ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes: protocol for the ELECTRIC randomised trial.

BACKGROUND: Urinary incontinence (UI) is highly prevalent in nursing and residential care homes (CHs) and profoundly impacts on residents' dignity and quality of life. CHs predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous posterior tibial nerve stimulation (TPTNS) is a non-invasive, safe and low-cost intervention with demonstrated effectiveness for reducing UI in adults. However, the effectiveness of TPTNS to treat UI in older adults living in CHs is not known. The ELECTRIC trial aims to establish if a programme of TPTNS is a clinically effective treatment for UI in CH residents and investigate the associated costs and consequences. METHODS: This is a pragmatic, multicentre, placebo-controlled, randomised parallel-group trial comparing the effectiveness of TPTNS (target n = 250) with sham stimulation (target n = 250) in reducing volume of UI in CH residents. CH residents (men and women) with self- or staff-reported UI of more than once per week are eligible to take part, including those with cognitive impairment. Outcomes will be measured at 6, 12 and 18 weeks post randomisation using the following measures: 24-h Pad Weight Tests, post void residual urine (bladder scans), Patient Perception of Bladder Condition, Minnesota Toileting Skills Questionnaire and Dementia Quality of Life. Economic evaluation based on a bespoke Resource Use Questionnaire will assess the costs of providing a programme of TPTNS. A concurrent process evaluation will investigate fidelity to the intervention and influencing factors, and qualitative interviews will explore the experiences of TPTNS from the perspective of CH residents, family members, CH staff and managers. DISCUSSION: TPTNS is a non-invasive intervention that has demonstrated effectiveness in reducing UI in adults. The ELECTRIC trial will involve CH staff delivering TPTNS to residents and establish whether TPTNS is more effective than sham stimulation for reducing the volume of UI in CH residents. Should TPTNS be shown to be an effective and acceptable treatment for UI in older adults in CHs, it will provide a safe, low-cost and dignified alternative to the current standard approach of containment and medication. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03248362. Registered on 14 August 2017. ISRCTN, ISRCTN98415244. Registered on 25 April 2018. https://www.isrctn.com/.

Addressing the social determinants of health at the local level: Opportunities and challenges.

AIMS: The gradient in health inequalities reflects a relationship between health and social circumstance, demonstrating that health worsens as you move down the socio-economic scale. For more than a decade, the Norwegian National government has developed policies to reduce social inequalities in health by levelling the social gradient. The adoption of the Public Health Act in 2012 was a further movement towards a comprehensive policy. The main aim of the act is to reduce social health inequalities by adopting a Health in All Policies approach. The municipalities are regarded key in the implementation of the act. The SODEMIFA project aimed to study the development of the new public health policy, with a particular emphasis on its implementation in municipalities. METHODS: In the SODEMIFA project, a mixed-methods approach was applied, and the data consisted of surveys as well as qualitative interviews. The informants were policymakers at the national and local level. RESULTS: Our findings indicate that the municipalities had a rather vague understanding of the concept of health inequalities, and even more so, the concept of the social gradient in health. The most common understanding was that policy to reduce social inequalities concerned disadvantaged groups. Accordingly, policies and measures would be directed at these groups, rather than addressing the social gradient. CONCLUSIONS: A movement towards an increased understanding and adoption of the new, comprehensive public health policy was observed. However, to continue this process, both local and national levels must stay committed to the principles of the act.

Work engagement: a practical measure for workplace health promotion?

The objectives of this study were to investigate whether psychological job demands, personal control and social support affect the negative health measure of depression differently than the positive measure of work engagement and to investigate whether work engagement mediates the effects of job demands and resources on the level of depression. We discuss the implications of using engagement as an outcome measure in workplace health promotion. We performed a cross-sectional questionnaire study among a general working population in Norway (n = 605). In the multivariate analysis, high psychological job demands as well as high control and social support correlated significantly with high work engagement. High demands as well as low control and social support correlated significantly with high levels of depression. When we included engagement as an independent variable together with demands, control and social support in the multivariate analysis, the positive correlation between demands and depression remained as well as the significant correlations between the level of depression and control and social support became non-significant. This indicates that engagement mediates the effects of control and social support on the level of depression. Encouraging enterprises to improve engagement in addition to focusing on preventing diseases may be worthwhile in workplace health promotion. Promoting engagement may have more positive organizational effects than a more traditional disease prevention focus, because engagement is contagious and closely related to good work performance and motivation.

Conservative treatment for urinary incontinence in Men After Prostate Surgery (MAPS): two parallel randomised controlled trials.

OBJECTIVE: To determine the clinical effectiveness and cost-effectiveness of active conservative treatment, compared with standard management, in regaining urinary continence at 12 months in men with urinary incontinence at 6 weeks after a radical prostatectomy or a transurethral resection of the prostate (TURP). BACKGROUND: Urinary incontinence after radical prostate surgery is common immediately after surgery, although the chance of incontinence is less after TURP than following radical prostatectomy. DESIGN: Two multicentre, UK, parallel randomised controlled trials (RCTs) comparing active conservative treatment [pelvic floor muscle training (PFMT) delivered by a specialist continence physiotherapist or a specialist continence nurse] with standard management in men after radial prostatectomy and TURP. SETTING: Men having prostate surgery were identified in 34 centres across the UK. If they had urinary incontinence, they were invited to enroll in the RCT. PARTICIPANTS: Men with urinary incontinence at 6 weeks after prostate surgery were eligible to be randomised if they consented and were able to comply with the intervention. INTERVENTIONS: Eligible men were randomised to attend four sessions with a therapist over a 3-month period. The therapists provided standardised PFMT and bladder training for male urinary incontinence and erectile dysfunction. The control group continued with standard management. MAIN OUTCOME MEASURES: The primary outcome of clinical effectiveness was urinary incontinence at 12 months after randomisation, and the primary measure of cost-effectiveness was incremental cost per quality-adjusted life-year (QALY). Outcome data were collected by postal questionnaires at 3, 6, 9 and 12 months. RESULTS: Within the radical group (n = 411), 92% of the men in the intervention group attended at least one therapy visit and were more likely than those in the control group to be carrying out any PFMT at 12 months {adjusted risk ratio (RR) 1.30 [95% confidence interval (CI) 1.09 to 1.53]}. The absolute risk difference in urinary incontinence rates at 12 months between the intervention (75.5%) and control (77.4%) groups was -1.9% (95% CI -10% to 6%). NHS costs were higher in the intervention group [£ 181.02 (95% CI £ 107 to £ 255)] but there was no evidence of a difference in societal costs, and QALYs were virtually identical for both groups. Within the TURP group (n = 442), over 85% of men in the intervention group attended at least one therapy visit and were more likely to be carrying out any PFMT at 12 months after randomisation [adjusted RR 3.20 (95% CI 2.37 to 4.32)]. The absolute risk difference in urinary incontinence rates at 12 months between the intervention (64.9%) and control (61.5%) groups for the unadjusted intention-to-treat analysis was 3.4% (95% CI -6% to 13%). NHS costs [£ 209 (95% CI £ 147 to £ 271)] and societal costs [£ 420 (95% CI £ 54 to £ 785)] were statistically significantly higher in the intervention group but QALYs were virtually identical. CONCLUSIONS: The provision of one-to-one conservative physical therapy for men with urinary incontinence after prostate surgery is unlikely to be effective or cost-effective compared with standard care that includes the provision of information about conducting PFMT. Future work should include research into the value of different surgical options in controlling urinary incontinence.

Predicting response to regulatory change in the small group health insurance market: the case of association health plans and HealthMarts.

Lack of health insurance continues to be a concern for many people, even among those who are employed, and employees of small firms are much less likely to be insured than employees of larger firms. For several years, the U.S. Congress has considered legislation that would establish two new vehicles for offering health insurance coverage to small employers: association health plans (AHPs) and HealthMarts. In this paper, we present a model for estimating the impact the new entities would have on coverage and premiums in the small group health insurance market. The model produces a range of estimates based on assumptions, among others, about demand for insurance among small firms and their willingness to switch to less expensive, less generous benefit plans. We estimate that approximately 4.6 million people would obtain coverage through AHPs and HealthMarts, but fewer than half a million of them would be newly insured (based on 1999 population figures). Premiums would increase slightly for firms that continued to purchase coverage in the traditional market.

A novel nonpeptide HIV-1 protease inhibitor: elucidation of the binding mode and its application in the design of related analogs.

HIV-1 protease has been identified as a significant target enzyme in AIDS research. While numerous peptide-derived inhibitors have been described, the identification of a nonpeptide inhibitor remains an important goal. Using an HIV-1 protease mass screening technique, 4-hydroxy-3-(3-phenoxypropyl)-2H-1-benzopyran-2-one (1) was identified as a nonpeptide competitive inhibitor of the enzyme. Employing a Monte Carlo-based docking procedure, the coumarin was docked in the active site of the enzyme, revealing a binding mode that was later confirmed by the X-ray crystal analysis. Several analogs were prepared to test the binding interactions and improve the overall binding affinity. The most active compound in the study was 4,7-dihydroxy-3-[4-(2-methoxyphenyl)butyl]-2H-1-benzopyran-2-one (31).