Prescribing in Chronic Severe Hepatic Impairment.

Therapeutic Reviews aim to provide essential independent information for health professionals about drugs used in palliative and hospice care. Additional content is available via www.palliativedrugs.com. The series editors welcome feedback on the articles.

FAST Club: The Impact of a Physical Activity Intervention on Executive Function in Children With Fetal Alcohol Spectrum Disorder.

Physical activity (PA) has been demonstrated to have positive effects on cognitive function, particularly executive function (EF) skills. Animal models suggest PA may be effective in ameliorating some of the neuropsychological effects of fetal alcohol spectrum disorder (FASD), but this approach has not been extended to humans. The purpose of this study was to develop a PA program, FAST Club, for children with FASD and to evaluate its effect on a measure of EF. Using a wait-list control design, 30 children age 7-14 yr participated in FAST Club for 2 × 1.5-hr sessions/week for 8 weeks. EF was assessed using the Children's Color Trails Test. Significant improvements in T scores on the Children's Color Trails Test were seen immediately postprogram, and this improvement was sustained at 3 months postprogram. These findings provide evidence to support the use of PA as a means to improve EF in children with FASD.

The influence of bedrock hydrogeology on catchment-scale nitrate fate and transport in fractured aquifers.

Characterising catchment scale biogeochemical processes controlling nitrate fate in groundwater constitutes a fundamental consideration when applying programmes of measures to reduce risks posed by diffuse agricultural pollutants to water quality. Combining hydrochemical analyses with nitrate isotopic data and physical hydrogeological measurements permitted characterisation of biogeochemical processes influencing nitrogen fate and transport in the groundwater in two fractured bedrock aquifers with contrasting hydrogeology but comparable nutrient loads. Hydrochemical and isotopic analyses of groundwater samples collected from moderately fractured, diffusely karstified limestone indicated nitrification controlled dissolved nitrogen fate and delivery to aquatic receptors. By contrast nitrate concentrations in groundwater were considerably lower in a low transmissivity highly lithified sandstone and pyrite-bearing shale unit with patchy subsoil cover. Geophysical and hydrochemical investigations showed shallower intervals contained hydraulically active fractures where denitrification was reflected through lower nitrogen levels and an isotopic enrichment ratio of 1.7 between δ(15)N and δ(18)O. Study findings highlight the influence of bedrock hydrogeological conditions on aqueous nitrogen mobility. Investigation results demonstrate that bedrock conditions need to be considered when implementing catchment management plans to reduce the impact of agricultural practices on the quality of groundwater and baseflow in receiving rivers. Nitrate isotopic signatures in the groundwater of a freely draining catchment underlain by a karstified aquifer and a poorly draining aquifer with a low transmissivity aquifer.

Geophysical and hydrogeological characterisation of the impacts of on-site wastewater treatment discharge to groundwater in a poorly productive bedrock aquifer.

Contaminants discharging from on-site wastewater treatment systems (OSWTSs) can impact groundwater quality, threatening human health and surface water ecosystems. Risk of negative impacts becomes elevated in areas of extreme vulnerability with high water tables, where thin unsaturated intervals limit vadose zone attenuation. A combined geophysical/hydrogeological investigation into the effects of an OSWTS, located over a poorly productive aquifer (PPA) with thin subsoil cover, aimed to characterise effluent impacts on groundwater. Groundwater, sampled from piezometers down-gradient of the OSWTS percolation area displayed spatially erratic, yet temporally consistent, contaminant distributions. Electrical resistivity tomography identified an area of gross groundwater contamination close to the percolation area and, when combined with seismic refraction and water quality data, indicated that infiltrating effluent reaching the water table discharged to a deeper more permeable zone of weathered shale resting on more competent bedrock. Subsurface structure, defined by geophysics, indicated that elevated chemical and microbiological contaminant levels encountered in groundwater samples collected from piezometers, down-gradient of sampling points with lower contaminant levels, corresponded to those locations where piezometers were screened close to the weathered shale/competent rock interface; those immediately up-gradient were too shallow to intercept this interval, and thus the more impacted zone of the contaminant plume. Intermittent occurrence of faecal indicator bacteria more than 100m down gradient of the percolation area suggested relatively short travel times. Study findings highlight the utility of geophysics as part of multidisciplinary investigations for OSWTS contaminant plume characterisation, while also demonstrating the capacity of effluent discharging to PPAs to impact groundwater quality at distance. Comparable geophysical responses observed in similar settings across Ireland suggest the phenomena observed in this study are more widespread than previously suspected.

Salivary cortisol levels are elevated in the afternoon and at bedtime in children with prenatal alcohol exposure.

Prenatal alcohol exposure can cause dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which may underlie some of the behavioral and adaptive problems seen in individuals with Fetal Alcohol Spectrum Disorders (FASD). Infants prenatally exposed to alcohol show altered basal and post-stress cortisol levels, but it is unknown if this persists beyond 2 years of age. It is also unknown if cortisol levels can be normalized through intervention programs. In this study, we investigated the effects of a physical activity program for children with FASD to determine: 1) if HPA dysregulation persists in school-age children with FASD, and 2) the effect of our program on cortisol levels. Twenty six children (ages 6-14 years) with FASD participated in an 8 week motor skill development program. Salivary cortisol levels were measured in 24 children and compared at 4 time points: before, immediately after, 3 months, and 1 year after program completion. Cortisol levels were also compared to 32 control children to evaluate the long-term effects of prenatal alcohol exposure on HPA regulation. For each time point, saliva was collected on each of 2 days at 3 times in the diurnal cycle: awakening, after school, and just before bedtime. Cortisol levels were significantly higher in the afternoon and at bedtime in children with FASD with confirmed prenatal exposure to high levels of alcohol (alcohol exposure rank 4), compared with Control children or children with FASD with exposure to low or unknown levels of alcohol (alcohol exposure rank 3). The program did not significantly affect cortisol levels in children with FASD as a group. These results provide support for long-term effects of prenatal alcohol exposure on the HPA system in humans, which could increase vulnerability to mental health issues and diseases later in life.

Accountability, responsiveness and quality for clients model of home support: a model for improved home support services to promote aging at home.

As the proportion of older adults increases within the Canadian population, healthcare systems across the country are facing increased demands for home-based services, including home care nursing, rehabilitation, case management, adult day programs, respite, meal programs and home support. Home support is one of the core care services required in the community to enable older adults to remain at home as long as possible. In 2006, Vancouver Community introduced a new home support delivery and performance management model: the Accountability, Responsiveness and Quality for Clients Model of Home Support (ARQ Model) (VCH 2006). The main components of the ARQ Model are an expanded use of "cluster care" along with stable monthly funding for high-density buildings and neighbourhoods; the introduction of specific monthly and quarterly quality performance reporting; and the implementation of performance-based funding for home support. This article discusses the setup of the ARQ model, its ongoing evaluation and results achieved thus far.

Dimensions of power: older women's experiences with electroconvulsive therapy (ECT).

Older women are particularly prone to being treated for depression, and, despite the controversy surrounding it, electroconvulsive therapy (ECT) has gained popularity as a treatment with this population. Research has examined the physical and cognitive changes associated with ECT but there is little understanding regarding how older women themselves experience this treatment. In order to gain better understanding into the subjective experience of receiving ECT, this qualitative study explored the experiences of six older women who were treated with ECT for a diagnosis of depression, using in-depth personal interviews. Analysis suggests that this experience for these older women could not be understood in isolation. Rather, their stories highlighted the importance of interpreting the ECT experience within a broader context that included the larger depression experience, the dynamics of helping relationships, and the discourse available to them for sense-making. Specifically, the central theme underpinning all of these women's stories was the shifting of power from themselves to others. This paper examines how this occurred and discusses implications for practice.