 2020.

Results

During the COVID-19 pandemic number of clients, client visits, naloxone distribution and HCV tests remained stable compared to 2019, while distribution of needles/syringes increased (p < 0.0001); number of HIV tests and HCV treatments decreased (p < 0.05); and mortality decreased (< 0.01). Overall, the level of health literacy concerning transmission routes and protective measures was high. SARS-CoV-2 antibody prevalence was 5.4% (95% CI 4.0–7.2).

Conclusions

The Stockholm NEP managed to maintain a high level of clients and services during the pandemic. In general, COVID-19 health literacy was adequate and the overall SARS-CoV-2 antibody prevalence was low compared to the general population, which highlights a need for prioritized and targeted COVID-19 vaccination among PWID.

Sudden gains and large intersession improvements in internet-based psychodynamic treatment (IPDT) for depressed adolescents

Objective: Sudden gains (SGs) have often been found associated with better treatment outcome across different psychiatric disorders. However, no studies have evaluated SGs in internet-based treatment targeting adolescent depression. Method: The sample consisted of 66 adolescents diagnosed with major depressive disorder, attending psychodynamic internet-based treatment. Effects of SGs were evaluated at posttreatment and 6-month follow-up. We also evaluated effects of large intersession improvements (LIIs; sudden and relatively large gains, between sessions, without the stability criterion). Effects of SGs and LIIs early in treatment were also investigated. Results: A total of 17 patients (25.75%) experienced an SG. The effect of having an SG or early SG was non-significant after treatment (d = 0.48) and at follow-up (d = 0.66). However, having an LII was related to better outcome after treatment (d = 0.97) and at follow-up (d = 0.76). Early LIIs were associated with significantly better results at end of treatment (d = 0.72). Conclusions: The original criteria of SGs might be overly conservative and thus miss important improvements in depression. Relatively large intersession gains, regardless of stability, seem to be predictive of outcome.

Internet-based psychodynamic versus cognitive behaviour therapy for adolescents with depression: study protocol for a non-inferiority randomized controlled trial (the ERiCA study)

Background

Adolescent depression is a common mental health problem and there is an urgent need for effective and accessible treatments. Internet-based interventions solve many obstacles for seeking and receiving treatment, thus increasing access to effective treatments. Internet-based cognitive behavioural therapy (ICBT) for adolescent depression has demonstrated efficacy in previous trials. In order to broaden the range of evidence-based treatments for young people, we evaluated a newly developed affect-focused Internet-based psychodynamic treatment (IPDT) in a previous study with promising results. The purpose of the planned study is to evaluate the efficacy of IPDT for adolescent depression in a non-inferiority trial, comparing it to ICBT.

Methods

The study will employ a parallel randomized non-inferiority design (ratio 1:1; n = 270). Eligible participants are adolescents 15–19 years suffering from depression. The primary hypothesis is that IPDT will be non-inferior to ICBT in reducing depressive symptoms from pre-treatment to end of treatment. Secondary research questions include comparing outcomes of IPDT and ICBT regarding anxiety symptoms, emotion regulation and self-compassion. Additional data will be collected to evaluate cost-effectiveness as well as investigating predictors, moderators and mediators of outcome. In addition, we will examine long-term outcome up to 1 year after end of treatment. Diagnostic interviews with MINI 7.0 will be used to establish primary diagnosis of depression as well as ruling out any exclusion criteria. Both treatments consist of eight modules over 10 weeks, complemented with therapist support through text messages and weekly chat sessions. Primary outcome measure is the Quick Inventory of Depressive Symptomatology in Adolescents Self-Rated (QIDS-A17-SR). Primary outcome will be analysed using data from all participants entering the study using a multilevel growth curve strategy based on the weekly measurements of QIDS-A17-SR. The non-inferiority margin is defined as d = 0.30.

Discussion

This trial will demonstrate whether IPDT is non-inferior to ICBT in the treatment of adolescent depression. The study might therefore broaden the range of evidence-based treatment alternatives for young people struggling with depression. Further analyses of data from this trial may increase our knowledge about “what works for whom” and the pathways of change for two distinct types of interventions.

Trial registration

ISRCTN12552584, Registered on 13 August 2019.

Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression: Randomized Controlled Trial

Background

Adolescent depression is one of the largest health issues in the world and there is a pressing need for effective and accessible treatments.

Objective

This trial examines whether affect-focused internet-based psychodynamic therapy (IPDT) with therapist support is more effective than an internet-based supportive control condition on reducing depression in adolescents.

Methods

The trial included 76 adolescents (61/76, 80% female; mean age 16.6 years), self-referred via an open access website and fulfilling criteria for major depressive disorder. Adolescents were randomized to 8 weeks of IPDT (38/76, 50%) or supportive control (38/76, 50%). The primary outcome was self-reported depressive symptoms, measured with the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR). Secondary outcomes were anxiety severity, emotion regulation, self-compassion, and an additional depression measure. Assessments were made at baseline, postassessment, and at 6 months follow-up, in addition to weekly assessments of the primary outcome measure as well as emotion regulation during treatment.

Results

IPDT was significantly more effective than the control condition in reducing depression (d=0.82, P=.01), the result of which was corroborated by the second depression measure (d=0.80, P<.001). IPDT was also significantly more effective in reducing anxiety (d=0.78, P<.001) and increasing emotion regulation (d=0.97, P<.001) and self-compassion (d=0.65, P=.003). Significantly more patients in the IPDT group compared to the control group met criteria for response (56% vs 21%, respectively) and remission (35% vs 8%, respectively). Results on depression and anxiety symptoms were stable at 6 months follow-up. On average, participants completed 5.8 (SD 2.4) of the 8 modules.

Conclusions

IPDT may be an effective intervention to reduce adolescent depression. Further research is needed, including comparisons with other treatments.

Trial Registration

International Standard Randomised Controlled Trial Number (ISRCTN) 16206254; http://www.isrctn.com/ISRCTN16206254

Emotion Regulation as a Time-Invariant and Time-Varying Covariate Predicts Outcome in an Internet-Based Psychodynamic Treatment Targeting Adolescent Depression

OBJECTIVE

Although psychodynamic psychotherapy is efficacious in the treatment of depression, research on mechanisms of change is still scarce. The aim of this study was to investigate if and how emotion regulation affects outcome both as a time-invariant and a lagged time-varying predictor.

METHOD

The sample consisted of 67 adolescents diagnosed with major depressive disorder, attending affect-focused psychodynamic internet-based treatment (IPDT). Linear mixed models were used to analyze emotion regulation as a baseline predictor and to assess the effect of within-person changes in emotion regulation on depression.

RESULTS

Analyses suggested that emotion regulation at baseline was a significant predictor of outcome, where participants with relatively larger emotion regulation deficits gained more from IPDT. Further, the results showed a significant effect of improved emotion regulation on subsequent depressive symptomatology. When not controlling for time, increased emotion regulation explained 41.23% of the variance in subsequent symptoms of depression. When detrending the results were still significant, but the amount of explained variance was reduced to 8.7%.

CONCLUSION

The findings suggest that patients with relatively larger deficits in emotion regulation gain more from IPDT. Decreased emotion regulation deficits seem to act as a mechanism of change in IPDT as it drives subsequent changes in depression.Clinical Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN) 16206254, https://doi.org/10.1186/ISRCTN16206254.

Psychometric evaluation of the Working Alliance Inventory-Therapist version: Current and new short forms

Background: The Working Alliance Inventory (WAI) and its short forms are widely used, although the properties of the therapists' versions have been little studied. Method: We examined the psychometric properties of two short forms (WAI-S-T, WAI-SR-T), and explored the creation of a psychometrically stronger short form using contemporary measure development techniques. Well-fitting items from the full 36-item WAI were identified in a development sample (131 therapists, 688 patients) using multi-level Bayesian Structural Equation Modeling, accounting for therapist rated effects. Multi-level Item Response Theory (IRT) methods aided creation of a revised short form (WAI-S-T-IRT). Factor structures of the three forms were assessed using multi-level ML estimation with robust standard errors. Results: Collinearity problems for the Goal and Task dimensions led to testing a two-factor model (Goal-Task, Bond). All three measures showed satisfactory fit; the WAI-S-T-IRT fit slightly better but differences were minor. Testing the structures in an independent sample (N = 1117) yielded essentially the same results. No version showed strong measurement invariance. Discussion: Continued use of current therapist forms is supported; differentiation of theoretical dimensions is difficult with current measures, and may not be possible with self-report forms.

Requirements Engineering for Inter-Organizational Health Information Systems with Functions for Spatial Analyses: Modeling a WHO Safe Community Applying Use Case Maps

Objectives: To evaluate Use Case Maps (UCMs) as a technique for Requirements Engineering (RE) in the development of information systems with functions for spatial analyses in inter-organizational public health settings.

Methods: In this study, Participatory Action Research (PAR) is used to explore the UCM notation for requirements elicitation and to gather the opinions of the users. The Delphi technique is used to reach consensus in the construction of UCMs.

Results: The results show that UCMs can provide a visualization of the system‘s functionality and in combination with PAR provide a sound basis for gathering requirements in inter-organizational settings. UCMs were found to represent a suitable level for describing the organization and the dynamic flux of information including spatial resolution to all stakeholders. Moreover, by using PAR, the voices of the users and their tacit knowledge is intercepted. Further, UCMs are found useful in generating intuitive requirements by the creation of use cases.

Conclusions: With UCMs and PAR it is possible to study the effects of design changes in the general information display and the spatial resolution in the same context. Both requirements on the information system in general and the functions for spatial analyses are possible to elicit when identifying the different responsibilities and the demands on spatial resolution associated to the actions of each administrative unit. However, the development process of UCM is not well documented and needs further investigation and formulation of guidelines.

Multilevel Exploratory Factor Analysis of the Feeling Word Checklist-24

Emotional reactions are a vital part of the therapeutic relationship. The Feeling Word Checklist-24 (FWC-24) is an instrument asking the clinician (or the patient) to report to what degree he or she has experienced various feelings during a therapeutic interaction. The aim of this study was to assess the factor structure of the clinician-rated FWC-24 when taking dependencies in the data into account. The sample was deliberately heterogeneous and consisted of 4,443 ratings made by 101 psychotherapists working with different psychotherapy methods in relation to 191 patients of different ages, genders, and with different primary diagnoses. A random intercept-only model revealed large intraclass correlation coefficients at the therapist level, indicating that a multilevel analysis was warranted. A two-level exploratory factor analysis with therapists as the between level and patients plus sessions as the within level was conducted. The items from FWC-24 were found to be best represented by four factors on the between level and four factors on the within level. The factor structures were largely similar on the two levels and were labeled Engaged, Inadequate, Relaxed, and Moved. The different factors explained different amounts of variance on different levels, indicating that some factors are more therapist dependent and some more patient dependent.

Efficacy of experiential dynamic therapy for psychiatric conditions: A meta-analysis of randomized controlled trials

Experiential dynamic therapy (EDT) is a subgroup of short-term psychodynamic psychotherapy (STPP) that emphasizes patients' in-session affective processing. To evaluate the efficacy of EDT for psychiatric conditions, we conducted a meta-analysis of randomized controlled trials. Twenty-eight studies published between 1978 and 2014 were included, encompassing 1,782 adult patients with mood, anxiety, personality, or mixed disorders. Across targeted outcome domains, medium-size between-groups effects (Cohen's ds ranging from 0.39 to 0.65) favored EDT over inactive controls at posttreatment and in symptom measures at follow-up. We found no differences between EDT and active treatments (e.g., medication, cognitive-behavioral therapy, manualized supportive therapy) at posttreatment, but EDT outperformed supportive therapy at follow-up (d = 0.75). In terms of within-group effect sizes, EDT was associated with large improvements in general psychiatric symptoms (d = 1.11), depression (d = 1.33), and anxiety (d = 1.09) and with small to moderate gains in the areas of interpersonal problems (d = 0.55) and global functioning (d = 0.86). Small but significant effects suggested continued improvement between posttreatment and follow-up. Heterogeneity in pre-post effects was explored in subgroup analyses, which indicated that EDT might be most effective in depressive disorders and that individual EDT had larger effects compared with group treatment. In addition, EDT performed better in higher quality studies. We conclude that EDT is a promising treatment for psychiatric conditions in adults. Further high-quality studies evaluating contemporary versions of EDT in specific psychiatric conditions are warranted.

Usual drinking patterns and non-fatal injury among patients seeking emergency care

OBJECTIVES

To explore the association between drinking patterns, irrespective of whether alcohol was consumed in the event of the injury or not, and different injury variables; and to identify settings and situations in which risky drinkers have an increased likelihood of injury.

STUDY DESIGN

The study population consisted of all patients aged 18-70 years registered for an injury according to ICD-10 at a Swedish emergency department during an 18-month period. After informed consent, the injury patients were screened for drinking habits by the AUDIT-C questionnaire. The gender, age and drinking pattern of injury patients were compared with the general population.

METHODS

A total of 2782 patients aged 18-70 years were registered for an injury during the study period. The number of drop-outs was 631. Drop-outs include those who did not consent to participate, were severely injured, too intoxicated or did not fill out the questionnaire satisfactory. Thus, 77.3% of the target group were included for further analysis (1944 drinkers and 207 abstainers). The patients were categorized into three drinking categories: abstainers, non-risky and risky drinkers. Risky drinkers were defined according to usual weekly consumption of 80g or more of alcohol for women and 110g or more for men and/or heavy episodic drinking (i.e. having six glasses or more one glass=12g alcohol), or both, on one occasion at least once a month, valid for both women and men. To estimate the relationship between drinking patterns and the injury variables (environment, cause of injury, activity and diagnosis), odds ratios (OR) were calculated by logistic regression. Multiple logistic regression was used in order to control for age and sex differences between the various drinking and injury categories.

RESULTS

The proportion of risky drinkers was higher in the study population compared with the general population in the same area. When controlling for age and sex, risky drinkers (OR 6.4(adj) Confidence interval CI 1.9-21.2) and non-risky drinkers (OR .4.5(adj) CI 1.4-14.5) displayed an increased risk for injury compared with abstainers, in amusement locations, parks, by or on lakes or seas, especially while engaged in play, hobby or other leisure activities (risky drinkers: OR 2.8(adj) CI 1.3-5.6; non-risky drinkers: OR 2.4(adj) CI 1.2-4.6). All differences between drinking patterns in external cause of injury disappeared when age and sex were considered. During rest, meals and attending to personal hygiene, the non-risky drinkers had a lower probability of injury compared with abstainers (OR 0.3(adj) CI 0.1-0.8). Non-risky drinkers had a higher probability than abstainers of suffering luxation (dislocation) or distortion (OR 1.6(adj) CI 1.1-2.5). Nine per cent of the study population reported that they believed that their injury was related to intake of alcohol. Half of this group were non-risky drinkers (CI for the 13.7% difference was 9.7-17.6).

CONCLUSIONS

Few significant associations between drinking pattern and injury remained when age and sex were controlled for.

The impact of home safety promotion on different social strata in a WHO safe community

OBJECTIVES

Few studies have investigated the impact of home safety promotion programmes on different social strata. The aim of this study was to investigate the distribution of effects of a community-based home safety programme on home injury rates among families with different connections to the labour market.

METHODS

A quasi-experimental design was used, with pre- and post-implementation registrations covering the total populations below 65 years of age in the programme implementation area (population 41,000) and in a neighbouring comparison municipality (population 26,000) in Ostergötland County, Sweden.

RESULTS

In the intervention and comparison areas, households in which the adults were not vocationally active displayed the highest rates of home injury. After 6 years of programme activity, the home injury rates for males and females in all social status categories displayed a decreasing trend in the intervention area. The opposite was true for the comparison area, i.e. the incidence of injury increased, with the exception of females in non-vocationally active households. The decline in injury rates in the intervention area was statistically significant for males and females in the employed category and for males in the non-vocationally active category. Changes in injury rates in the comparison area were not statistically significant.

CONCLUSION

The programme was partially successful in that it reduced the injury rate in non-vocationally active households, but it did not influence the injury rate in the employed households. The study design did not allow for conclusions regarding why the post-intervention injury rates remained higher in non-vocationally active households. Further research on the association between the incidence of home injury and socio-economic factors is warranted.

Attitude changes among emergency department triage staff after conducting routine alcohol screening

Excessive alcohol consumption is common among injury patients, but routine alcohol interventions seem to be difficult to implement in emergency departments. An obstacle seen in previous studies is the limited time available in a real-world setting for staff to participate in routine alcohol screening and interventions. In the present study, ordinary staff participated in a simple alcohol screening procedure. The aim of the study was to evaluate the feasibility of this procedure and if there was any change in attitudes and practices among triage staff after the implementation. We analyzed interviews with six staff members and questionnaires completed by 29 nurses and medical secretaries before and after a period of systematic routine screening. The staff reported that the routine worked well and that few patients reacted negatively. A positive change was seen in attitudes towards alcohol preventive measures in general. However, this seems not to be sufficient for the staff to spontaneously engage more actively. In fact, more of the staff were uncertain after the study period whether the emergency department is an appropriate place for alcohol screening and intervention despite an increased role legitimacy and perceived competence. There is a need for further development of alcohol prevention models that are acceptable for the staff to implement as part of the daily routine.

Impact of social standing on sports injury prevention in a WHO safe community: intervention outcome by household employment contract and type of sport

OBJECTIVES

As physical activity is promoted as part of a healthy lifestyle, sports injuries are becoming an important public health concern in many countries. The objective of this study is to investigate rates of sports injuries before and after implementation of a WHO Safe Community program.

METHODS

Sports injury data were collected pre- and post-implementation from all individuals below 65 years of age during 1 year in the targeted municipality (population 41,000) and in a control municipality (population 26,000). A quasi-experimental design was used and individuals were divided into three categories based on household relationship to the labour market.

RESULTS

There were no differences between socio-economic categories regarding pre-intervention injury rates. No statistically significant post-intervention changes in injury rate were observed in the control area or among any females in either area. In the intervention area, a statistically significant (p = 0.011) decrease in injury rate was observed among male members of households in which the vocationally important member was employed. A statistically significant decrease was observed in injuries sustained in team sports among male members of households in which the vocationally important member was employed (p = 0.001) and among members of households in which the vocationally important member was self employed (p<0.05).

CONCLUSIONS

The study indicates areas for improvement in the civic network based WHO Safe Community model. The results show that females, participants in individual sports, and members of non-vocationally active households were less affected by the interventions. These facts have to be addressed in planning future community based sports injury prevention programmes and their evaluations.

Impact of social standing on injury prevention in a World Health Organization Safe Community--intervention outcome by household employment contract

BACKGROUND

Although social inequality in health has been an argument for community-based injury prevention programmes, intervention outcomes with regard to differences in social standing have not been analysed. The objective of this study was to investigate rates of injuries treated in health-care among members of households at different levels of labour market integration before and after the implementation of a WHO Safe Community programme.

METHODS

A quasi-experimental design was used with pre- and post-implementation data collection covering the total populations <65 years of age during one year in the programme implementation municipality (population 41 000) and in a control municipality (population 26 000). Changes in injury rates were studied using prospective registration of all acute care episodes with regard to social standing in both areas during the study periods.

RESULTS

Male members of households categorized as not vocationally active displayed the highest pre-intervention injury rates. Also after the intervention, males in households classified as not vocationally active displayed notably elevated injury rates in both the control and study areas. Households in the study area in which the significant member was employed showed a post-intervention decrease in injury rate among both men (P < 0.001) and women (P < 0.01). No statistically significant change was observed in households in which the significant member was self-employed or not vocationally active. In the control area, only an aggregate-level decrease (P < 0.05) among members of households in which the significant member was employed was observed.

CONCLUSIONS

The study displayed areas for improvement in the civic network-based WHO Safe Community model. Even though members of non-vocationally active households, in particular men, were at higher pre-intervention injury risk, they were not affected by the interventions. This fact has to be addressed when planning future community-based injury prevention programmes.

Mechanical properties of a permanent dental restorative material based on calcium aluminate

This paper deals with some important mechanical properties (hardness, dimensional stability, compressive and flexural strength) of an experimental version of a translucent calcium aluminate dental restorative material. All samples investigated have been made from pre-pressed tablets, with a compaction degree of approximately 60%, hydrated using a 0.15 wt % Li salt solution as an accelerator. The samples were stored in water at 37 degrees C between the measurements. As reference materials one composite, Tetric Ceram, and one glass ionomer, Fuji II, were used with specimens prepared according to the manufacturer's recommendations. For the reference materials some of the properties were published data. The results show that the calcium aluminate material has sufficient mechanical properties to be used as a permanent dental restorative taking as a reference the ISO 9917 and the ISO 4049 as well as the reference materials. In addition the results indicate that the mechanical properties are controlled by the microstructure, which is mainly determined by the grain size of the filler.

Requirements Engineering for inter-organizational health information systems with functions for spatial analyses: modeling a WHO safe community applying Use Case Maps

OBJECTIVES

To evaluate Use Case Maps (UCMs) as a technique for Requirements Engineering (RE) in the development of information systems with functions for spatial analyses in inter-organizational public health settings.

METHODS

In this study, Participatory Action Research (PAR) is used to explore the UCM notation for requirements elicitation and to gather the opinions of the users. The Delphi technique is used to reach consensus in the construction of UCMs.

RESULTS

The results show that UCMs can provide a visualization of the system's functionality and in combination with PAR provide a sound basis for gathering requirements in inter-organizational settings. UCMs were found to represent a suitable level for describing the organization and the dynamic flux of information including spatial resolution to all stakeholders. Moreover, by using PAR, the voices of the users and their tacit knowledge is intercepted. Further, UCMs are found useful in generating intuitive requirements by the creation of use cases.

CONCLUSIONS

With UCMs and PAR it is possible to study the effects of design changes in the general information display and the spatial resolution in the same context. Both requirements on the information system in general and the functions for spatial analyses are possible to elicit when identifying the different responsibilities and the demands on spatial resolution associated to the actions of each administrative unit. However, the development process of UCM is not well documented and needs further investigation and formulation of guidelines.

Evaluation of a child safety program based on the WHO safe community model

OBJECTIVES

To evaluate the outcome of the World Health Organization (WHO) Safe Community model with respect to child injuries.

STUDY DESIGN

A population based quasiexperimental design was used. Cross sectional pre-implementation and post-implementation data were collected in intervention (Motala municipality) and control (Mjölby municipality) areas, both in Ostergötland county, Sweden.

RESULTS

The total relative risk of child injury in the intervention community decreased more (odds ratio 0.74; 95% confidence interval (CI) 0.68 to 0.81) than in a control community exposed only to national level injury prevention programs (0.93; 95% CI 0.82 to 1.05). The relative risk of moderately (abbreviated injury scale (AIS) 2) severe injury in the study area was reduced to almost a half (odds ratio 0.49; 95% Cl 0.41 to 0.57), whereas the risk of minor (AIS 1) injuries decreased only slightly (odds ratio 0.89; 95% CI 0.80 to 0.99). The risk of severe or fatal (AIS 3-6) injuries remained constant.

CONCLUSIONS

After introduction of an injury prevention program based on the WHO Safe Community model, the relative risk for child injury in the intervention community decreased significantly more than in a control community exposed only to national injury prevention programs.

Evaluation of an inter-organizational prevention program against injuries among the elderly in a WHO Safe Community

The aim of the study was to evaluate the outcome of a participatory community-based prevention program against injuries among the elderly. A population-based quasi-experimental design was used with pre- and post-implementation measurements in an intervention and a control area. The program was based on cross-sectoral participation in detecting and taking action against injuries among the elderly. Change in the relative risk of injury was estimated by the odds ratio. Morbidity in moderately (AIS 2) severe injury in the study area was reduced from 46 per 1000 population years to 25 per 1000 population years (odds ratio 0.55; 95% confidence interval 0.46-0.65), while the minor (AIS 1) injuries increased (odds ratio 1.55; 95% confidence interval 1.21-1.91). The risk of severe or fatal (AIS 3-6) injuries remained constant. In the study area, only a slight decrease in the total morbidity rate was observed (odds ratio 0.87; 95% confidence interval 0.77-0.99). In the control area, there was no evident change in the total morbidity rates. Falls decreased or showed a tendency to decrease in the age groups 65 to 79-y-old in the study area, while they increased in the older age group. The results indicate that no sharp boundaries should be drawn between safety education, physical conditioning, environmental adjustments and secondary prevention measures when planning safety promotion among the elderly. Future studies should address these issues along with the methodological complexity associated with assessment of participatory community-based safety promotion programs.

Evaluation of inter-organizational traffic injury prevention in a WHO safe community

The objective of the study was to examine the effect of a community-based injury prevention program on traffic injuries. A population-based quasi-experimental design was used with pre- and post-implementation measurements in an intervention and a control area. The program was based on inter-organizational participation in detecting and taking action against traffic injuries. The total relative risk for traffic injury in the study area showed only a tendency to decrease following program exposure (odds ratio 0.91; 95% confidence interval 0.81-1.02). No change in relative risk was observed in the control area. The analyses of program impact on injury severity showed that the relative risk for moderate injuries in the study area was reduced by almost half (odds ratio 0.59; 95% confidence interval 0.49-0.69), the risk for severe or fatal injuries remained constant (odds ratio 1.27; 95% confidence interval 0.80-2.02), and the risk for minor injuries increased (odds ratio 1.34; 95% confidence interval 1.13-1.59). The relative risk for moderate injuries was reduced by at least half for mopedists, cyclists, pedestrians, and those leaving or entering a motor vehicle. Community-based injury prevention can be a complement to national traffic safety programs.

A cost-benefit analysis of the community-based injury prevention programme in Motala, Sweden--a WHO Safe Community

The objective in this study was to calculate costs and benefits caused by a safe community injury prevention programme in Motala, Sweden. The study design was a quasi-experimental evaluation involving an intervention population and a non-random control population. All injuries were recorded before and after an intervention programme. The presented calculations show that costs of injuries in a societal perspective decreased from 116 million Swedish Crowns (SEK) to 96 million SEK, while the cost for the intervention was estimated at approximately 10 million SEK. Thus, the safe community injury prevention programme in Motala should be judged as cost-effective.

Direct and indirect costs of dental trauma in Sweden: a 2-year prospective study of children and adolescents

OBJECTIVES

To study total costs, including direct costs (health care service, loss of personal property, medicine and transport) and indirect costs (loss of production or leisure) of dental trauma to children and adolescents with special reference to predictors.

METHODS

The study was based on a random sample of 192 children and adolescents with a dental trauma reported to an insurance company and prospectively followed up by telephone interviews over a period of 2 years.

RESULTS

On average, health care service costs represented 2,955 SEK (SD=3,818) and total costs 4,569 SEK (SD=3,053) for dental trauma to permanent teeth, and 837 SEK (SD=898) and 1,746 SEK (SD=1,183) for trauma to primary teeth. The most extensive type of indirect cost was loss of production or leisure, which averaged 1,286 SEK (SD=1,830) for injuries to permanent teeth and 699 SEK (SD=1,239) for injuries to primary teeth. Multiple regression analysis of demographic and dental injury variables showed that complicated trauma was of special importance to costs for permanent and primary teeth injuries. The average relative increase in total costs to patients and companions for complicated injury to permanent teeth was 140% (95% confidence interval [CI], 66-248%) for patients and 132% (95% CI, 54-249%) for companions. Lack of access to a dental clinic near the place of residence could increase the average total costs of injuries to permanent teeth by 91% for companions (95% CI, 20-204%) and for primary teeth by 134% (95% CI, 38-296%).

CONCLUSIONS

Dental traumas result in both direct and indirect costs, with a predominance of direct costs. The direct costs primarily depend on degree of severity, while indirect costs are mostly due to compromised access to health care service. Traumas to permanent teeth are especially costly and, due to additional maintenance, the care may continue for several years. This study has drawn attention to the significant implications of dental trauma to patient and companion, a new area where further studies are warranted.

Evidence based prevention of acute injuries during physical exercise in a WHO safe community

OBJECTIVE

To evaluate a community based programme for evidence based prevention of injuries during physical exercise.

DESIGN

Quasi-experimental evaluation using an intervention population and a non-random control population.

PARTICIPANTS

Study municipality (population 41,000) and control municipality (population 26,000) in Sweden.

MAIN OUTCOME MEASURES

Morbidity rate for sports related injuries treated in the health care system; severity classification according to the abbreviated injury scale (AIS).

RESULTS

The total morbidity rate for sports related injuries in the study area decreased by 14% from 21 to 18 injuries per 1,000 population years (odds ratio 0.87; 95% confidence interval (CI) 0.79 to 0.96). No tendency towards a decrease was observed in people over 40. The rate of moderately severe injury (AIS 2) decreased to almost half (odds ratio 0.58; 95% CI 0.50 to 0.68), whereas the rate of minor injuries (AIS 1) increased (odds ratio 1.22; 95% CI 1.06 to 1.40). The risk of severe injuries (AIS 3-6) remained constant. The rate of total sports injury in the control area did not change (odds ratio 0.93; 95% CI 0.81 to 1.07), and the trends in the study and control areas were not statistically significantly different.

CONCLUSION

An evidence based prevention programme based on local safety rules and educational programmes can reduce the burden of injuries related to physical exercise in a community. Future studies need to look at adjusting the programme to benefit all age groups.

Knowledge discovery and case based reasoning in health promotion: development of a help-desk for prevention of occupational injuries

This paper presents the concepts, ideas and techniques behind Case Based Reasoning (CBR) in relation to knowledge extraction techniques for health promotion. The ultimate goal is to develop a help-desk service for advice about preventive measures to be taken concerning concrete occupational injury hazards. CBR has been suggested to be a complimentary method to knowledge extraction in order to take direct advantages of large databases for building decision support systems. In this work a database on work injuries is being used to develop a CBR application using a CBR shell-called Recall.

Community-based injury prevention: effects on health care utilization

BACKGROUND

Worldwide, an estimated 78 million people are disabled each year because of unintentional injuries and about 3 million die. The WHO Safe Community model is a framework for community-based injury prevention programmes. The aim of this study is to evaluate the outcome on health care utilization of a Safe Community programme.

METHODS

The incidence of injuries treated at health care facilities in an intervention municipality (pop. 41,000) was compared to the injury incidence in a control municipality (pop. 26,000). The incidence was recorded immediately before and one year after programme implementation from registrations made during all first-contact health care visits and from examination of hospital discharge registers.

RESULTS

The incidence of health care treated injuries in the intervention area had decreased by 13% (95% CI: 9-16%) from 119 (95% CI: 115-122) per 1000 population-years to 104 (95% CI: 101-107). In the control area, the corresponding injury incidences were 104 (95% CI: 100-108) and 106 (95% CI: 102-109). The hospital-treated injuries in the intervention area decreased by 15% (95% CI: 7-24%) from 19 (95% CI: 17-20) per 1000 population-years to 16 (95% CI: 15-17), while in the control area, the incidences remained at 13 (95% CI: 11-14) per 1000 population-years. Utilization of acute care in the intervention area for reasons other than injuries increased by 8% (95% CI: 6-10%), while in the control area, the number of visits did not show significant change.

CONCLUSION

This first controlled evaluation showed that an injury prevention programme based on local action groups can significantly reduce injuries requiring health care in a community. Local prevention can provide a complement to national level campaigns.

The WHO safe community program for injury prevention: evaluation of the impact on injury severity

Despite the fact that injuries consume a considerable amount of health care resources world-wide, 3.5 million people die from unintentional injuries each year. To handle this central public health problem, WHO has introduced the Safe Community accreditation for injury prevention programs. This study was to investigate the impact from a Safe Community program with regard to injury severity. Data were collected in Motala municipality (population = 41,000), Ostergötland county, Sweden, during one year before and one year after program intervention, from two sources: registration of trivial (AIS 1) and non-trivial (AIS 2-6) unintentional injuries from all acute care episodes in the area and recollection of hospital bed days from discharge registers. The incidence of non-trivial injuries treated in health care was found to have decreased by 41% (95% confidence interval, 37-45%), while the trivial injuries increased by 16% (9-22%). The larger decrease of non-trivial injuries was observed in all ages and injury event environments. The total number of bed days at emergency hospitals due to injuries decreased by 39% (37-41%) from 1983-84 to 1989, while the hospital bed utilization for other reasons decreased by 9% (8-9%). The study showed the implementation of a WHO Safe Community program led to the harm from unintentional injuries within the community being considerably more reduced than that of the injury incidence. In future assessments of injury prevention programs, classification of injury severity should be included to increase the validity of inter-program comparisons.

Extracorporeal shock wave lithotripsy for the treatment of renal stones. Treatment policy is as important for success as type of lithotriptor and patient selection

OBJECTIVE

To compare the efficiency of different machines for extracorporeal shock wave lithotripsy (ESWL) of renal stones and to analyze treatment strategies and stone characteristics as determinants of treatment failure.

DESIGN

Prospective cohort study.

SETTING

Nationwide study in Sweden. All 11 hospitals in Sweden using 1 of 7 lithotriptors in 1991 were included.

PATIENTS

The study cohort comprised 1171 (97.6%) of the 1200 patients in Sweden who underwent ESWL for the first time because of renal stones between February 18, 1991, and December 31, 1991.

MAIN OUTCOME MEASURE

Treatment failure, defined as 1 or more residual renal stone fragments larger than 4 mm 1 of 3 months after the end of treatment, was analyzed after ESWL monotherapy and after ESWL plus auxiliary treatment using a multivariate analysis.

RESULTS

Treatment failure varied by center from 12% to 48% (mean, 24%) after ESWL monotherapy and from 4% to 40% (mean, 18%) after ESWL plus auxiliary procedures. After adjusting for differences in the patient mix, the risk of treatment failure, measured as the odds ratio, varied by center almost 7-fold after ESWL monotherapy and 20-fold after ESWL plus auxiliary treatment. Substantial differences also existed for the same equipment used at different centers. The risk of treatment failure increased rapidly for renal stones larger than 15 mm, and it was at least 2-fold higher in patients who had multiple stones or a cavity.

CONCLUSIONS

When ESWL is used for the treatment of renal stones, the treatment policy has as great an effect on the success rate and need for auxiliary treatment as optimal equipment and proper patient selection. Meaningful comparisons of different lithotriptors require multivariate analyses with adjustment for patient selection.

Ten years of experiences from a participatory community-based injury prevention program in Motala, Sweden

Exploratory studies in the Scandinavian countries have suggested that the national cost of unintentional injuries is equal to 4% of the Gross National Product (GNP). One way for Swedish society to handle this situation has been through community-based injury prevention programs. This study used action research methods to supplement the understanding of the community development for injury prevention. The aim of this paper is to present the participative model used in one of the first of these programs, the Motala Injury Prevention Program, and lessons learned from the first 10 years of its operation. The program 'succeeded' in 1993, when Motala Municipality formed a regular Safety Board chaired by the Municipal Commissioner. These are five main messages from the initial phases of the program: a community-based injury prevention program has to be regarded as a long-term project; preferably over more than a 10 year period, economic calculations are important in the community analysis phase of the program, inter-linkage between community organizations is essential in the design phase, the hand-over from the initial program developers to practitioners is critical in the implementation phase, it is important to maintain a high-quality data collection routine even after the conclusion of the community analysis phase of the program. These observations have a potential to be valid at least for Northern Europe, which, by comparison with other parts of the world is a relatively homogenous area with regard to external causes of injuries. Regarding other communities, there are known differences in injury rates and community organization.

Norfloxacin as prophylaxis against urethral strictures following transurethral resection of the prostate: an open, prospective, randomized study

An open, prospective, randomized study was performed to investigate the effect of norfloxacin prophylaxis on stricture formation and operative outcome after transurethral resection of the prostate. After resection, the 359 patients studied were randomly divided into 2 groups: 1) those given norfloxacin as prophylaxis for 15 days following removal of the catheter (norfloxacin group) and 2) those given no antimicrobial prophylaxis during the same period (control group). Of the patients 94 were excluded. At followup 6 to 12 months postoperatively, the number of strictures in the anterior urethra was 2 of 135 in the norfloxacin group and 22 of 130 in the control group (p < 0.01). Strictures in the bladder neck developed in 3 of 135 and 4 of 130 patients, respectively (not significant). As a consequence of a lower structure incidence in the anterior urethra in the norfloxacin group, fewer patients in that group were dissatisfied with the operative outcome. The results suggest that norfloxacin provides effective prophylaxis against stricture formation after transurethral resection of the prostate.

Suprapubic catheter following transurethral resection of the prostate: a way to decrease the number of urethral strictures and improve the outcome of operations

A prospective, randomized study was done to investigate the role of transurethral catheters in stricture formation after transurethral resection of the prostate. The operative outcome after using transurethral catheters made of 2 different materials compared with suprapubic catheters was also investigated. We studied 344 patients who underwent transurethral resection of the prostate. After resection the patients were randomly divided into 3 groups: 1) those drained by a transurethral polytetrafluoroethylene (Teflon)-coated latex catheter, 2) those drained by a transurethral polyvinylchloride catheter and 3) those drained by a suprapubic polyvinylchloride catheter. At 6 to 24 months the numbers of strictures in the anterior urethra were 10 of 102 and 11 of 102 in the transurethral drainage groups, respectively. The corresponding number of strictures in the suprapubic drainage group was 1 of 94 (p less than 0.01). Strictures in the bladder neck had developed in 5 of 102, 3 of 103 and 3 of 94 patients, respectively (not significant). As a consequence of a lower incidence of strictures in the anterior urethra in the suprapubic drainage group, more patients in that group were satisfied with the results of the operation.

Urethral strictures following transurethral resection of the prostate. The role of the catheter

Urethral stricture is the most common late complication of transurethral prostatectomy (TURP). The cause is unknown. A prospective, randomised study was undertaken to investigate the role of the transurethral catheter in stricture formation. A total of 205 patients subjected to TURP were studied. Following resection, they were randomly divided into 2 groups: those drained by a transurethral siliconised latex catheter and those drained by a suprapubic siliconised latex catheter. At follow-up, 6 to 24 months later, 17% of the patients in the transurethral group had developed urethral stricture; the corresponding figure in the suprapubic group was 4%. As a consequence of the higher incidence of stricture in the transurethrally drained group, more patients in that group were dissatisfied with the results of the operation. It was concluded that the post-operative transurethral catheter was an important factor in stricture formation following TURP and that transurethral drainage with a siliconised latex catheter resulted in a higher incidence of stricture. This led to a greater number of patients being dissatisfied with the results of the operation, but the catheter did not affect the results in any other way.

A comparison of the oxytetracycline preparations Aquacycline and Terramycin 100 with regard to absorption characteristics, local tissue reactions and residues following dewlap injections in calves

In an experiment with 12 calves, Aquacycline® in a 5 % (OTC-A5) and a 10 % (OTC-A10) solution, was compared with Terramycin®-100 (OTC-C) by injecting 20 mg OTC/kg bwt. of these preparations in the dewlap and monitoring serum concentrations as well as tissue reactions and residues at the site of injection. All 3 preparations resulted in oxytetracycline (OTC) serum concentrations above 0.5 µg/ml of approximately 60 h. During this period, OTC-A5 resulted in a 39 % and OTC-A10 in a 20 % larger area under the serum concentration-time curve, as compared to OTC-C (P < 0.05). The recorded tissue reaction in the form of swelling during the first week following injection of OTC-A5 averaged 72 % of that after OTC-C (P < 0.01), while the mean swelling after OTC-A10 was 81 % of the corresponding value after OTC-C (P < 0.05). The OTC residue levels at the sites of injection were lower after OTC-A5, but none of the preparations resulted in OTC residues exceeding 0.3 mg at 28 days and about 0.15 mg at 42 days after injection. The pathological changes at the site of injection were somewhat more pronounced in those calves which received OTC-C. Accordingly, these results give some support to the claims that Aquacycline® offers advantages with respect to absorption characteristics and tissue tolerance.