Tuakana-teina peer education programme to help Maori elders enhance wellbeing and social connectedness.

BACKGROUND: There are significant inequities between Maori (Indigenous people) and non-Maori in ageing outcomes. This study used a strengths-based approach based on the key cultural concept of mana motuhake (autonomy and self-actualisation) to develop a tuakana-teina (literally older sibling-younger sibling) peer education programme to assist kaumatua (elders) in addressing health and social needs. The purpose of this study was to test the impact on those receiving the programme. Three aims identify the impact on outcomes, resources received and the cost effectiveness of the programme. METHODS: Five Kaupapa Maori (research and services guided by Maori worldviews) iwi (tribe) and community providers implemented the project using a partnership approach. Tuakana (peer educators) had up to six conversations each with up to six teina (peer learners) and shared information related to social and health services. A pre- and post-test, clustered staggered design was the research design. Participants completed a baseline and post-programme assessment of health and mana motuhake measures consistent with Maori worldviews. Open-ended questions on the assessments, five focus groups, and four individual interviews were used for qualitative evaluation. FINDINGS: A total of 113 kaumatua were recruited, and 86 completed the programme. The analysis revealed improvements in health-related quality of life, needing more help with daily tasks, life satisfaction, paying bills and housing problems. Qualitative results supported impacts of the programme on mana motuhake and hauora (holistic health) through providing intangible and tangible resources. Cost-effectiveness analysis showed that the intervention is cost effective, with a cost per QALY of less than the conventional threshold of three times GDP per capita. CONCLUSIONS: A culturally-resonant, strengths-based programme developed through a participatory approach can significantly improve health and social outcomes in a cost-effective way. TRIAL REGISTRY: Clinical trial registry: Trial registration: (ACTRN12620000316909). Prospectively registered 06/03/2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379302&isClinicalTrial=False .

Enhancing health outcomes for Maori elders through an intergenerational cultural exchange and physical activity programme: a cross-sectional baseline study.

Background: The study offers baseline data for a strengths-based approach emphasizing intergenerational cultural knowledge exchange and physical activity developed through a partnership with kaumatua (Maori elders) and kaumatua service providers. The study aims to identify the baseline characteristics, along with correlates of five key outcomes. Methods: The study design is a cross-sectional survey. A total of 75 kaumatua from six providers completed two physical functioning tests and a survey that included dependent variables based in a holistic model of health: health-related quality of life (HRQOL), self-rated health, spirituality, life satisfaction, and loneliness. Results: The findings indicate that there was good reliability and moderate scores on most variables. Specific correlates included the following: (a) HRQOL: emotional support (ß = 0.31), and frequent interaction with a co-participant (ß = 0.25); (b) self-rated health: frequency of moderate exercise (ß = 0.32) and sense of purpose (ß = 0.27); (c) spirituality: sense of purpose (ß = 0.46), not needing additional help with daily tasks (ß = 0.28), and level of confidence with cultural practices (ß = 0.20); (d) life satisfaction: sense of purpose (ß = 0.57), frequency of interaction with a co-participant (ß = -0.30), emotional support (ß = 0.25), and quality of relationship with a co-participant (ß = 0.16); and (e) lower loneliness: emotional support (ß = 0.27), enjoyment interacting with a co-participant (ß = 0.25), sense of purpose (ß = 0.24), not needing additional help with daily tasks (ß = 0.28), and frequency of moderate exercise (ß = 0.18). Conclusion: This study provides the baseline scores and correlates of important social and health outcomes for the He Huarahi Tautoko (Avenue of Support) programme, a strengths-based approach for enhancing cultural connection and physical activity.

Faculty Development and Infrastructure to Support Educational Scholarship: A Scoping Review on Author Development.

PURPOSE: Medical educators are expected to produce educational scholarship, which can lead to career advancement and promotion. Institutions have developed author development programs, which vary in duration, instructional approach, and effectiveness. However, no summation of the evidence exists for academic medicine leaders to use as guidance for building similar programs. This scoping review characterizes faculty development programs that support educational scholarship and author development in academic medicine. METHOD: The authors searched PubMed, Scopus, Google Scholar, and ProQuest (Healthcare Administration Database and Social Science Premium Collection) for articles published from inception to June 14, 2021. Articles that described formal instruction on scholarly writing for publishing were included. Data were analyzed by program participation, structure, content delivery, and outcomes. RESULTS: Of 923 articles identified, 20 met inclusion criteria. The included studies covered 18 unique programs of which 1 was sponsored jointly by a university and professional society, 5 by professional societies, 5 by university or medical school organizations, and 7 by medical departments. Nine programs relied at least in part on volunteers. Instructional approaches included didactics (7 programs) and mentoring (5 programs) but mostly featured group-based work (11 programs). Expectations for participants ranged from participation to manuscript submission. The main funding sources were grants (8 programs) and internal funds (7 programs) from the sponsoring institution. Only 4 programs reported participation fees. The impact of these programs included scholarly work products, other measures of career advancement, and participant perceptions. CONCLUSIONS: Author development programs require resource investment and a culture that values educational scholarship. Workshops, 1-on-1 mentoring, and peer writing groups are cornerstones of the experiential learning approach needed to build scholarship skills and can pay dividends in supporting the academic mission in medicine. These findings may benefit leaders in academic medicine who want to develop evidence-based programs in author development.

Abrocitinib monotherapy in Investigator's Global Assessment nonresponders: improvement in signs and symptoms of atopic dermatitis and quality of life.

BACKGROUND: Abrocitinib, a once-daily, oral Janus kinase 1 selective inhibitor, was shown to be an effective treatment for moderate-to-severe atopic dermatitis in phase 2 b/3 monotherapy trials. METHODS: These analyses included data for Investigator's Global Assessment responder (clear [0] or almost clear [1] with ≥2-grade improvement) and nonresponder patients with moderate-to-severe atopic dermatitis who received abrocitinib (200 mg or 100 mg) or placebo in three abrocitinib monotherapy trials (phase 2 b, NCT02780167; two phase 3, NCT03349060/JADE MONO-1 and NCT03575871/JADE MONO-2). Outcomes measuring skin clearance, itch, and quality of life were evaluated. RESULTS: Both nonresponders (n = 548) and responders (n = 260) treated with abrocitinib had rapid and clinically meaningful improvement in skin clearance, itch, and quality of life compared with placebo. CONCLUSION: Patients with moderate-to-severe atopic dermatitis treated with abrocitinib who did not achieve an Investigator's Global Assessment 0/1 response at week 12 still experienced rapid, clinically meaningful improvements across several other validated measures of efficacy and quality of life. CLINICALTRIALS.GOV: NCT02780167, NCT03349060, NCT03575871.

Pre-drinking behaviour of people in the night-time economy: Evidence from a street-intercept survey in New Zealand.

INTRODUCTION: Pre-drinking behaviour has grown in prevalence and generates harm for pre-drinkers and others. In this article, we answer three research questions: (i) Where and when do pre-drinkers obtain their alcohol?; (ii) What is the difference in the level of intoxication of pre-drinkers versus non-pre-drinkers, and how does this difference vary over the course of a night?; and (iii) Is the level of intoxication of pre-drinkers related to where and when they obtain their alcohol? METHODS: We obtained data from 469 respondents using a street-intercept survey conducted in Hamilton, New Zealand in 2019. Data were analysed by cross-tabulation, linear regression and plotting the average intoxication level in the night-time economy over time. RESULTS: The majority of pre-drinkers purchase their alcohol for pre-drinking on the day of consumption. Half of the same-day purchasers purchase before 6 pm. The average level of intoxication increases over the course of the night, and is unambiguously higher for pre-drinkers than non-pre-drinkers. The level of intoxication does not differ based on the source or timing of pre-drinking purchases. The main motivation for pre-drinking was price, especially among women. DISCUSSION AND CONCLUSIONS: Pre-drinking is a contributor to intoxication in the night-time economy, but most drinkers purchase their alcohol for pre-drinking before 7 pm. Further research is required to understand whether trading hours restrictions for off-premises alcohol suppliers will affect the most harmful drinking patterns. Price interventions to reduce the price differential between on-licenced and off-licence alcohol outlets offer the greatest potential to reduce pre-drinking and associated harm.

Side-loading prevalence and intoxication in the night-time economy.

Although pre-drinking has attracted considerable research interest, side-loading (any drinking occurring outside of licensed premises during a night out, and excluding drinking at home) is comparatively under-studied. In this paper, we investigate the prevalence of side-loading behaviour and intoxication in the night-time economy of Hamilton, New Zealand's fourth-largest city. Using a street-intercept survey conducted over six nights (n = 469) in March and April 2019, we found that 17.5% of research participants (82/469), and 19.9% of drinkers (82/413), had engaged in side-loading. Of those engaging in side-loading, the majority did so in a car (61.0%), with smaller proportions engaging in side-loading in the street (17.1%), a carpark (12.2%), or somewhere else (13.4%). Men were significantly more likely than women to engage in side-loading behaviour (p = 0.001). In linear models controlling for time of the night, day of the week, and demographic variables, side-loading was not statistically significantly associated with breath alcohol content. This contrasts with pre-drinking, which was associated with statistically significantly higher breath alcohol content. Our results suggest that side-loading might not be used as a method for drinkers to enhance intoxication, but instead as a means of sustaining a target level of intoxication during an evening.

Breast cancer costs in New Zealand's public health system.

AIM: This study aims to estimate the mean costs of breast cancer in New Zealand's public health system. METHOD: This study included women diagnosed with invasive breast cancer between 1 July 2010 and 30 June 2018 who received services in public hospitals. These patients were identified from the National Breast Cancer Register or the New Zealand Cancer Registry and linked with the Pharmaceutical Collection, National Minimum Dataset, National Non-Admitted Patient Collection and Mortality Collection. RESULTS: 22,948 breast cancer patients were included. The mean public health cost of breast cancer was NZ$44,954 per patient for the period of three months preceding and five years following cancer diagnosis, with the treatment phase accounting for 70% of the cost and the follow-up phase accounting for the remaining 30%. During the treatment phase, surgery costs accounted for the biggest proportion (35%) of the total cost, followed by immunotherapy costs (18%), radiotherapy costs (17%) and costs of diagnostic test, scan and biopsy (16%). The costs decreased substantially with age, from $69,121 for women younger than 45 years old to $23,805 for those aged 80 or over. CONCLUSIONS: The costs of breast cancer in New Zealand's public health system are substantial and have been increasing. However, outcomes of breast cancer have been improving. The results of this study can be used as a baseline of actual costs for comparing the costs of introducing new diagnosis and treatment modalities in the future.

Interventions to mitigate indoor air pollution: A cost-benefit analysis.

Globally, around three billion people depend upon solid fuels such as firewood, dry animal dung, crop residues, or coal, and use traditional stoves for cooking and heating purposes. This solid fuel combustion causes indoor air pollution (IAP) and severely impairs health and the environment, especially in developing countries like Pakistan. A number of alternative household energy strategies can be adopted to mitigate IAP, such as using liquefied petroleum gas (LPG), natural gas, biogas, electric stoves, or improved cook stoves (ICS). In this study, we estimate the benefit-cost ratios and net present value of these interventions over a ten-year period in Pakistan. Annual costs include both fixed and operating costs, whereas benefits cover health, productivity gains, time savings, and fuel savings. We find that LPG has the highest benefit-cost ratio, followed by natural gas, while ICS has the lowest benefit-cost ratio. Electric stoves and biogas have moderate benefit-cost ratios that nevertheless exceed one. To maximize the return on cleaner burning technology, the government of Pakistan should consider encouraging the adoption of LPG, piped natural gas, and electric stoves as means to reduce IAP and adopt clean technologies.

Telehealth for Family Guidance: Acceptance and Commitment Therapy, Parent-Focused Preference Assessment, and Activity-Based Instruction for the Support of Children with Autism Spectrum Disorder and Their Families.

A 5-stage protocol was used to support Board Certified Behavior Analysts providing telehealth support for children with autism spectrum disorder and their families. Stage 1 of the protocol involves 2 acceptance and commitment therapy exercises. Specifically, the Valued Living Questionnaire is used to identify a family member's values, and the Bull's-Eye Values Survey is employed to determine the extent to which a family member is living in accordance with stated values. Stage 2 of the protocol involves administering an adult version of the Meaningful Activity Participation Assessment to identify preferred activities of parents of a child with autism spectrum disorder. During Stage 3 of the protocol, the goals and objectives of a child with autism spectrum disorder are yoked to the preferred activities of a family member in order to promote child-parent engagement. Stage 4 of the protocol is focused on parent-implemented interventions, and Stage 5 of the protocol is designed as a primer for comprehensive support within an acceptance and commitment therapy model. The 5-stage protocol provides guidelines for Board Certified Behavior Analysts interested in structuring telehealth sessions and optimizing engagement between a family member and a child with autism spectrum disorder.

Maori Becoming Peer Educators in Later Life: Impacts on Identity, Well-being, and Social Connectedness.

OBJECTIVE: The aim of this study was to examine ways that older Maori (New Zealand's Indigenous people) enhanced their ability to be peer educators and how this role impacted on their sense of purpose and well-being in later life. METHOD: Kaupapa Maori and community-based participatory research principles guided the peer intervention involving 26 Maori kaumatua (older people 55 years and older) as peer educators (tuakana) for 121 other kaumatua (teina) facing transitions in later life. Each pair held up to 3 conversations; independent coders rated tuakana communication skills. We used mixed methods in a pre- and post-test, clustered staggered design. Participants completed baseline and post-intervention assessments of health and well-being consistent with Maori worldviews. 5 focus groups involving 22 teina and 1 with 5 tuakana were held. RESULTS: Tuakana communication skills were rated as high by teina and independent coders. Qualitative analysis supported the importance of Maori communication processes for the role. Further, three measures increased significantly from the baseline to the final period for tuakana accounting for about 15% of the variance in these variables: sense of purpose (p = .07), self-rated health (p = .05), and health-related quality of life (p = .04). The qualitative analysis supported the benefits of the peer educator role for older Maori including enhanced sense of identity, well-being, and social connectedness. DISCUSSION: The results demonstrated that kaumatua had strong communication in the peer educator role and that the intervention has positive impacts for them. The study contributes to peer intervention research that may help to improve experiences ofIndigenous and other older people.

Kaumatua Mana Motuhake Poi: a study protocol for enhancing wellbeing, social connectedness and cultural identity for Maori elders.

BACKGROUND: The Aotearoa New Zealand population is ageing accompanied by health and social challenges including significant inequities that exist between Maori and non-Maori around poor ageing and health. Although historically kaumatua (elder Maori) faced a dominant society that failed to realise their full potential as they age, Maori culture has remained steadfast in upholding elders as cultural/community anchors. Yet, many of today's kaumatua have experienced 'cultural dissonance' as the result of a hegemonic dominant culture subjugating an Indigenous culture, leading to generations of Indigenous peoples compelled or forced to dissociate with their culture. The present research project, Kaumatua Mana Motuhake Poi (KMMP) comprises two interrelated projects that foreground dimensions of wellbeing within a holistic Te Ao Maori (Maori epistemology) view of wellbeing. Project 1 involves a tuakana-teina/peer educator model approach focused on increasing service access and utilisation to support kaumatua with the greatest health and social needs. Project 2 focuses on physical activity and cultural knowledge exchange (including te reo Maori--Maori language) through intergenerational models of learning. METHODS: Both projects have a consistent research design and common set of methods that coalesce around the emphasis on kaupapa kaumatua; research projects led by kaumatua and kaumatua providers that advance better life outcomes for kaumatua and their communities. The research design for each project is a mixed-methods, pre-test and two post-test, staggered design with 2-3 providers receiving the approach first and then 2-3 receiving it on a delayed basis. A pre-test (baseline) of all participants will be completed. The approach will then be implemented with the first providers. There will then be a follow-up data collection for all participants (post-test 1). The second providers will then implement the approach, which will be followed by a final data collection for all participants (post-test 2). DISCUSSION: Two specific outcomes are anticipated from this research; firstly, it is hoped that the research methodology provides a framework for how government agencies, researchers and relevant sector stakeholders can work with Maori communities. Secondly, the two individual projects will each produce a tangible approach that, it is anticipated, will be cost effective in enhancing kaumatua hauora and mana motuhake. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry ( ACTRN12620000316909 ). Registered 6 March 2020.

Correlates of Health-Related Quality of Life for Maori Elders Involved in a Peer Education Intervention.

The purpose of this study was to identify social determinant and communication correlates of health-related quality of life for kaumatua (Maori elders) in New Zealand. A total of 209 kaumatua completed a self-report survey of self-rated health, physical/mental quality of life, spirituality, and a series of questions about social determinants (e.g., factors related to income) and communication variables (e.g., loneliness, social support, cultural identity, and perceived burden/benefit). The survey was baseline data for a peer education intervention to help kaumatua work through life transitions in older age. The main findings of this study were that social determinants, particularly difficulty paying bills, accounted for a small amount of variance in physical/mental quality of life and self-rated health. Further, the communication correlates of loneliness, perceived burden, and desired support accounted for about three times as much variance in these two outcomes all with negative associations. Strength of tribal identity, importance of whanau (extended family), and knowledge of tikanga (customs and protocols) accounted for a moderate amount variance in spirituality with positive associations. These findings have important theoretical and practical implications for positive aging.

Kaumatua Mana Motuhake: A study protocol for a peer education intervention to help Maori elders work through later-stage life transitions.

BACKGROUND: The Aotearoa/New Zealand population is ageing and numerous studies demonstrate with this phenomenon comes increases in non-communicable diseases, injuries and healthcare costs among other issues. Further, significant inequities exist between Maori (Indigenous peoples of Aotearoa/New Zealand) and non-Maori around poor ageing and health. Most research addressing these issues is deficit oriented; however, the current research project takes a strengths-based approach that highlights the potential of kaumatua (elders) by asserting mana motuhake (autonomy, identity and self-actualisation). We believe that the esteem of elders in Maori culture signals transformative potential. Specifically, this project utilises a 'tuakana-teina' (older sibling/younger sibling) peer-educator model, where kaumatua work with other kaumatua in relation to health and wellbeing. The objectives of the project are (a) to develop the capacity of kaumatua as peer educators, whilst having positive impacts on their sense of purpose, health and wellbeing; and (b) to enhance the social and health outcomes for kaumatua receiving the intervention. METHODS: The research is grounded in principles of Kaupapa Maori and community-based participatory research, and brings together an Indigenous community of kaumatua, community health researchers, and academic researchers working with two advisory boards. The project intervention involves an orientation programme for tuakana peer educators for other kaumatua (teina). The research design is a pre- and post-test, clustered staggered design. All participants will complete a baseline assessment of health and wellbeing consistent with Maori worldviews (i.e., holistic model). The tuakana and teina participants will be divided into two groups with the first group completing the intervention during the first half of the project and the second group during the second half of the project. All participants will complete post-test assessments following both interventions allowing comparison of the two groups along with repeated measures over time. DISCUSSION: The findings will provide an evidence base for the importance and relevancy of kaumatua knowledge to create contextually based and culturally safe age-friendly environments that facilitate engagement and participation by kaumatua for kaumatua. If the model is effective, we will seek to facilitate the dissemination and scalability of the intervention. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry ( ACTRN12617001396314 ); Date Registered: 3 October 2017 (retrospectively registered).

The acute effects of a multi-ingredient pre-workout supplement on resting energy expenditure and exercise performance in recreationally active females.

BACKGROUND: The use of dietary supplements to improve performance is becoming increasingly popular among athletes and fitness enthusiasts. Unfortunately, there is a tremendous lack of research being done regarding female athletes and the use of sport supplements. The purpose of this study was to examine the acute effects of multi-ingredient pre-workout supplement (MIPS) ingestion on resting metabolism and exercise performance in recreationally-active females. METHODS: Fifteen recreationally-active females participated in a randomized, double-blind, placebo controlled study. Subjects completed baseline, and two experimental testing sessions in a cross-over design fashion. Experimental testing included assessment of resting energy expenditure (REE), heart rate, and blood pressure following the ingestion of a MIPS or placebo. Subjects also completed a repetition to failure test for the back squat (BS) and bench press (BP) at 85% of their 5-repetition maximum followed by the assessment of anaerobic power using a counter-movement vertical jump test and a sprint test on a force-treadmill. Subjective measurements of energy, focus, and fatigue were also assessed using a 5-point Likert scale. Separate repeated measures analysis of variance (ANOVA) were used to assess differences in REE, cardiovascular responses, and subjective markers between conditions. Performance data were analyzed using paired Student's T-tests. RESULTS: A significant main effect for condition was observed for REE (p = 0.021) and diastolic blood pressure (p = 0.011) following ingestion of the MIPS. The supplement condition resulted in a greater number of BP repetitions to failure and total work completed during treadmill test (p = 0.039) compared to placebo (p = 0.037). A significant condition x time interaction for focus was observed with the supplement treatment exhibiting improved focus at 80-min post ingestion (p = 0.046). CONCLUSIONS: Consumption of a MIPS increased resting metabolism following a single dose accompanied by an increase in diastolic blood pressure. Furthermore, acute MIPS ingestion improved upper body muscular endurance and anaerobic capacity while improving feelings of focus following high-intensity exercise in recreationally active females.

The marginal willingness-to-pay for attributes of a hypothetical HIV vaccine.

This paper estimates the marginal willingness-to-pay for attributes of a hypothetical HIV vaccine using discrete choice modeling. We use primary data from 326 respondents from Bangkok and Chiang Mai, Thailand, in 2008-2009, selected using purposive, venue-based sampling across two strata. Participants completed a structured questionnaire and full rank discrete choice modeling task administered using computer-assisted personal interviewing. The choice experiment was used to rank eight hypothetical HIV vaccine scenarios, with each scenario comprising seven attributes (including cost) each of which had two levels. The data were analyzed in two alternative specifications: (1) best-worst; and (2) full-rank, using logit likelihood functions estimated with custom routines in Gauss matrix programming language. In the full-rank specification, all vaccine attributes are significant predictors of probability of vaccine choice. The biomedical attributes of the hypothetical HIV vaccine (efficacy, absence of VISP, absence of side effects, and duration of effect) are the most important attributes for HIV vaccine choice. On average respondents are more than twice as likely to accept a vaccine with 99% efficacy, than a vaccine with 50% efficacy. This translates to a willingness to pay US$383 more for a high efficacy vaccine compared with the low efficacy vaccine. Knowledge of the relative importance of determinants of HIV vaccine acceptability is important to ensure the success of future vaccination programs. Future acceptability studies of hypothetical HIV vaccines should use more finely grained biomedical attributes, and could also improve the external validity of results by including more levels of the cost attribute.

Alcohol outlet density is related to police events and motor vehicle accidents in Manukau City, New Zealand.

OBJECTIVES: To explore the cross-sectional association between alcohol outlet density and police events in Manukau City, New Zealand. METHODS: Using data for the Census Area Unit (suburb) level, per-capita measures of alcohol outlet density for January 2009 were calculated for off-licence outlets, clubs and bars, and restaurants and cafés. Data on police events and motor vehicle accidents were obtained for the period 1 July 2008 to 30 June 2009, and also converted into per capita measures. A spatial seemingly unrelated regression model was developed, which simultaneously assessed the relationship between densities and all nine categories of police events, and motor vehicle accidents, while controlling for relevant covariates. RESULTS: All three outlet density measures were significantly associated with a range of police events, but only off-licence density was significantly associated with motor vehicle accidents. An additional off-licence outlet in a given area was associated with 85.4 additional police events and 10.3 additional motor vehicle accidents; an additional club or bar was associated with 34.7 additional police events and 0.5 additional motor vehicle accidents; and an additional restaurant or cafe was associated with 13.2 additional police events and 2.1 additional motor vehicle accidents. CONCLUSIONS: The results do not imply causality. However, they are broadly consistent with availability theory, and imply that local alcohol policy should account for the effects of additional outlets when new licences are granted. While the methodological approach described here is easily transferable to investigate the relationships elsewhere, we suggest some areas for improvement of future studies.

The Value of Statistical Life and the Economics of Landmine Clearance in Developing Countries.

This paper presents estimates of the value of statistical life (VSL) in rural Thailand using the contingent-valuation (CV) method. These estimates are applied to an economic analysis of landmine clearance. The estimated VSL of US$250 000 suggests that the value of lives saved from landmine clearance is at least an order of magnitude greater than the values used in existing studies.

Improved gapped alignment in BLAST.

Homology search is a key tool for understanding the role, structure, and biochemical function of genomic sequences. The most popular technique for rapid homology search is BLAST, which has been in widespread use within universities, research centers, and commercial enterprises since the early 1990s. In this paper, we propose a new step in the BLAST algorithm to reduce the computational cost of searching with negligible effect on accuracy. This new step-semigapped alignment-compromises between the efficiency of ungapped alignment and the accuracy of gapped alignment, allowing BLAST to accurately filter sequences with lower computational cost. In addition, we propose a heuristic-restricted insertion alignment-that avoids unlikely evolutionary paths with the aim of reducing gapped alignment cost with negligible effect on accuracy. Together, after including an optimization of the local alignment recursion, our two techniques more than double the speed of the gapped alignment stages in BLAST. We conclude that our techniques are an important improvement to the BLAST algorithm. Source code for the alignment algorithms is available for download at http://www.bsg.rmit.edu.au/iga/.