Evaluating remote facilitation intensity for multi-national translation of nurse-initiated stroke protocols (QASC Australasia): a protocol for a cluster randomised controlled trial.

BACKGROUND: Facilitated implementation of nurse-initiated protocols to manage fever, hyperglycaemia (sugar) and swallowing difficulties (FeSS Protocols) in 19 Australian stroke units resulted in reduced death and dependency for stroke patients. However, a significant gap remains in translating this evidence-based care bundle protocol into standard practice in Australia and New Zealand. Facilitation is a key component for increasing implementation. However, its contribution to evidence translation initiatives requires further investigation. We aim to evaluate two levels of intensity of external remote facilitation as part of a multifaceted intervention to improve FeSS Protocol uptake and quality of care for patients with stroke in Australian and New Zealand acute care hospitals. METHODS: A three-arm cluster randomised controlled trial with a process evaluation and economic evaluation. Australian and New Zealand hospitals with a stroke unit or service will be recruited and randomised in blocks of five to one of the three study arms-high- or low-intensity external remote facilitation or a no facilitation control group-in a 2:2:1 ratio. The multicomponent implementation strategy will incorporate implementation science frameworks (Theoretical Domains Framework, Capability, Opportunity, Motivation - Behaviour Model and the Consolidated Framework for Implementation Research) and include an online education package, audit and feedback reports, local clinical champions, barrier and enabler assessments, action plans, reminders and external remote facilitation. The primary outcome is implementation effectiveness using a composite measure comprising six monitoring and treatment elements of the FeSS Protocols. Secondary outcome measures are as follows: composite outcome of adherence to each of the combined monitoring and treatment elements for (i) fever (n=5); (ii) hyperglycaemia (n=6); and (iii) swallowing protocols (n=7); adherence to the individual elements that make up each of these protocols; comparison for composite outcomes between (i) metropolitan and rural/remote hospitals; and (ii) stroke units and stroke services. A process evaluation will examine contextual factors influencing intervention uptake. An economic evaluation will describe cost differences relative to each intervention and study outcomes. DISCUSSION: We will generate new evidence on the most effective facilitation intensity to support implementation of nurse-initiated stroke protocols nationwide, reducing geographical barriers for those in rural and remote areas. TRIAL REGISTRATION: ACTRN12622000028707. Registered 14 January, 2022.

Comparing medication adherence in patients receiving bisphosphonates for preventing fragility fractures: a comprehensive systematic review and network meta-analysis.

BACKGROUND: Bisphosphonates are effective in preventing fragility fractures; however, high rates of adherence are needed to preserve clinical benefits. OBJECTIVE: To investigate persistence and compliance to oral and intravenous bisphosphonates (alendronate, ibandronate, risedronate, and zoledronate). METHODS: Searches of 12 databases, unpublished sources, and trial registries were conducted, covering the period from 2000 to April 2021. Screening, data extraction, and risk of bias assessment (Cochrane Collaboration risk-of-bias tool 1.0 & ROBINS-I) were independently undertaken by two study authors. Randomised controlled trials (RCTs) and observational studies that used prescription claim databases or hospital medical records to examine patients' adherence were included. Network meta-analyses (NMA) embedded within a Bayesian framework were conducted, investigating users' likelihood in discontinuing bisphosphonate treatment. Where meta-analysis was not possible, data were synthesised using the vote-counting synthesis method. RESULTS: Fifty-nine RCTs and 43 observational studies were identified, resulting in a total population of 2,656,659 participants. Data from 59 RCTs and 24 observational studies were used to populate NMAs. Zoledronate users were the least likely to discontinue their treatment HR = 0.73 (95%CrI: 0.61, 0.88). Higher rates of compliance were observed in those receiving intravenous treatments. The paucity of data and the heterogeneity in the reported medication possession ratio thresholds precluded a NMA of compliance data. CONCLUSIONS: Users of intravenously administered bisphosphonates were found to be the most adherent to treatment among bisphosphonates' users. Patterns of adherence will permit the more precise estimation of clinical and cost-effectiveness of bisphosphonates. TRIAL REGISTRATION: PROSPERO 2020 CRD42020177166.

Patients' attitudes towards cost feedback to doctors to prevent unnecessary testing: a qualitative focus group study.

OBJECTIVES: There is a need to improve efficiency in healthcare delivery without compromising quality of care. One approach is the development and evaluation of behavioural strategies to reduce unnecessary use of common tests. However, there is an absence of evidence on patient attitudes to the use of such approaches in the delivery of care. Our objective was to explore patient acceptability of a nudge-type intervention that aimed to modify blood test requests by hospital doctors. STUDY DESIGN: Single-centre qualitative study. METHODS: The financial costs of common blood tests were presented to hospital doctors on results reports for 1 year at a hospital. Focus group discussions were conducted with recent inpatients at the hospital using a semi-structured question schedule. Discussions were transcribed and analysed using qualitative content analysis to identify and prioritise common themes explaining attitudes to the intervention approach. RESULTS: Three focus groups involving 17 participants were conducted. Patients were generally apprehensive about the provision of blood test cost feedback to doctors. Attitudes were organised around themes representing beliefs about blood tests, the impact on doctors and their autonomy, and beliefs about unnecessary testing. Patients thought that blood tests were important, powerful and inexpensive, and cost information could place doctors under additional pressure. CONCLUSION: The findings identify predominantly positive beliefs about testing and negative attitudes to the use of financial costs in the decision-making of hospital doctors. Public discussion and education about the possible overuse of common tests may allow more resources to be allocated to evidence-based healthcare, by reducing the perception that such strategies to improve healthcare efficiency negatively impact on quality of care.

What is the association between price and economic activity with cigarette consumption in Cuba from 1980 to 2014?

OBJECTIVES: Cuba is a tobacco-producing country that has been economically isolated as a consequence of an embargo imposed by the USA. It has also experienced a severe economic depression in the 1990s after the withdrawal of support by the former Soviet Union. These characteristics provide a unique opportunity to study the relation between large changes in economic activity, cigarette price and demand for cigarettes in a relatively isolated socialist economy. STUDY DESIGN: This is an observational epidemiological study. METHODS: Data were obtained on the annual price of a packet of cigarettes and the mean number of cigarettes consumed per adult living in Cuba from 1980 to 2014. Descriptive and regression analysis were used to explore the relationship between cigarette consumption and price in Cuba. RESULTS: In 1980, the mean price of a packet of cigarettes was 1.53 Cuban peso (CUP) in 1997 prices and the mean annual per capita consumption was 2237 cigarettes. In 2014, the mean price had increased to 5.57 CUP (1997 prices) per packet of cigarettes, and consumption had fallen to 1527 cigarettes per capita. There were significant negative associations between annual cigarette consumption and both price and living through an economic depression. The elasticity was approximately -0.31 with price, and living through an economic depression was also associated with lower consumption of cigarettes (a reduction of 9%, 95% confidence intervals -0.18 to -0.001). CONCLUSIONS: Higher cigarette pricing, along with other public health interventions, are required to protect the national population from the adverse effects of tobacco smoke exposure.

A qualitative study exploring factors influencing clinical decision-making for influenza-like illness in Solapur city, Maharashtra, India.

The co-existence of different types of medical systems (medical pluralism) is a typical feature of India's healthcare system. For conditions such as influenza-like illness (ILI), where non-specific disease signs/symptoms exist, clinical reasoning in the context of medical pluralism becomes crucial. Recognising this need, we undertook a qualitative study, which explored factors underpinning clinical decisions on diagnosis and management of ILI. The study involved semi-structured interviews including clinical vignettes with 20 healthcare practitioners (working within allopathy, homeopathy and Ayurveda) working in the private healthcare sector in Solapur city, India. An inquiry was conducted into criteria influencing the diagnosis, treatment, referral to specialist care and role of treatment guidelines for ILI. Thematic analysis was used to identify aspects relating to ILI diagnosis, treatment and referral. The diagnosis of influenza was based largely on clinical symptoms suggestive of influenza in the absence of other diagnoses. Referral for laboratory tests was only initiated if illness did not resolve, generally after 2-3 consultations. Antibiotics were often prescribed for persistent illness, with antivirals rarely considered. Some differences between practitioners from different medical systems were observed in relation to treatment and referral in case of persistent illness. A combination of analytical and intuitive clinical reasoning was used by the participants and clinical decisions were based on both social and clinical factors. Clinical decision-making was rarely a linear process and respondents felt that broad guidelines on influenza that allowed doctors to account for the sociocultural context within which they practised medicine would be helpful.

Effectiveness of tobacco control television advertisements with different types of emotional content on tobacco use in England, 2004-2010.

AIM: To examine the effects of tobacco control television advertisements with positive and negative emotional content on adult smoking prevalence and cigarette consumption. DESIGN: Analysis of monthly cross-sectional surveys using generalised additive models. SETTING: England. PARTICIPANTS: 60 000 adults aged 18 years or over living in England and interviewed in the Opinions and Lifestyle Survey from 2004 to 2010. MEASUREMENTS: Current smoking status, daily cigarette consumption, tobacco control gross rating points (GRPs-a measure of per capita advertising exposure), cigarette costliness, concurrent tobacco control policies, sociodemographic variables. RESULTS: After adjusting for cigarette costliness, other tobacco control policies and individual characteristics, we found that a 400-point increase in positive emotive GRPs was associated with 7% lower odds of smoking (odds ratio (OR) 0.93, 95% CI 0.87 to 0.98) 1 month later and a similar increase in negative emotive GRPs was significantly associated with 4% lower odds of smoking (OR 0.96, 95% CI 0.92 to 0.999) 2 months later. An increase in negative emotive GRPs from 0 to 400 was also associated with a significant 3.3% (95% CI 1.1 to 5.6) decrease in average cigarette consumption. There was no evidence that the association between positive emotive GRPs and the outcomes differed depending on the intensity of negative emotive GRPs (and vice versa). CONCLUSIONS: This is the first study to explore the effects of campaigns with different types of emotive content on adult smoking prevalence and consumption. It suggests that both types of campaign (positive and negative) are effective in reducing smoking prevalence, whereas consumption among smokers was only affected by campaigns evoking negative emotions.

The effectiveness of tobacco control television advertisements in increasing the prevalence of smoke-free homes.

BACKGROUND: There is considerable evidence that tobacco control mass media campaigns can change smoking behaviour. In the UK, campaigns over the last decade have contributed to declines in smoking prevalence and been associated with falls in cigarette consumption among continuing smokers. However, it is less evident whether such campaigns can also play a role in changing smokers' behaviour in relation to protecting others from the harmful effects of their smoking in the home. We investigated whether exposure to English televised tobacco control campaigns, and specifically campaigns targeting second hand smoking, is associated with smokers having a smoke-free home. METHODS: We used repeated cross-sectional national survey data on 9872 households which participated in the Health Survey for England between 2004 and 2010, with at least one adult current smoker living in the household. Exposure to all government-funded televised tobacco control campaigns, and to those specifically with a second hand smoking theme, was quantified in Gross Rating Points (GRPs), an average per capita measure of advert exposure where 100 GRPs indicates 100 % of adults exposed once or 50 % twice. Our outcome was self-reported presence of a smoke-free home (where no one smokes in the home on most days). Analysis used generalised additive models, controlling for individual factors and temporal trends. RESULTS: There was no association between monthly televised campaigns overall and the probability of having a smoke-free home. However, exposure to campaigns specifically targeting second hand smoke was associated with increased odds of a smoke-free home in the following month (odds ratio per additional 100 GRPs, 1.07, 95 % CI 1.01 to 1.13), though this association was not seen at other lags. These effects were not modified by socio-economic status or by presence of a child in the home. CONCLUSIONS: Our findings provide tentative evidence that mass media campaigns specifically focussing on second hand smoke may be effective in reducing smoking in the home, and further evaluation of campaigns of this type is needed. General tobacco control campaigns in England, which largely focus on promoting smoking cessation, do not impact on smoke-free homes over and above their direct effect at reducing smoking.

The humoral response to human factor VIII in hemophilia A mice.

BACKGROUND: Inhibitory antibodies (Abs) to factor VIII (FVIII inhibitors) constitute the most significant complication in the management of hemophilia A. The analysis of FVIII inhibitors is confounded by polyclonality and the size of FVIII. OBJECTIVES: The goal of this study was to dissect the polyclonal response to human FVIII in hemophilia A mice undergoing a dosage schedule that mimics human use. METHODS: Splenic B-cell hybridomas were obtained following serial i.v. injections of submicrogram doses of FVIII. Results of a novel, anti-FVIII domain-specific enzyme-linked immunosorbent assay were compared to Ab isotype and anti-FVIII inhibitory activity. RESULTS: The robust immune response resulted in the production of approximately 300 hybridomas per spleen. We characterized Abs from 506 hybridomas, representing the most comprehensive analysis of a protein antigen to date. Similar to the human response to FVIII, anti-A2 and anti-C2 Abs constituted the majority of inhibitors. A novel epitope was identified in the A2 domain by competition ELISA. Anti-A2 and anti-C2 Abs were significantly associated with IgG(1) and IgG(2a) isotypes, respectively. Because the IgG(2a) isotype is associated with enhanced Fc receptor-mediated effector mechanisms, this result suggests that anti-C2 Abs and inflammation may be linked. Additionally, we identified a novel class of Abs with dual specificity for the A1 and A3 domains. Forty per cent of the Abs had no detectable inhibitory activity, indicating that they are prominent and potentially pathologically significant. CONCLUSION: The expanded delineation of the humoral response to FVIII may lead to improved management of hemophilia A through mutagenesis of FVIII B-cell epitopes.

Training staff to provide a continence helpline.

Incontinence is still a taboo subject with many people suffering in silence. A telephone helpline can encourage people to make contact with health professionals, but those running the helpline must be appropriately trained. Essential ingredients for a training session include assessment of prior knowledge, a clear overall aim and learning objectives, an environment condusive to learning, involvement of the learners and feedback from them.

Physical fitness and intraocular pressure.

The ability of moderate to intense aerobic exercise to reduce intraocular pressure (IOP) has been reported. Previous studies have focused on a single postexercise recovery period not considering the long-term effect of improved physical fitness on IOP. A total of 32 adult subjects, all having IOP's of greater than 18 mmm Hg in each eye as determined by an American Optical Corporation Non-Contact Tonometer, were selected for the study. After a complete medical and visual evaluation, participants were randomly assigned to either an intervention group (N = 18) receiving a 6-month supervised exercise program to improve physical fitness or into a control group (N = 14). After 6 months, each group was reevaluated to observe changes in physical fitness and IOP. Pre- and poststudy measurements of maximum oxygen uptake (ml/kg/min) made with a Beckman O2 analyzer showed significant improvement in physical fitness in the intervention group (p less than 0.05). There was a significant decrease (p less than 0.05) in IOP, 2.0 mmm Hg in the right eye and 1.3 mm Hg in the left eye, in the intervention group; however, decreases in IOP were comparable and significant (p less than 0.05) in the control group. Results from multiple regression analysis for each individual group and for combined groups indicated that changes in IOP were not dependent upon changes in physical fitness.

Improving physical fitness by exercise training programs.

Thirteen young men completed a ten-week exercise training program on bicycle ergometers. Training sessions were conducted five days per week, with eight men randomly assigned to low-effort (LE) and five to high-effort (HE) regimens. LE participants worked continuously at 50% of their maximal oxygen intake (exercise HR congruent to 135 BPM); HE participants performed two minutes alternating work-rest intervals at 80% of their maximal oxygen intake (exercise HR congruent to 170 BPM). Total work done was held constant for the two groups. LE and HE participants increased maximal oxygen intake (P < .01), but there was no difference in changes between the two groups. LE exercise training programs are more comfortable for participants and perhaps should be recommended over HE programs for most individuals, since improvements in physical fitness appear to be comparable.

Somatic-evoked brain responses as indicators of adaptation to nitrogen narcosis.

Two 2-week experimental pressure chamber exposures to nitrogen-oxygen breathing mixtures afforded an opportunity to study adaptation to nitrogen narcosis. Somatic-evoked brain responses induced by electrical stimulation of the median nerve in the wrist were processed on-line with a signal averager. The N1P2 interval was seen generally to be reduced in amplitude as a result of exposure to increased nitrogen partial pressure. Compressions with air were made from sea level and saturation to 200, 250 and 300 ft of sea water (fsw) equivalent (61, 76, and 91m). The decrement was found to be less, for equivalent exposures, in subjects who had been saturated at the pressure of 90 and 120 fsw (27 and 36 m); we interpret this as evidence of a nonspecific "adaptation." Less adaptation was seen from 30 and 60 fsw (9 and 18 m). These results are consistent with performance tests on the same exposures, and with subjective impressions. Saturation with 3 0r 4 atm of nitrogen may permit somewhat deeper diving without serious narcosis, than is possible from sea level.