Anti-stigma training and positive changes in mental illness stigma outcomes in medical students in ten countries: a mediation analysis on pathways via empathy development and anxiety reduction.

PURPOSE: Studies of mental illness stigma reduction interventions have been criticised for failing to evaluate behavioural outcomes and mechanisms of action. This project evaluates training for medical students entitled 'Responding to Experienced and Anticipated Discrimination' (READ), developed to focus on skills in addition to attitudes and knowledge. We aimed to (i) evaluate the effectiveness of READ with respect to knowledge, attitudes, and clinical communication skills in responding to mental illness-related discrimination, and (ii) investigate whether its potential effectiveness was mediated via empathy or/and intergroup anxiety. METHODS: This is an international multisite non-randomised pre- vs post-controlled study. Eligible medical students were currently undertaking their rotational training in psychiatry. Thirteen sites across ten countries (n = 570) were included in the final analysis. RESULTS: READ was associated with positive changes in knowledge (mean difference 1.35; 95% CI 0.87 to 1.82), attitudes (mean difference - 2.50; 95% CI - 3.54 to - 1.46), skills (odds ratio 2.98; 95% CI 1.90 to 4.67), and simulated patient perceived empathy (mean difference 3.05; 95% CI 1.90 to 4.21). The associations of READ with knowledge, attitudes, and communication skills but not with simulated patient perceived empathy were partly mediated through student reported empathy and intergroup anxiety. CONCLUSION: This is the first study to identify mediating effects of reduced intergroup anxiety and increased empathy in an evaluation of anti-stigma training that includes behavioural measures in the form of communication skills and perceived empathy. It shows the importance of both mediators for all of knowledge, skills, and attitudes, and hence of targeting both in future interventions.

Patient Journey Champions: A project to facilitate delivery of effective board rounds for inpatients, aiding flow through the hospital.

Our quality improvement project was designed to enable delivery of high-quality board rounds across the hospital with a view to improving patient flow. We designed a Patient Journey Champion campaign to enable this. As part of our campaign, we ran sessions with junior doctors. These comprised education on the structure of a board round, giving them an insight into the bigger picture on patient flow and eventually aiming to empower them to lead an effective board round on their respective wards, where they would act as 'Patient Journey Champions'. Following the workshops, we audited the quality of board rounds and compared it with baseline. The quality was measured against the hospital standard operating procedure. We noticed an improvement in the quality of board rounds and also a positive effect on length of stay on the acute admissions ward. We anticipate a continuing trend of improvement as this intervention is rolled out across more doctors and other staff groups, although this relies on the need to involve doctors in board rounds and empowering them with the appropriate skills. Simultaneously, work is now being undertaken by matrons of respective wards to upskill ward nurses and other allied healthcare professionals to aid delivery of improved board rounds.

Responding to experienced and anticipated discrimination (READ): anti -stigma training for medical students towards patients with mental illness - study protocol for an international multisite non-randomised controlled study.

BACKGROUND: Stigma and discrimination are a significant public health concern and cause great distress to people with mental illness. Healthcare professionals have been identified as one source of this discrimination. In this article we describe the protocol of an international, multisite controlled study, evaluating the effectiveness of READ, an anti-stigma training for medical students towards patients with mental illness. READ aims to improve students' ability to minimise perceived discriminatory behaviours and increase opportunities for patients, therefore developing the ability of future doctors to address and challenge mental illness related discrimination. READ includes components that medical education research has shown to be effective at improving attitudes, beliefs and understanding. METHODS/DESIGN: READ training was developed using evidence based components associated with changes in stigma related outcomes. The study will take place in multiple international medical schools across high, middle and low income countries forming part of the INDIGO group network, with 25 sites in total. Students will be invited to participate via email from the lead researcher at each site during their psychiatry placement, and will be allocated to an intervention or a control arm according to their local teaching group at each site. READ training will be delivered solely to the intervention arm. Standardised measures will be used to assess students' knowledge, attitudes and skills regarding discrimination in both the intervention and control groups, at baseline and at follow up immediately after the intervention. Statistical analyses of individual-level data will be conducted using random effects models accounting for clustering within sites to investigate changes in mean or percentages of each outcome, at baseline and immediately after the intervention. DISCUSSION: This is the first international study across high, middle and low income countries, which will evaluate the effectiveness of training for medical students to respond effectively to patients' experiences and anticipation of discrimination. The results will promote implementation of manualised training that will help future doctors to reduce the impact of mental illness related discrimination on their patients. Limitations of the study are also discussed.

Novel Method for Assessment of His Bundle Pacing Morphology Using Near Field and Far Field Device Electrograms.

BACKGROUND: The 12-lead ECG is considered the gold standard to differentiate between selective (S), nonselective (NS) His bundle pacing (HBP), and right ventricular septal capture in routine clinical practice. We sought to assess the utility of device EGM recordings as a tool to identify the type of HBP morphology. METHODS: One hundred forty-eight consecutive patients underwent HBP with a 3830 Select Secure lead (Medtronic, Inc) at 3 centers between October 2016 and October 2017. The near field V-EGM morphology (NF EGM), near field V-EGM time to peak (NFTime to peak), and far-field EGM QRS duration (QRSd) were recorded while pacing the His lead with simultaneous 12-lead ECG rhythm strips. RESULTS: Indications for HBP were sinus node dysfunction, atrioventricular conduction disease, and cardiac resynchronization therapy in 68 (46%), 56 (38%), and 24 (16%) patients, respectively. Baseline QRSd was 108±38 ms with QRSd >120 ms in 57 (39%) patients (27 right bundle branch block, 18 left bundle branch block, and 12 intraventricular conduction delay). S-HBP was noted in 54 (36%) patients. A positive NFEGM and NFTime to peak >40 ms were highly sensitive (94% and 93%, respectively) and specific (90% and 94%) for S-HBP irrespective of baseline QRSd. All 3 parameters (+NFEGM, NFTime to peak >40 ms, and far-field EGM QRSd <120 ms) had high negative predictive value (97%, 95%, and 92%). A novel device-based algorithm for S-HBP was proposed. EGM transitions correlated with ECG transitions during threshold testing and can help accurately differentiate between S-HBP, NS-HBP, and right ventricular septal pacing with a cumulative positive predictive value of 91% (positive predictive value =100% in patients with baseline QRSd <120 ms). CONCLUSIONS: We propose a novel and simple criteria for accurate differentiation between S-HBP, NS-HBP, and right ventricular septal capture morphologies by careful analysis of device EGMs alone. This study paves the way for future studies to assess autocapture algorithms for devices with HBP.

Novel Signal Noise Reduction Method through Cluster Analysis, Applied to Photoplethysmography.

Physiological signals can often become contaminated by noise from a variety of origins. In this paper, an algorithm is described for the reduction of sporadic noise from a continuous periodic signal. The design can be used where a sample of a periodic signal is required, for example, when an average pulse is needed for pulse wave analysis and characterization. The algorithm is based on cluster analysis for selecting similar repetitions or pulses from a periodic single. This method selects individual pulses without noise, returns a clean pulse signal, and terminates when a sufficiently clean and representative signal is received. The algorithm is designed to be sufficiently compact to be implemented on a microcontroller embedded within a medical device. It has been validated through the removal of noise from an exemplar photoplethysmography (PPG) signal, showing increasing benefit as the noise contamination of the signal increases. The algorithm design is generalised to be applicable for a wide range of physiological (physical) signals.

Exploring experiences of and attitudes towards mental illness and disclosure amongst health care professionals: a qualitative study.

BACKGROUND: The literature suggests that many health professionals hold stigmatising attitudes towards those with mental illness and that this impacts on patient care. Little attention has been given to how these attitudes affect colleagues with a mental illness. Current research demonstrates that stigma and discrimination are common in the UK workplace and impact on one's decision to disclose mental illness. AIMS: This study aims to explore health professionals' experiences of and attitudes towards mental illness and disclosure in the workplace. METHODS: This qualitative study involved semi-structured interviews with 24 health professionals employed by an NHS (National Health Service) trust. 13 of these worked in mental health, and 11 in other health fields. Interviews were transcribed and thematic analysis was used to identify themes. RESULTS: Five key themes were identified from the data: personal experiences and their effect in changing attitudes; perceived stigmatising views of mental illness in other staff members; hypothetical disclosure: factors affecting one's decision; attitudes towards disclosure; support in the workplace after disclosure; and, applying only to those working outside of the mental health field, mental illness is not talked about. The results indicated that participants had a great deal of experience with colleagues with a mental illness and that support in the workplace for such illnesses is variable. Attitudes of participating health professionals towards colleagues with a mental illness appeared to be positive, however, they did report that other colleagues held negative attitudes. Deciding to disclose a mental illness was a carefully thought out decision with a number of advantages and disadvantages noted. In particular, it was found that health professionals' fear stigma and discrimination from colleagues and that this would dissuade participants from disclosing a mental illness. CONCLUSION: In many respects, this research supports the findings in other workplaces. Such findings need to be investigated further to identify the degree to which these experiences and attitudes can be applied to other health professionals in other healthcare settings to determine what intervention is necessary. Importantly, this study has also indicated that the level of support available to NHS health professionals with a mental illness is variable, suggesting the need to identify and replicate positive practice.

Characteristics of an Effective International Humanitarian Assistance: A Systematic Review.

INTRODUCTION: The objective of this study is to identify the effectiveness characteristics, review the definition of them, and develop a conceptual mapping of existing domains in the field of International Humanitarian Assistance (IHA). METHODS: We conducted a systematic review and searched the major databases (Science Direct, Scopus, Springer and Pubmed) and grey literature, including references of potentially eligible articles and conference proceedings through March 2015. Articles were included if they focused on IHA effectiveness. Reviewers independently identified the eligible studies and extracted data. RESULTS: 10 studies were included and 48 characteristics were identified. There is a lack of scientific studies and agreement on the characteristics of IHA effectiveness.  CONCLUSION: This study could be the step toward an understanding of IHA effectiveness characteristics and its definitions with the findings making a base line for more research in this area.

Inhibition of iron-catalyzed oxidations by attainable uric acid and ascorbic acid levels: therapeutic implications for Alzheimer's disease and late cognitive impairment.

BACKGROUND: Alzheimer's disease (AD) has become one of the major health problems of the developed world. Previous studies have shown that oxidant-induced changes occur in cerebral tissue in AD and in late-onset amnestic mild cognitive impairment. The oxidative damage begins early and involves free radical-mediated effects that cause lipid peroxidations and oxidative protein and nucleic acid damages which begin before the cardinal neuropathologic manifestations. Impaired cerebral iron homeostasis and iron accumulation are postulated to be primary and seminal in the pathogenesis. OBJECTIVE: To demonstrate that the Fenton reaction involving hydrogen peroxide and iron at very low concentrations as has been found in human plasma and cerebrospinal fluid may produce promptly oxidations which may be inhibited by preventive use of uric acid and ascorbic acid as hydrophilic antioxidants. METHODS: A photometric study in vitro at physiologic pH using concentrations of uric acid and ascorbic acid readily attainable in human extracellular fluids. RESULTS: Uric acid levels of 0.5 and 6.0 mg/dl (below the saturation level for urate precipitation) and ascorbic acid at a level readily attainable in blood plasma inhibited significantly and completely, respectively, oxidations caused by reactions of 20 microM concentrations of hydrogen peroxide with free bivalent iron at 9.8 muM and at a low hemoglobin level of 12 mg/dl of saline. CONCLUSION: Results suggest that supplemental use orally of ascorbic acid combined with use of metabolic precursor to uric acid, like inosine or hypoxanthine, has the potential for preventing or attenuating the progression of AD and amnestic mild cognitive impairment.

L-citrulline reduces time to exhaustion and insulin response to a graded exercise test.

PURPOSE: Oral L-arginine supplementation has been shown to improve treadmill time to exhaustion and resting insulin sensitivity in individuals with peripheral vascular disease and type 2 diabetes, respectively. Furthermore, L-citrulline supplementation increases plasma L-arginine concentration to a level higher than that achieved by oral L-arginine supplementation. The purpose of this investigation was therefore to determine whether time to exhaustion during a graded treadmill test, as well as plasma insulin and glucose profiles, could be improved with oral L-citrulline supplementation in healthy individuals. METHODS: Seventeen young (18-34 yr), healthy male and female volunteers performed incremental treadmill tests to exhaustion following either placebo or citrulline ingestion (3 g 3 h before test, or 9 g over 24 h prior to testing). RESULTS: Steady-state submaximal respiratory exchange ratio and VO2max were not significantly different between placebo and citrulline trials. Treadmill time to exhaustion was lower following citrulline ingestion than during placebo trials (888.2 +/- 17.7 vs 895.4 +/- 17.9 s; P < 0.05; N = 17), which was accompanied by a higher rating of perceived exertion during exercise in the L-citrulline compared with the placebo condition. There was also an increase in plasma insulin in response to this high-intensity exercise in the placebo, but not in the L-citrulline, condition (P < 0.05). CONCLUSIONS: It can be concluded that, contrary to the hypothesized improvement in treadmill time following L-citrulline ingestion, there is a reduction in treadmill time following L-citrulline ingestion over the 24 h prior to testing. The normal response of increased plasma insulin following high-intensity exercise is also not present in the L-citrulline condition, indicating that L-citrulline ingestion may reduce nitric oxide-mediated pancreatic insulin secretion or increased insulin clearance.

Simplified method to assay total plasma peroxidase activity and ferriheme products in sickle cell anemia, with initial results in assessing clinical severity in a trial with citrulline therapy.

A method using dianisidine is described to measure promptly the total plasma peroxidase (POX) activity of methemoglobin and other ferrihemes. Methemoglobin (35 mg/dL) is used as POX standard. Three-minute POX activities and total POX concentrations measured by a classic benzidine method were compared in a three-patient trial with citrulline supplementation. High POX values became progressively lower. In two of the patients, 3-minute POX activities were reduced more than total concentrations. Oral citrulline reduced harmful plasma ferriheme levels. Free ferriheme also exhibited POX activity. POX levels may be useful to judge severity in sickle cell anemia and to monitor therapeutic efficacy.

An innovative approach to managing depression: focus on HEDIS standards.

This article reviews a disease management program that was developed to improve the treatment of depression in members of a managed care organization (MCO). The program's focus is on medication monitoring to improve members' compliance with their antidepressant medication regimen. Within the first year of the program's implementation, medication compliance rates improved by more than 10%. This was accomplished through a collaborative team effort among the MCO, the MCO's behavioral health vendor, the MCO's pharmacy benefit management provider, and a physician advisory committee. The program's positive outcomes demonstrate that patient monitoring works when there is collaboration among healthcare providers and physician support is achieved.

Rates of discontinuation and change of glaucoma therapy in a managed care setting.

BACKGROUND: Comparing discontinuation and change rates of glaucoma pharmacotherapies provides insight as to which agents perform more effectively. OBJECTIVE: To quantify the rates of discontinuation and change of different glaucoma therapies. METHODS: This retrospective, observational study using managed care administrative claims data included patients who were between 20 and 64 years of age and received at least 1 prescription for 1 of the following glaucoma agents as monotherapy: betaxolol, brimonidine, latanoprost, or timolol. Patients receiving any glaucoma medication during the 180 days prior to their index prescription were excluded, as were those who did not have continuous plan enrollment during this period. The primary outcome measures were the discontinuation and change (switching/adding on) of the index glaucoma medication. Rates of discontinuation and change were compared using a proportional hazard model. RESULTS: A total of 1006 patients comprised the final study population. Approximately 62% of patients discontinued their index glaucoma medication, and 18% of patients changed to a different therapy within 18 months of starting therapy. Among those discontinuing therapy, latanoprost patients remained on therapy the longest (mean: 217 days) compared to other study cohorts (range: 182 to 184 days). Compared with latanoprost, patients initiated on any of the other agents were more likely to discontinue or change therapy. CONCLUSIONS: This study indicates that latanoprost therapy results in a lower rate of discontinuation or change compared to patients started on betaxolol, brimonidine, or timolol.