Aboriginal community controlled health organisations address health equity through action on the social determinants of health of Aboriginal and Torres Strait Islander peoples in Australia.

BACKGROUND: Indigenous populations globally are continually striving for better health and wellbeing due to experiencing significant health and social inequities. The social determinants of health are important contributors to health outcomes. Comprehensive primary health care that is governed and delivered by Indigenous people extends beyond the biomedical model of care to address the social determinants of health. Aboriginal Community Controlled Health Organisations (ACCHOs) are known to provide culturally informed, holistic health services that directly and indirectly address the social determinants of health. The range and extent of their activities in addressing the social determinants of health, however, is not well documented. METHODS: The most recent ACCHO annual reports were retrieved online or by direct correspondence. For coding consistency, a dictionary informed by the World Health Organization's Conceptual Framework for Action on the Social Determinants of Health was developed. A document and textual analysis of reports coded ACCHO activities and the determinants of health they addressed, including intermediary determinants, socio-economic position and/or socio-political context. Summary statistics were reported. Representative quotes illustrating the unique nature of ACCHO service provision in addressing the social determinants of health were used to contextualise the quantitative findings. RESULTS: Sixty-seven annual reports were collected between 2017 and 2018. Programs were delivered to population groups across the life span. Fifty three percent of reports identified programs that included work at the socio-political level and all annual reports described working to improve socioeconomic position and intermediary determinants of health through their activities. Culture had a strong presence in program delivery and building social cohesion and social capital emerged as themes. CONCLUSIONS: This study provides evidence of the considerable efforts of the ACCHO sector, as a primary health care provider, in addressing the social determinants of health and health inequity experienced by Indigenous communities. For the Aboriginal and Torres Strait Islander population, ACCHOs not only have an essential role in addressing immediate healthcare needs but also invest in driving change in the more entrenched structural determinants of health. These are important actions that are likely to have an accumulative positive effect in closing the gap towards health equity.

Nutrition and physical activity in the prevention and treatment of sarcopenia: systematic review.

This systematic review summarizes the effect of combined exercise and nutrition intervention on muscle mass and muscle function. A total of 37 RCTs were identified. Results indicate that physical exercise has a positive impact on muscle mass and muscle function in subjects aged 65 years and older. However, any interactive effect of dietary supplementation appears to be limited. INTRODUCTION: In 2013, Denison et al. conducted a systematic review including 17 randomized controlled trials (RCTs) to explore the effect of combined exercise and nutrition intervention to improve muscle mass, muscle strength, or physical performance in older people. They concluded that further studies were needed to provide evidence upon which public health and clinical recommendations could be based. The purpose of the present work was to update the prior systematic review and include studies published up to October 2015. METHODS: Using the electronic databases MEDLINE and EMBASE, we identified RCTs which assessed the combined effect of exercise training and nutritional supplementation on muscle strength, muscle mass, or physical performance in subjects aged 60 years and over. Study selection and data extraction were performed by two independent reviewers. RESULTS: The search strategy identified 21 additional RCTs giving a total of 37 RCTs. Studies were heterogeneous in terms of protocols for physical exercise and dietary supplementation (proteins, essential amino acids, creatine, ß-hydroxy-ß-methylbuthyrate, vitamin D, multi-nutrients, or other). In 79% of the studies (27/34 RCTs), muscle mass increased with exercise but an additional effect of nutrition was only found in 8 RCTs (23.5%). Muscle strength increased in 82.8% of the studies (29/35 RCTs) following exercise intervention, and dietary supplementation showed additional benefits in only a small number of studies (8/35 RCTS, 22.8%). Finally, the majority of studies showed an increase of physical performance following exercise intervention (26/28 RCTs, 92.8%) but interaction with nutrition supplementation was only found in 14.3% of these studies (4/28 RCTs). CONCLUSION: Physical exercise has a positive impact on muscle mass and muscle function in healthy subjects aged 60 years and older. The biggest effect of exercise intervention, of any type, has been seen on physical performance (gait speed, chair rising test, balance, SPPB test, etc.). We observed huge variations in regard to the dietary supplementation protocols. Based on the included studies, mainly performed on well-nourished subjects, the interactive effect of dietary supplementation on muscle function appears limited.

Approaches to improving the contribution of the nursing and midwifery workforce to increasing universal access to primary health care for vulnerable populations: a systematic review.

BACKGROUND: Despite considerable evidence showing the importance of the nursing and midwifery workforce, there are no systematic reviews outlining how these cadres are best supported to provide universal access and reduce health care disparities at the primary health care (PHC) level. This review aims to identify nursing and midwifery policy, staffing, education and training interventions, collaborative efforts and strategies that have improved the quantity, quality and relevance of the nursing and midwifery workforce leading to health improvements for vulnerable populations. METHODS: We undertook a structured search of bibliographic databases for peer-reviewed research literature using a focused review question and inclusion/exclusion criteria. The quality of retrieved papers was appraised using standard tools. The characteristics of screened papers were described, and a deductive qualitative content analysis methodology was applied to analyse the interventions and findings of included studies using a conceptual framework. RESULTS: Thirty-six papers were included in the review, the majority (25) from high-income countries and nursing settings (32). Eleven papers defined leadership and governance approaches that had impacted upon the health outcomes of disadvantaged groups including policies at the national and state level that had led to an increased supply and coverage of nursing and midwifery staff and scope of practice. Twenty-seven papers outlined human resource management strategies to support the expansion of nurse's and midwives' roles that often involved task shifting and task sharing. These included approaches to managing staffing supply, distribution and skills mix; workloads; supervision; performance management; and remuneration, financial incentives and staffing costs. Education and training activities were described in 14 papers to assist nurses and midwives to perform new or expanded roles and prepare nurses for inclusive practice. This review identified collaboration between nurses and midwives and other health providers and organizations, across sectors, and with communities and individuals that resulted in improved health care and outcomes. CONCLUSIONS: The findings of this review confirm the importance of a conceptual framework for understanding and planning leadership and governance approaches, management strategies and collaboration and education and training efforts to scale up and support nurses and midwives in existing or expanded roles to improve access to PHC for vulnerable populations.

Midwives' experiences of caring for women with female genital mutilation: Insights and ways forward for practice in Australia.

BACKGROUND: Female genital mutilation (FGM) has serious health consequences, including adverse obstetric outcomes and significant physical, sexual and psychosocial complications for girls and women. Migration to Australia of women with FGM from high-prevalence countries requires relevant expertise to provide women and girls with FGM with specialised health care. Midwives, as the primary providers of women during pregnancy and childbirth, are critical to the provision of this high quality care. AIM: To provide insight into midwives' views of, and experiences working with, women affected by FGM. METHODS: A descriptive qualitative study was undertaken using focus group discussions with midwives from four purposively selected antenatal clinics and birthing units in three hospitals in urban New South Wales. The transcripts were analysed thematically. FINDINGS: Midwives demonstrated knowledge and recalled skills in caring for women with FGM. However, many lacked confidence in these areas. Participants expressed fear and a lack of experience caring for women with FGM. Midwives described practice issues, including the development of rapport with women, working with interpreters, misunderstandings about the culture of women, inexperience with associated clinical procedures and a lack of knowledge about FGM types and data collection. CONCLUSION: Midwives require education, training and supportive supervision to improve their skills and confidence when caring for women with FGM. Community outreach through improved antenatal and postnatal home visitation can improve the continuity of care provided to women with FGM.

Auditory event-related potential changes in chronic occupational exposure to organophosphate pesticides.

OBJECTIVE: To determine whether chronic occupational exposure to organophosphates (OP) pesticides leads to cognitive impairment using event-related potentials (ERPs). METHODS: ERPs of 38 vegetable farmers applying OP pesticides and 35 controls were recorded using an auditory oddball paradigm. The N1, P2, N2 and P300 ERP components and the number of counting errors were compared between the groups. RESULTS: The farmers made significantly more counting errors than controls in the oddball task. The mixed model ANOVA of component latencies revealed a significant componentxgroup interaction, suggesting farmers had a greater delay in later ERP components. Intergroup comparisons of individual components showed significant delays in N2 and P300 latencies. Subsequent ANCOVA showed significant P300 delay even after adjusting for the latency of the preceding component, N2. Intergroup differences of P300 amplitudes were not significant, although there was limited evidence of a difference in scalp topography. CONCLUSION: Our findings indicate that chronic low-level occupational exposure to OP pesticides is associated with progressively increasing delay in successive ERP components, particularly P300. SIGNIFICANCE: Chronic exposure to OP pesticides may delay the neurophysiological processes underlying early stages of selective attention and late stages of sensory information processing that include stimulus evaluation and updating of working memory.

Seasonal differences in the secretion of luteinising hormone and prolactin in response to N-methyl-DL-aspartate in starlings (Sturnus vulgaris).

In birds, unlike mammals, seasonal changes in reproductive function are associated with marked changes in the amount of gonadotrophin-releasing hormone (GnRH) stored in the hypothalamus. Prolonged exposure to long photoperiods leads to photorefractoriness after the breeding season. Photorefractory birds have low hypothalamic concentrations of chicken GnRH-I (cGnRH-I). Exposure to short photoperiods results in renewed cGnRH-I synthesis and increased hypothalamic stores. Birds are then photosensitive and subsequent exposure to an increase in photoperiod results in increased cGnRH-I secretion and gonadal maturation. However, it is unclear whether the reverse is true at the time of gonadal regression during long photoperiods (i.e. that a decrease in GnRH-I synthesis precedes regression). Hypothalamic stores of cGnRH-I, and possibly therefore of releasable GnRH-I, decrease after regression. Single injections of the glutamate agonist N-methyl-DL-aspartate (NMA) were used as a probe to assess releasable stores of cGnRH-I in male starlings at four physiologically different reproductive stages. Treatment induced the greatest increase in luteinising hormone (LH) in photosensitive birds in January, and a slight increase in sexually mature birds in April. There was a slight but significant increase in June, immediately after testicular regression, but no increase in fully photorefractory birds in September. These data confirm that photorefractoriness is associated with a lack of releasable cGnRH-I, but that decreased synthesis of cGnRH-I is not the proximate cause of regression. There was an increase in prolactin in response to NMA at all times. The magnitude of the response was proportional to pre-treatment concentrations, with the greatest response in June. It is suggested that high circulating prolactin may fine-tune the timing of gonadal regression in advance of the inhibition of cGnRH-I synthesis.

Changes in basal hypothalamic chicken gonadotropin-releasing hormone-I and vasoactive intestinal polypeptide associated with a photo-induced cycle in gonadal maturation and prolactin secretion in intact and thyroidectomized starlings (Sturnus vulgaris).

Chicken gonadotropin-releasing hormone-I (GnRH-I) and the avian prolactin-releasing hormone, vasoactive intestinal polypeptide (VIP), were measured in the basal hypothalamus in male starlings during photo-induced gonadal growth and the subsequent development and maintenance of reproductive photorefractoriness. Comparisons were made with thyroidectomized birds, which maintain breeding condition irrespective of changes in photoperiod. In intact birds, basal hypothalamic GnRH-I increased four-fold after photostimulation and then decreased 115-fold over 12 weeks to values characteristic of long-term photorefractoriness. Pituitary and plasma prolactin increased after photostimulation, reaching peak values when the testes were regressing, and returned to low values in long-term photorefractory birds. Basal hypothalamic VIP did not change after photostimulation in intact birds. In photostimulated thyroidectomized birds, values for basal hypothalamic GnRH-I and VIP, and for pituitary and plasma prolactin, remained no different to those of nonphotostimulated intact birds. These observations confirm that reproductive photorefractoriness is related to a decrease in hypothalamic GnRH-I. However, photorefractoriness in terms of prolactin secretion is not similarly related to a decrease in basal hypothalamic VIP. The mechanisms responsible for the decrease in prolactin in long-term photorefractory birds and for the total lack of photoperiodic responses in thyroidectomized birds remain unresolved.

Domiciliary midwifery support in high-risk pregnancy incorporating telephonic fetal heart rate monitoring: a health technology randomized assessment.

We conducted a health technology assessment of the care of women with high-risk pregnancies in the South Wales valleys. Women in the control arm were intended to receive conventional care with standard midwifery visits. Women in the intervention arm received additional or longer visits and domiciliary fetal heart rate telemonitoring. Eighty-one mothers were randomized. There were significant differences in midwifery intervention resources between domiciliary and control groups, with the former receiving a mean of 3.7 visits lasting 33.5 min, compared with 1.4 visits lasting 12.8 min for the latter. There were slightly more spontaneous labours and fewer Caesarean sections in the domiciliary group. Maternal satisfaction and anxiety were high in both groups. Domiciliary care increased the service costs by 21.02 Pounds per woman in terms of extra midwife travel and visiting time, and by a further 18.38 Pounds per woman in home monitoring equipment costs. This, however, was more than offset by health service savings from fewer clinic visits (35.60 Pounds) and fewer clinic ultrasound scans (9.01 Pounds). Adding the reductions in lost productivity to women and their partners (34.51 Pounds) suggests that domiciliary care was cheaper than conventional care, even if it did not greatly reduce inpatient days (a reduction nonetheless saving 184.24 Pounds). While clinical processes were similar in both groups, there were useful practical advantages and savings for patients and the health service from the domiciliary intervention.

Control of luteinizing hormone and prolactin secretion in birds.

In birds, the secretion of luteinizing hormone (LH) and prolactin is controlled by the releasing hormones, gonadotrophin releasing hormone-I (GnRH-I) and vasoactive intestinal polypeptide (VIP), respectively. The secretion of LH is depressed and the secretion of prolactin is at its highest, during incubation/brooding young and during the development of reproductive photorefractoriness. In incubating domestic chickens, decreased LH and increased prolactin secretion are correlated with decreased hypothalamic GnRH-I mRNA and increased hypothalamic VIP mRNA. Increased plasma prolactin contributes to the suppression of LH secretion in incubating poultry, possibly acting at the levels of the hypothalamus and the anterior pituitary gland. During the development of photorefractoriness, decreased plasma LH and increased plasma prolactin are correlated with decreased hypothalamic GnRH-I and increased hypothalamic VIP. In birds exposed to seasonal changes in daylength, the seasonally maximal concentrations of plasma prolactin associated with the development of photorefractoriness can be explained, in part, by the saturation daylength for photoinduced prolactin release being reached in late spring/mid summer. During the development of photorefractoriness, high concentrations of plasma prolactin play a role in ensuring the rapid regression of the gonads but are not essential for the maintenance of the condition.

Thyroidectomy of house sparrows (Passer domesticus) prevents photo-induced testicular growth but not the increased hypothalamic gonadotrophin-releasing hormone.

Thyroidectomy of starlings (Sturnus vulgaris) prevents the decrease in hypothalamic gonadotrophin-releasing hormone (GnRH) which normally occurs at the onset of photorefractoriness. To extend this observation to another species, changes in testicular mass, bill colour, moult, and hypothalamic GnRH content were monitored in photostimulated and nonphotostimulated intact and thyroidectomized house sparrows (Passer domesticus). Photostimulated intact birds rapidly increased testicular mass and GnRH. Later, testicular mass and GnRH decreased, and birds moulted, as they became photorefractory. Nonphotostimulated intact birds showed an increase in testicular mass and GnRH. Neither photostimulated nor nonphotostimulated thyroidectomized birds showed a marked increase in testicular mass, but both showed an increase in GnRH. Photostimulated thyroidectomized birds showed no subsequent decrease in GnRH and they did not moult. It is suggested that in this species, thyroidectomy inhibits the release of GnRH as well as preventing the downregulation of GnRH synthesis normally associated with the development of photorefractoriness.

Changes in gonadotrophin-releasing hormone (GnRH-I) in the pre-optic area and median eminence of starlings (Sturnus vulgaris) during the recovery of photosensitivity and during photostimulation.

Changes in GnRH-I in the pre-optic (POA) and medio-basal (MBH) areas of the hypothalamus and in pituitary and plasma LH were measured in starlings (Sturnus vulgaris) during the recovery of photosensitivity under short days, and following photostimulation at various times during the recovery of photosensitivity. During exposure to short days there was a significant increase in GnRH-I in the POA, with the first detectable increase after only 10 days. There was no increase in GnRH-I in the MBH or in pituitary or plasma LH. In birds photostimulated after 10 short days, there was an increase in GnRH-I in the POA, but this was no greater than that in birds remaining under short days. There was no increase in GnRH-I in the MBH or in plasma LH. Photostimulation after 20 short days caused an immediate increase in GnRH-I in the POA, delayed increase in GnRH-I in the MBH, but no increase in plasma LH. Photostimulation after 30 short days caused an immediate increase in GNRH-I in the POA and the MBH and in plasma LH. The results show that the recovery of photosensitivity is gradual; the first measurable change occurs in the POA, consistent with photosensitivity being due to renewed GnRH-I synthesis. The effects of photostimulation increase, both in magnitude and in terms of how far 'downstream' of the POA changes are apparent, as photosensitivity is gradually restored. The results support the hypothesis that daylength has a dual role, controlling both synthesis and secretion of GnRH.

Calcium channel blocking drug overdose: an Australian series.

1. A descriptive case study of calcium channel-blocking drug (CCB) overdoses in the Hunter Region of NSW was performed to analyse the in-hospital morbidity and mortality of CCB drug overdoses in an Australian population. 2. The patients were admitted to major hospitals within the Hunter Region and treated initially with gastrointestinal decontamination, including the use of oral activated charcoal. Further management was required in most cases and included intravenous calcium, atropine and inotropic support. 3. Of the 15 CCB overdoses, four patients died. Noncardiogenic pulmonary oedema occurred in two other cases. Cardiac conduction defects occurred in 11 cases. 4. Atropine was found to be effective only after intravenous calcium had been administered. 5. Overdose with slow-release verapamil required prolonged treatment with intravenous calcium salts. 6. Overdose with verapamil or diltiazem in doses greater than 300 mg carries a significant risk of death and potentially life threatening arrhythmias occur with lower doses. 7. Recommended initial management includes early, effective gastrointestinal decontamination. High dose intravenous calcium salts should be given to reverse hypotension and bradycardia. Atropine and inotropic support are frequently required.

Slow-release verapamil poisoning. Use of polyethylene glycol whole-bowel lavage and high-dose calcium.

OBJECTIVE: To present three cases of slow-release verapamil poisoning that demonstrate the prolonged absorption of the drug and the role of polyethylene glycol and high-dose calcium in management. CLINICAL FEATURES: Three patients with slow-release verapamil poisoning are presented. An 18-year-old woman took 2.3 g and developed hypotension and bradyarrhythmias 18 hours after ingestion, despite gastric lavage and administration of charcoal at three hours. A 23-year-old woman took 4.8 g and presented two hours later clinically unaffected. A 44-year-old woman presented 24 hours after taking 15-20 g. She had a systolic blood pressure of 50 mmHg, no measurable diastolic blood pressure and bradyarrhythmias. INTERVENTION AND OUTCOME: Case 1 responded to administration of 30 g of calcium and fluids intravenously. Case 2 was given polyethylene glycol on admission which resulted in passage of a tablet bezoar and no toxicity. Polyethylene glycol was ineffective in Case 3. She responded initially to high doses of calcium and other treatments, but subsequently died of hypotension and cardiac conduction block 39 hours after the overdose. CONCLUSION: The severity of poisoning with slow-release verapamil warrants aggressive pre-emptive treatment. Polyethylene glycol should be used routinely irrespective of the clinical state. High doses of calcium may be required to treat conduction block and hypotension.

Efficacy of traditional Chinese herbal therapy in adult atopic dermatitis.

There has been considerable interest in traditional Chinese herbal therapy (TCHT) as a new treatment for atopic dermatitis. To establish the efficacy and safety of this treatment, a daily decoction of a formula containing ten herbs that has been found to be beneficial in open studies was tested in a double-blind placebo-controlled study. 40 adult patients with longstanding, refractory, widespread, atopic dermatitis were randomised into two groups to receive 2 months' treatment of either the active formulation of herbs (TCHT) or placebo herbs, followed by a crossover to the other treatment after a 4-week washout period. The main outcome measures were extent and severity of erythema and surface damage as judged by standardised body scores. The patients' own assessments of the overall response to treatment were also sought. The geometric mean score for erythema at the end of active treatment was 12.6 (95% confidence interval [CI] 5.9 to 22.0) and at the end of the placebo phase was 113 (65 to 180). The geometric mean score for surface damage was 11.3 (5.8 to 21.8) and 111.0 (68 to 182), respectively. The 95% CI for the mean geometric ratio for the two values with active treatment was 0.04 to 0.22 for erythema (p less than 0.0005) and 0.04 to 0.27 for surface damage (p less than 0.0005). Of the 31 patients who completed the study and expressed a preference, 20 preferred that phase of the trial in which they received TCHT whereas 4 patients preferred placebo (p less than 0.02). There was a subjective improvement in itching (p less than 0.001) and sleep (p less than 0.078) during the TCHT treatment phase. No side-effects were reported by the patients although many commented on the unpalatability of the decoction. TCHT seems to benefit patients with atopic dermatitis. Palatability of the treatment needs to be improved and its safety assured.

Bone mineral density (BMD) in patients with lymphoma: the effects of chemotherapy, intermittent corticosteroids and premature menopause.

Young women with a chemotherapy-induced early menopause are theoretically at considerable risk of developing post-menopausal osteoporosis with problems developing earlier and more severely. In this study bone mineral density (BMD) measurements were made, using a dual-energy X-ray absorptiometer (DXA), at the spine and hip of 50 young women who had been treated for lymphoma, 24 of whom were post-menopausal and 78, healthy age-matched controls. On analysis of the results, there was no significant difference between the control group and the 26 post-treatment, pre-menopausal patients, but the BMD levels were significantly lower than the controls in the post-menopausal group particularly in 16 patients who had been menopausal greater than 18 months. The results confirm that these young women with treatment-induced premature menopause are at considerable risk of developing osteoporotic problems. Early recognition of this is important so that preventative measures with hormone replacement therapy can be initiated where this is safely possible. The results also indicate that chemotherapy for lymphoma (cytotoxics and high dose intermittent steroids), are unlikely to contribute directly to the lowering of the BMD of these patients.

Thapsigargin, a tumor promoter, discharges intracellular Ca2+ stores by specific inhibition of the endoplasmic reticulum Ca2(+)-ATPase.

Thapsigargin, a tumor-promoting sesquiterpene lactone, discharges intracellular Ca2+ in rat hepatocytes, as it does in many vertebrate cell types. It appears to act intracellularly, as incubation of isolated rat liver microsomes with thapsigargin induces a rapid, dose-dependent release of stored Ca2+. The thapsigargin-releasable pool of microsomal Ca2+ includes the pools sensitive to inositol 1,4,5-trisphosphate and GTP. Thapsigargin pretreatment of microsomes blocks subsequent loading with 45Ca2+, suggesting that its target is the ATP-dependent Ca2+ pump of endoplasmic reticulum. This hypothesis is strongly supported by the demonstration that thapsigargin causes a rapid inhibition of the Ca2(+)-activated ATPase activity of rat liver microsomes, with an identical dose dependence to that seen in whole cell or isolated microsome Ca2+ discharge. The inhibition of the endoplasmic reticulum isoform of the Ca2(+)-ATPase is highly selective, as thapsigargin has little or no effect on the Ca2(+)-ATPases of hepatocyte or erythrocyte plasma membrane or of cardiac or skeletal muscle sarcoplasmic reticulum. These results suggest that thapsigargin increases the concentration of cytosolic free Ca2+ in sensitive cells by an acute and highly specific arrest of the endoplasmic reticulum Ca2+ pump, followed by a rapid Ca2+ leak from at least two pharmacologically distinct Ca2+ stores. The implications of this mechanism of action for the application of thapsigargin in the analysis of Ca2+ homeostasis and possible forms of Ca2+ control are discussed.

Sexual maturation in starlings raised on long or short days: changes in hypothalamic gonadotrophin-releasing hormone and plasma LH concentrations.

Is the extended prepubertal period which occurs in most birds due to a juvenile photorefractoriness analogous to photorefractoriness in adults? Starlings were taken from nest boxes 4 days after hatching and hand-reared on long days or short days. In females on long days, hypothalamic gonadotrophin-releasing hormone (GnRH) content and plasma LH concentration remained low. In intact males on long days, plasma LH remained low and the testes remained small, and in castrated birds, plasma LH also remained low. In females reared on short days, hypothalamic GnRH content began to increase dramatically from 4 weeks of age and plasma LH increased from 6 weeks of age. In intact males on short days, there was a slight increase in plasma LH and testicular size, and in castrated males, plasma LH increased markedly from six weeks of age. All birds on long days moulted into adult plumage, whereas those on short days retained juvenile plumage. The changes in birds reared on short days were similar to those found when photorefractory adult birds are transferred to short days. This adds to the evidence that juvenile photorefractoriness is analogous to photorefractoriness in adults, and therefore that the seasonal termination of photorefractoriness is an annual puberty. However, the responses to short days occur later in birds raised on short days than in older birds transferred to short days, which suggests either that short day-induced changes occur more slowly in young birds, or that birds only respond to short days after a certain age.

A randomised study of a domiciliary antenatal care scheme: maternal psychological effects.

The Cardiff Integrated Antenatal Care Scheme (CIACS) places emphasis on home-centred care for selected women with a high-risk pregnancy. The Scheme is intended to make better use of midwifery and obstetric resources, and it provides a new type of care where close surveillance is required. A randomised controlled trial was undertaken in which anxiety levels were compared between two groups of women with an identified high-risk pregnancy. Sixty-five women were eligible for entry to the study. Five refused randomisation and 60 were randomised 2:1 either to care under the CIAC Scheme (domiciliary group n = 40) or to conventional hospital antenatal care (conventional group n = 17). Zung depression and STAI 'trait' levels conducted at weekly intervals were similar in both groups whilst 'state' levels were 34.05 (SD 9.24) in the domiciliary group and 41.05 (SD 9.93) in the conventional care group (P less than 0.01). It is suggested that the observed difference is due to the greater security provided by the home environment coupled with individual support from a midwife.