Exploring Support Provided by Community Managed Organisations to Address Health Risk Behaviours Associated with Chronic Disease among People with Mental Health Conditions: A Qualitative Study with Organisational Leaders.

People living with mental health conditions experience a significantly reduced life expectancy compared to people without, largely linked to health risk behaviours and associated chronic disease. Community managed organisations (CMOs) represent an important setting in which to address health risk behaviours among people with mental health conditions. However, little is known about how these behaviours (smoking, poor nutrition, alcohol consumption, inadequate physical activity, poor sleep: SNAPS) are being addressed in this setting. One-on-one, semi-structured telephone interviews were conducted with a sample of 12 senior staff, representing 12 CMOs in New South Wales, Australia to: (1) explore types of support provided by CMOs to address the SNAPS behaviours of consumers living with a mental health condition; and (2) assess perceived organisational and staff level barriers and facilitators to providing such support. Transcribed interviews were analysed using inductive thematic analysis. This study found there was a range of supports offered by CMOs, and these differed by health risk behaviour. Findings suggest CMOs are well-placed to embed SNAPS supports as a part of their service provision; however, available funding, consistency of supports, workplace policies and culture, collaboration with other available supports, staff training and education, all impacted capacity.

Preventive care practices to address health behaviours among people living with mental health conditions: A survey of Community Managed Organisations.

People living with mental health conditions have a reduced life expectancy of approximately 10 years compared to the general population, largely due to physical chronic diseases and higher rates of tobacco smoking, poor nutrition, harmful alcohol consumption, physical inactivity and poor sleep behaviours. Community managed organisations (CMOs) may play a valuable role in providing preventive care to people with mental health conditions (consumers) to address these health behaviours. This paper reports the findings of a cross-sectional survey undertaken between November 2018 and February 2019 with leaders of CMOs (n = 76) that support people with mental health conditions in the state of New South Wales, Australia to: 1) measure the provision of preventive care (screening, support, and connections to specialist services) for five health behaviours; 2) identify the presence of key organisational features (e.g., data collection, staff training); and 3) explore if these organisational features were associated with the provision of preventive care. Preventive care provision to a majority of consumers (50% or more) was least frequently reported for tobacco smoking and most frequently reported for physical activity. Staff training and guidelines regarding the provision of preventive care were associated with the provision of such care. The results demonstrate that CMOs are already engaged in providing preventive care to some extent, with certain behaviours and preventive care elements addressed more frequently than others. Further research with additional CMO stakeholders, including staff and consumers, is needed to gain a deeper understanding of factors that may underlie CMOs capacity to routinely provide preventive care.

Awareness and use of telephone-based behaviour change support services among clients of a community mental health service.

OBJECTIVE: To determine the prevalence of, and factors associated with, awareness and use of telephone-based behaviour change support services among clients of a community mental health service. METHODS: Adult clients (n=375) of one Australian community mental health service completed a telephone interview and self-reported not meeting Australian National Guidelines for smoking, nutrition, alcohol consumption and/or physical activity. Descriptive statistics summarised awareness and use of the New South Wales Quitline® and Get Healthy Service® for participants with lifestyle risk factors addressed by each service. Chi-squares and logistic regressions explored associations between client characteristics, and service awareness and use. RESULTS: Awareness (16.1%) and use (1.9%) of the Get Healthy Service was lower than that of Quitline (89.1%; 18.1%). Television was the most common source of awareness (39.7% Get Healthy Service; 74.0% Quitline). In the regression models, persons in a relationship were more likely to have heard of the Get Healthy Service (OR:2.19, CI:1.15-4.18), and persons aged 36-50 were more likely to have used the Quitline (OR:5.22, CI:1.17-23.37). CONCLUSIONS: Opportunities exist for increasing awareness and use of both services, particularly the Get Healthy Service, among clients of community mental health services. Implications for public health: Strategies to optimise reach for this population group are recommended.

Effect of electronic screening and brief intervention on hazardous or harmful drinking among adults in the hospital outpatient setting: A randomized, double-blind, controlled trial.

BACKGROUND: Most trials of electronic alcohol screening and brief intervention (e-SBI) have been conducted in young people. The aim of this study was to evaluate the effect of e-SBI in adults with hazardous or harmful drinking. METHODS: This individually randomized, parallel, two-group, double-blind controlled trial was conducted in the outpatient department of a large public hospital in Australia. Consenting adults who scored 5-9 on the AUDIT-C (837/3225; 26%) were randomized in a 1:1 ratio by computer to screening alone (442/837; 53%) or to 10 min of assessment and personalized feedback on their alcohol consumption (comparisons with medical guidelines and age and sex-specific norms), peak blood alcohol concentration, expenditure on alcohol, and risk of alcohol dependence (395/837; 47%). The two primary outcomes, assessed six months after randomization, were the number of standard drinks (10 g ethanol) consumed by participants in the last seven days and their AUDIT score. RESULTS: 693/837 (83%) and 635/837 (76%) participants were followed-up at 6 and 12 months, respectively. There was no statistically significant difference between the groups in the median number of standard drinks consumed in the last seven days (intervention: 12; control: 10.5; rate ratio, 1.12 [95% confidence interval, 0.96-1.31]; P = .17) or in their median AUDIT score (intervention: 7; control: 7; mean difference, 0.28 [-0.42 to 0.98]; P = .44). CONCLUSION: These results do not support the implementation of an e-SBI program comprising personalized feedback and normative feedback for adults with hazardous or harmful drinking in the hospital outpatient setting.

Effect of electronic brief intervention on uptake of specialty treatment in hospital outpatients with likely alcohol dependence: Pilot randomized trial and qualitative interviews.

BACKGROUND: A large proportion of hospital outpatients are alcohol dependent (AD) but few are engaged in treatment for their drinking. Brief intervention, designed to raise patients' awareness of their drinking, might encourage uptake of referral to specialty treatment. We assessed the feasibility of conducting a randomized trial evaluating the effectiveness of electronic brief intervention on the uptake of specialty treatment in hospital outpatients with likely AD. METHODS: This study was conducted in the outpatient department of a large public hospital in Newcastle, Australia. We randomly assigned adults who scored ≥10 on the AUDIT-C and were not currently receiving treatment for their drinking to electronic brief intervention (comprising an assessment of their drinking and personalized feedback) and referral (n = 59), or to referral alone (n = 64). We pre-specified two co-primary outcomes as the proportions of patients who (1) accepted and (2) attended a Drug and Alcohol outpatient clinic appointment. We interviewed 15 study participants to investigate why they had declined the appointment and what sort of help they might prefer to receive. RESULTS: Ten patients (five in each group) accepted an appointment, and one patient (control) attended. Most interviewees' did not see their drinking as a problem or were confident they could manage it by themselves. Those who identified a preferred source of help expressed a preference for treatment by a GP. CONCLUSION: Uptake of specialty treatment in hospital outpatients with likely AD was low regardless of whether they received brief intervention. Accordingly, a large randomized trial does not appear to be feasible.

Genetic feedback to reduce alcohol consumption in hospital outpatients with risky drinking: feasibility and acceptability.

OBJECTIVE: There have been no trials in healthcare settings of genetic susceptibility feedback in relation to alcohol consumption. The purpose of this study was to determine the feasibility and acceptability of conducting a full-scale randomised trial estimating the effect of personalised genetic susceptibility feedback on alcohol consumption in hospital outpatients with risky drinking. METHODS: Outpatients ≥18 years of age who reported drinking more than 14 standard drinks in the past week or in a typical week were asked to provide a saliva sample for genetic testing. Genetic susceptibility feedback was posted to participants 6 months after recruitment. The co-primary outcomes were the proportion of participants who (i) provided a saliva sample that could be genotyped, and (ii) spoke with a genetic counsellor. Secondary outcomes included changes in patients' weekly alcohol consumption; scores on scales measuring readiness to change, importance of changing and confidence in ability to change drinking habits; knowledge about which cancers are alcohol-attributable; and acceptability of the saliva collection procedure and the genetic-feedback intervention. McNemar's test and paired t-tests were used to test for differences between baseline and follow-up in proportions and means, respectively. RESULTS: Of 100 participants who provided a saliva sample, 93 had adequate DNA for at least one genotyping assay. Three participants spoke to a genetic counsellor. Patients' readiness to change their drinking, their views on the importance of changing and their stated confidence in their ability to change increased between baseline and follow-up. There was no increase in patients' knowledge about alcohol-attributable cancers nor any reduction in how much alcohol they drank 4 months after receiving the feedback. Most participants (80%) were somewhat comfortable or very comfortable with the process used to collect saliva, 84% understood the genetic feedback, 54% found it useful, 10% had sought support to reduce their drinking after receiving the feedback, and 37% reported that the feedback would affect how much they drink in the future. CONCLUSION: Results of this study suggest it would be feasible to conduct a methodologically robust trial estimating the effect of genetic susceptibility feedback on alcohol consumption in hospital outpatients with risky drinking.

Videomicroscopy as a tool for investigation of the microcirculation in the newborn.

The perinatal period remains a time of significant risk of death or disability. Increasing evidence suggests that this depends on microcirculatory behavior. Sidestream dark-field orthogonal polarized light videomicroscopy (OPS) has emerged as a useful assessment of adult microcirculation but the values derived are not delineated for the newborn. We aimed to define these parameters in well term newborn infants. Demographic details were collected prospectively on 42 healthy term neonates (n = 20 females, n = 22 males). OPS videomicroscopy (Microscan) was used to view ear conch skin microcirculation at 6, 24, and 72 h of age. Stored video was analyzed by a masked observer using proprietary software. There were no significant differences between the sexes for any structural parameters at any time point. There was a significant increase over time in small vessel perfusion in female infants only (P = 0.009). A number of 6- and 72-h measurements were significantly correlated, but differed from the 24-h values. These observations confirm the utility of the ear conch for neonatal microvascular videomicroscopy. They provide a baseline for studies into the use of OPS videomicroscopy in infants. The changes observed are comparable with previous studies of term infants using these and other microvascular techniques. It is recommended that studies for examining the mature neonatal microvascular structure be delayed until 72 h of life, but studies of the physiology of cardiovascular transition should include the 24-h time point after delivery.

Influence of sympathetic activity in the control of peripheral microvascular tone in preterm infants.

BACKGROUND: Microvascular dysregulation following preterm birth is associated with increased illness severity and hypotension, particularly in males. Sympathetic nervous vascular regulation is evident in females. We hypothesized that sympathetic dysfunction in male preterm infants may contribute to a failure of peripheral microvascular vasoconstriction. METHODS: Microvascular blood flow of infants 24-43 wk gestational age was assessed at 6, 24, and 72 h of age by laser Doppler. Blood flow Fourier transformed frequency distribution spectra (low frequency/high frequency ratio) were used to assess the influence of sympathetic tone on microvascular regulation. Total sympathetic output was assessed as urinary normetanephrine. RESULTS: Microvascular sympathetic activity at 24 h postnatal age decreased in early preterm males, but not females. Peripheral sympathetic activity increased with advancing postnatal age in females, but decreased in males. In early preterm infants, total normetanephrine outputs increase significantly with postnatal age, in both sexes. CONCLUSION: Sympathetic activation following preterm birth is sexually dimorphic, with preterm males having reduced sympathetic tone and reduced upregulation of sympathetic tone following birth. There is evidence of a disconnect between central sympathetic activity and local peripheral microcirculatory sympathetic drive. This may relate to autonomic nervous immaturity and highlights the need to understand how preterm birth may affect autonomic function.

Interactions of the gasotransmitters contribute to microvascular tone (dys)regulation in the preterm neonate.

BACKGROUND & AIMS: Hydrogen sulphide (H2S), nitric oxide (NO), and carbon monoxide (CO) are involved in transitional microvascular tone dysregulation in the preterm infant; however there is conflicting evidence on the interaction of these gasotransmitters, and their overall contribution to the microcirculation in newborns is not known. The aim of this study was to measure the levels of all 3 gasotransmitters, characterise their interrelationships and elucidate their combined effects on microvascular blood flow. METHODS: 90 preterm neonates were studied at 24h postnatal age. Microvascular studies were performed by laser Doppler. Arterial COHb levels (a measure of CO) were determined through co-oximetry. NO was measured as nitrate and nitrite in urine. H2S was measured as thiosulphate by liquid chromatography. Relationships between levels of the gasotransmitters and microvascular blood flow were assessed through partial correlation controlling for the influence of gestational age. Structural equation modelling was used to examine the combination of these effects on microvascular blood flow and derive a theoretical model of their interactions. RESULTS: No relationship was observed between NO and CO (p = 0.18, r = 0.18). A positive relationship between NO and H2S (p = 0.008, r = 0.28) and an inverse relationship between CO and H2S (p = 0.01, r = -0.33) exists. Structural equation modelling was used to examine the combination of these effects on microvascular blood flow. The model with the best fit is presented. CONCLUSIONS: The relationships between NO and H2S, and CO and H2S may be of importance in the preterm newborn, particularly as NO levels in males are associated with higher H2S levels and higher microvascular blood flow and CO in females appears to convey protection against vascular dysregulation. Here we present a theoretical model of these interactions and their overall effects on microvascular flow in the preterm newborn, upon which future mechanistic studies may be based.

Effect of telephone follow-up on retention and balance in an alcohol intervention trial.

OBJECTIVES: Telephone follow-up is not currently recommended as a strategy to improve retention in randomized trials. The aims of this study were to estimate the effect of telephone follow-up on retention, identify participant characteristics predictive of questionnaire completion during or after telephone follow-up, and estimate the effect of including participants who provided follow-up data during or after telephone follow-up on balance between randomly allocated groups in a trial estimating the effect of electronic alcohol screening and brief intervention on alcohol consumption in hospital outpatients with hazardous or harmful drinking. METHOD: Trial participants were followed up 6 months after randomization (June-December 2013) using e-mails containing a hyperlink to a web-based questionnaire when possible and by post otherwise. Telephone follow-up was attempted after two written reminders and participants were invited to complete the questionnaire by telephone when contact was made. RESULTS: Retention before telephone follow-up was 62.1% (520/837) and 82.8% (693/837) afterward: an increase of 20.7% (173/837). Therefore, 55% (95% CI 49%-60%) of the 317 participants who had not responded after two written reminders responded during or after the follow-up telephone call. Age < 55 years, a higher AUDIT-C score and provision of a mobile/cell phone number were predictive of questionnaire completion during or after telephone follow-up. Balance between randomly allocated groups was present before and after inclusion of participants who completed the questionnaire during or after telephone follow-up. CONCLUSION: Telephone follow-up improved retention in this randomized trial without affecting balance between the randomly allocated groups.

Early microvascular changes in the preterm neonate: a comparative study of the human and guinea pig.

Dysfunction of the transition from fetal to neonatal circulatory systems may be a major contributor to poor outcome following preterm birth. Evidence exists in the human for both a period of low flow between 5 and 11 h and a later period of increased flow, suggesting a hypoperfusion-reperfusion cycle over the first 24 h following birth. Little is known about the regulation of peripheral blood flow during this time. The aim of this study was to conduct a comparative study between the human and guinea pig to characterize peripheral microvascular behavior during circulatory transition. Very preterm (≤28 weeks GA), preterm (29-36 weeks GA), and term (≥37 weeks GA) human neonates underwent laser Doppler analysis of skin microvascular blood flow at 6 and 24 h from birth. Guinea pig neonates were delivered prematurely (62 day GA) or at term (68-71 day GA) and laser Doppler analysis of skin microvascular blood flow was assessed every 2 h from birth. In human preterm neonates, there is a period of high microvascular flow at 24 h after birth. No period of low flow was observed at 6 h. In preterm animals, microvascular flow increased after birth, reaching a peak at 10 h postnatal age. Blood flow then steadily decreased, returning to delivery levels by 24 h. Preterm birth was associated with higher baseline microvascular flow throughout the study period in both human and guinea pig neonates. The findings do not support a hypoperfusion-reperfusion cycle in the microcirculation during circulatory transition. The guinea pig model of preterm birth will allow further investigation of the mechanisms underlying microvascular function and dysfunction during the initial extrauterine period.

Prevalence of unhealthy alcohol use in hospital outpatients.

BACKGROUND: Few studies have examined the prevalence of unhealthy alcohol use in the hospital outpatient setting. Our aim was to estimate the prevalence of unhealthy alcohol use among patients attending a broad range of outpatient clinics at a large public hospital in Australia. METHODS: Adult hospital outpatients were invited to complete the Alcohol Use Disorders Identification Test Consumption questions (AUDIT-C) using an iPad as part of a randomised trial testing the efficacy of alcohol electronic screening and brief intervention. Unhealthy alcohol use was defined as an AUDIT-C score ≥5 among men and ≥4 among women. RESULTS: Sixty percent (3616/6070) of invited hospital outpatients consented, of whom 89% (3206/3616) provided information on their alcohol consumption (either reported they had not consumed any alcohol in the last 12 months or completed the AUDIT-C). The prevalence of unhealthy alcohol use was 34.7% (95% confidence interval [CI]: 33.0-36.3%). The prevalence among men aged 18-24 years, 25-39 years, 40-59 years and 60 years and older, was 74.4% (95% CI: 68.4-80.4%), 54.3% (95% CI: 48.7-59.8%), 44.1% (95% CI: 39.9-48.3%), and 27.0% (95% CI: 23.6-30.4%), respectively (43.1% overall; 95% CI: 40.8-45.5%). The prevalence among women aged 18-24 years, 25-39 years, 40-59 years, and 60 years and older, was 48.6% (95% CI: 39.2-58.1%), 36.9% (95% CI: 31.2-42.6%), 25.2% (95% CI: 21.5-29.0%) and 14.5% (95% CI: 11.7-17.3%), respectively (24.9% overall; 95% CI: 22.7-27.1%). CONCLUSION: A large number of hospital outpatients who are not currently seeking treatment for their drinking could benefit from effective intervention in this setting.

A role for H2S in the microcirculation of newborns: the major metabolite of H2S (thiosulphate) is increased in preterm infants.

Excessive vasodilatation during the perinatal period is associated with cardiorespiratory instability in preterm neonates. Little evidence of the mechanisms controlling microvascular tone during circulatory transition exists. We hypothesised that hydrogen sulphide (H2S), an important regulator of microvascular reactivity and central cardiac function in adults and animal models, may contribute to the vasodilatation observed in preterm newborns. Term and preterm neonates (24-43 weeks gestational age) were studied. Peripheral microvascular blood flow was assessed by laser Doppler. Thiosulphate, a urinary metabolite of H2S, was determined by high performance liquid chromatography as a measure of 24 hr total body H2S turnover for the first 3 days of postnatal life. H2S turnover was greatest in very preterm infants and decreased with increasing gestational age (p = 0.0001). H2S turnover was stable across the first 72 hrs of life in older neonates. In very preterm neonates, H2S turnover increased significantly from day 1 to 3 (p =0.0001); and males had higher H2S turnover than females (p = 0.04). A significant relationship between microvascular blood flow and H2S turnover was observed on day 2 of postnatal life (p = 0.0004). H2S may play a role in maintaining microvascular tone in the perinatal period. Neonates at the greatest risk of microvascular dysfunction characterised by inappropriate peripheral vasodilatation--very preterm male neonates--are also the neonates with highest levels of total body H2S turnover suggesting that overproduction of this gasotransmitter may contribute to microvascular dysfunction in preterms. Potentially, H2S is a target to selectively control microvascular tone in the circulation of newborns.

Progesterone activates multiple innate immune pathways in Chlamydia trachomatis-infected endocervical cells.

PROBLEM: Susceptibility to Chlamydia trachomatis infection is increased by oral contraceptives and modulated by sex hormones. We therefore sought to determine the effects of female sex hormones on the innate immune response to C. trachomatis infection. METHOD OF STUDY: ECC-1 endometrial cells, pre-treated with oestradiol or progesterone, were infected with C. trachomatis and the host transcriptome analysed by Illumina Sentrix HumanRef-8 microarray. Primary endocervical epithelial cells, prepared at either the proliferative or secretory phase of the menstrual cycle, were infected with C. trachomatis and cytokine gene expression determined by quantitative RT-PCR analysis. RESULTS: Chlamydia trachomatis yield from progesterone-primed ECC-1 cells was significantly reduced compared with oestradiol-treated cells. Genes upregulated in progesterone-treated and Chlamydia-infected cells only included multiple CC and CXC chemokines, IL-17C, IL-29, IL-32, TNF-α, DEFB4B, LCN2, S100A7-9, ITGAM, NOD2, JAK1, IL-6ST, type I and II interferon receptors, numerous interferon-stimulated genes and STAT6. CXCL10, CXCL11, CX3 CL1 and IL-17C, which were also upregulated in infected secretory-stage primary cells, and there was a trend towards higher levels of immune mediators in infected secretory-phase compared with proliferative-phase cells. CONCLUSION: Progesterone treatment primes multiple innate immune pathways in hormone-responsive epithelial cells that could potentially increase resistance to chlamydial infection.

Modulation of the Chlamydia trachomatis in vitro transcriptome response by the sex hormones estradiol and progesterone.

BACKGROUND: Chlamydia trachomatis is a major cause of sexually transmitted disease in humans. Previous studies in both humans and animal models of chlamydial genital tract infection have suggested that the hormonal status of the genital tract epithelium at the time of exposure can influence the outcome of the chlamydial infection. We performed a whole genome transcriptional profiling study of C. trachomatis infection in ECC-1 cells under progesterone or estradiol treatment. RESULTS: Both hormone treatments caused a significant shift in the sub-set of genes expressed (25% of the transcriptome altered by more than 2-fold). Overall, estradiol treatment resulted in the down-regulation of 151 genes, including those associated with lipid and nucleotide metabolism. Of particular interest was the up-regulation in estradiol-supplemented cultures of six genes (omcB, trpB, cydA, cydB, pyk and yggV), which suggest a stress response similar to that reported previously in other models of chlamydial persistence. We also observed morphological changes consistent with a persistence response. By comparison, progesterone supplementation resulted in a general up-regulation of an energy utilising response. CONCLUSION: Our data shows for the first time, that the treatment of chlamydial host cells with key reproductive hormones such as progesterone and estradiol, results in significantly altered chlamydial gene expression profiles. It is likely that these chlamydial expression patterns are survival responses, evolved by the pathogen to enable it to overcome the host's innate immune response. The induction of chlamydial persistence is probably a key component of this survival response.