Designing and implementing an Advanced Nurse Practice in Critical Care programme from a university perspective within Northern Ireland.

The number of advanced practice roles in healthcare is increasing in response to several factors such as changes in medical education, economic pressures, workforce shortages and the increasing complexity of health needs of the population. The Advanced Critical Care Practitioner Curriculum, developed by the Faculty of Intensive Care Medicine in the UK (United Kingdom), enables the development and delivery of a structured education programme which can contribute to addressing these challenges. This article outlines how one university designed and implemented this programme, the first of its kind in Northern Ireland.

Valuing EQ-5D-Y: the current state of play.

BACKGROUND: For nearly a decade, value sets for the EQ-5D-Y were not available, reflecting challenges in valuing child HRQoL. A methodological research programme led to publication of a valuation protocol in 2020, which was rapidly taken up by local study teams. By the end of 2022, between 11 and 17 EQ-5D-Y value sets will be available, more than for any other child HRQoL measure. It is timely to review the experience of those using the protocol to identify early learnings and remaining issues where more research is needed. METHODS: In June 2021, the EuroQol Group organised a three-day workshop, bringing together all those involved in EQ-5D-Y value set studies and related methodological research concerning EQ-5D-Y and valuation. Workshop discussions were captured by note taking and recording all sessions and online chat. A narrative summary of all sessions was produced and synthesised to identify points of agreement and aspects of methods where uncertainty remains. RESULTS: There was broad agreement that DCE is working well as the principal valuation method. However, the most appropriate means of anchoring the latent scale values produced by DCE remains unclear. Some studies have deviated from the protocol by extending the number of states included in TTO tasks, to better support modelling of DCE and TTO. There is ongoing discussion about the relative merits of alternative variants of TTO and other methods for anchoring. Very few studies have consulted with local end-users to gauge the acceptability of methods used to value EQ-5D-Y. CONCLUSIONS: Priority areas for research include testing alternative methods for anchoring DCE data; exploring the preferences of adolescents; and scale differences in values for EQ-5D-Y and adult EQ-5D states, and implications of such differences for the use of EQ-5D-Y values in HTA. Given the normative elements of the protocol, engaging with HTA bodies and other local users should be the first step for all future value set studies. Value sets undertaken to date are for the three-level EQ-5D-Y. However, the issues discussed in this paper are equally relevant to valuation of the five-level version of EQ-5D-Y; indeed, similar challenges are encountered valuing any measure of child HRQoL.

Molecular characterization of putative neuropeptide, amine, diffusible gas and small molecule transmitter biosynthetic enzymes in the eyestalk ganglia of the American lobster, Homarus americanus.

The American lobster, Homarus americanus, is a model for investigating the neuromodulatory control of physiology and behavior. Prior studies have shown that multiple classes of chemicals serve as locally released/circulating neuromodulators/neurotransmitters in this species. Interestingly, while many neuroactive compounds are known from Homarus, little work has focused on identifying/characterizing the enzymes responsible for their biosynthesis, despite the fact that these enzymes are key components for regulating neuromodulation/neurotransmission. Here, an eyestalk ganglia-specific transcriptome was mined for transcripts encoding enzymes involved in neuropeptide, amine, diffusible gas and small molecule transmitter biosynthesis. Using known Drosophila melanogaster proteins as templates, transcripts encoding putative Homarus homologs of peptide precursor processing (signal peptide peptidase, prohormone processing protease and carboxypeptidase) and immature peptide modifying (glutaminyl cyclase, tyrosylprotein sulfotransferase, protein disulfide isomerase, peptidylglycine-α-hydroxylating monooxygenase and peptidyl-α-hydroxyglycine-α-amidating lyase) enzymes were identified in the eyestalk assembly. Similarly, transcripts encoding full complements of the enzymes responsible for dopamine [tryptophan-phenylalanine hydroxylase (TPH), tyrosine hydroxylase and DOPA decarboxylase (DDC)], octopamine (TPH, tyrosine decarboxylase and tyramine ß-hydroxylase), serotonin (TPH or tryptophan hydroxylase and DDC) and histamine (histidine decarboxylase) biosynthesis were identified from the eyestalk ganglia, as were those responsible for the generation of the gases nitric oxide (nitric oxide synthase) and carbon monoxide (heme oxygenase), and the small molecule transmitters acetylcholine (choline acetyltransferase), glutamate (glutaminase) and GABA (glutamic acid decarboxylase). The presence and identity of the transcriptome-derived transcripts were confirmed using RT-PCR. The data presented here provide a foundation for future gene-based studies of neuromodulatory control at the level of neurotransmitter/modulator biosynthesis in Homarus.

Neuropeptidergic Signaling in the American Lobster Homarus americanus: New Insights from High-Throughput Nucleotide Sequencing.

Peptides are the largest and most diverse class of molecules used for neurochemical communication, playing key roles in the control of essentially all aspects of physiology and behavior. The American lobster, Homarus americanus, is a crustacean of commercial and biomedical importance; lobster growth and reproduction are under neuropeptidergic control, and portions of the lobster nervous system serve as models for understanding the general principles underlying rhythmic motor behavior (including peptidergic neuromodulation). While a number of neuropeptides have been identified from H. americanus, and the effects of some have been investigated at the cellular/systems levels, little is currently known about the molecular components of neuropeptidergic signaling in the lobster. Here, a H. americanus neural transcriptome was generated and mined for sequences encoding putative peptide precursors and receptors; 35 precursor- and 41 receptor-encoding transcripts were identified. We predicted 194 distinct neuropeptides from the deduced precursor proteins, including members of the adipokinetic hormone-corazonin-like peptide, allatostatin A, allatostatin C, bursicon, CCHamide, corazonin, crustacean cardioactive peptide, crustacean hyperglycemic hormone (CHH), CHH precursor-related peptide, diuretic hormone 31, diuretic hormone 44, eclosion hormone, FLRFamide, GSEFLamide, insulin-like peptide, intocin, leucokinin, myosuppressin, neuroparsin, neuropeptide F, orcokinin, pigment dispersing hormone, proctolin, pyrokinin, SIFamide, sulfakinin and tachykinin-related peptide families. While some of the predicted peptides are known H. americanus isoforms, most are novel identifications, more than doubling the extant lobster neuropeptidome. The deduced receptor proteins are the first descriptions of H. americanus neuropeptide receptors, and include ones for most of the peptide groups mentioned earlier, as well as those for ecdysis-triggering hormone, red pigment concentrating hormone and short neuropeptide F. Multiple receptors were identified for most peptide families. These data represent the most complete description of the molecular underpinnings of peptidergic signaling in H. americanus, and will serve as a foundation for future gene-based studies of neuropeptidergic control in the lobster.

Psychotic experiences in a mental health clinic sample: implications for suicidality, multimorbidity and functioning.

BACKGROUND: Recent community-based research has suggested that psychotic experiences act as markers of severity of psychopathology. There has, however, been a lack of clinic-based research. We wished to investigate, in a clinical sample of adolescents referred to a state-funded mental health service, the prevalence of (attenuated or frank) psychotic experiences and the relationship with (i) affective, anxiety and behavioural disorders, (ii) multimorbid psychopathology, (iii) global functioning, and (iv) suicidal behaviour. METHOD: The investigation was a clinical case-clinical control study using semi-structured research diagnostic psychiatric assessments in 108 patients newly referred to state adolescent mental health services. RESULTS: Psychotic experiences were prevalent in a wide range of (non-psychotic) disorders but were strong markers of risk in particular for multimorbid psychopathology (Z = 3.44, p = 0.001). Young people with psychopathology who reported psychotic experiences demonstrated significantly poorer socio-occupational functioning than young people with psychopathology who did not report psychotic experiences, which was not explained by multimorbidity. Psychotic experiences were strong markers of risk for suicidal behaviour. Stratified analyses showed that there was a greatly increased odds of suicide attempts in patients with a major depressive disorder [odds ratio (OR) 8.89, 95% confidence interval (CI) 1.59-49.83], anxiety disorder (OR 15.4, 95% CI 1.85-127.94) or behavioural disorder (OR 3.13, 95% CI 1.11-8.79) who also had psychotic experiences compared with patients who did not report psychotic experiences. CONCLUSIONS: Psychotic experiences (attenuated or frank) are an important but under-recognized marker of risk for severe psychopathology, including multimorbidity, poor functioning and suicidal behaviour in young people who present to mental health services.

Understanding the effects on HR-QoL of treatment for overactive bladder: a detailed analysis of EQ-5D clinical trial data for mirabegron.

BACKGROUND: Analysis of EQ-5D data often focuses on changes in utility, ignoring valuable information from other parts of the instrument. The objective was to explore how the utility index, EQ-5D profile, and EQ-VAS captured change in clinical trials of mirabegron, a new treatment for overactive bladder (OAB). DATA: Data were pooled from three phase III clinical trials that investigated the efficacy and safety of mirabegron vs placebo. Tolterodine ER 4 mg was included as an active control in one study: (1) placebo, mirabegron 50 mg and 100 mg, and tolterodine 4 mg ER; (2) placebo, mirabegron 50 mg and 100 mg; (3) placebo, and mirabegron 25 mg and 50 mg. Data were collected at baseline, week 4, 8, and 12. METHODS: Analyses were performed on full analysis and modified intention to treat (ITT) data sets using UK utilities. Analysis controlled for relevant patient characteristics. Analysis of Covariance identified changes from baseline at each time point in utilities and EQ-VAS. Areas Under the Curve were estimated to summarize inter-temporal differences in effect. EQ-5D profile data were analysed using the Paretian Classification of Health Change. RESULTS: In modified ITT analyses, mirabegron 50 mg was superior to tolterodine 4 mg in changes from baseline utilities after 12 weeks (p < 0.05); similarly, AUC results showed mirabegron 50 mg to be superior to tolterodine (p < 0.05) and placebo (p < 0.05) with the benefit already apparent at 4 weeks (p < 0.05). EQ-VAS more consistently indicated superior outcomes: all three mirabegron doses showed statistically significant greater effectiveness compared to tolterodine at 12 weeks. Individual EQ-5D dimensions and the overall profile showed no significant differences between study arms. CONCLUSION: Mirabegron showed quicker and superior improvement in HR-QoL compared to tolterodine 4 mg ER. A limitation of the study is that EQ-5D was a secondary outcome in the pivotal trials, which were not powered to measure differences on EQ-5D.

Prevalence of psychotic symptoms in childhood and adolescence: a systematic review and meta-analysis of population-based studies.

BACKGROUND: Psychotic symptoms occur more frequently in the general population than psychotic disorder and index risk for psychopathology. Multiple studies have reported on the prevalence of these symptoms using self-report questionnaires or clinical interviews but there is a lack of consensus about the prevalence of psychotic symptoms among children and adolescents. METHOD: We conducted a systematic review of all published literature on psychotic symptom prevalence in two age groups, children aged 9-12 years and adolescents aged 13-18 years, searching through electronic databases PubMed, Ovid Medline, PsycINFO and EMBASE up to June 2011, and extracted prevalence rates. RESULTS: We identified 19 population studies that reported on psychotic symptom prevalence among children and adolescents. The median prevalence of psychotic symptoms was 17% among children aged 9-12 years and 7.5% among adolescents aged 13-18 years. CONCLUSIONS: Psychotic symptoms are relatively common in young people, especially in childhood. Prevalence is higher in younger (9-12 years) compared to older (13-18 years) children.

The validity and reliability of EQ-5D health state valuations in a survey of Maori.

This note reports on a 2000 study of the content validity of the EQ-5D's representation of health for 66 Maori (New Zealand's indigenous people, comprising 14.5% of the population) accessed through cultural networks. Also examined was the construct validity of the health state valuation instrument and its test-retest reliability based on repeated valuations for the two extreme health states. The possibility that the EQ-SD fails to capture what Maori regard as 'health' derives from the so-called 'Maori health model' that augments biological health with mental, spiritual and family well-being. Seventy six percent of respondents considered the EQ-5D's representation of health to be adequate. This proportion is not statistically significantly different from the rates for non-Maori and Maori respectively in an earlier study and might suggest the EQ-5D has content validity for Maori. However, the high prevalence of missing valuations, particularly for dead, and logical inconsistencies suggests that the health state valuation instrument lacks construct validity, although there is evidence of test retest reliability.

The delivery of orthodontic care in New Zealand. Part I: Analysis of a census of orthodontists.

A two-part study was undertaken to determine the supply of orthodontic services in New Zealand. Part I focuses on services supplied by specialist orthodontists. A companion paper will describe the amount and characteristics of orthodontic services supplied by dentists. All orthodontists in New Zealand in 1999 were surveyed to provide information on practice location and days practiced in 1996 (the year of the last population Census), and the amount and type of orthodontic treatment carried out in the year 1 July 1998 to 30 June 1999. The response rate was 78.9 percent. Data from 1996 were used to establish and quantify the location and distribution of orthodontists in New Zealand, and their spatial relationship to 12-year-olds and 10- to 14-year-olds using Geographic Information Systems. The information from 1998-1999 was used to determine the amount and variety of services provided by orthodontists and the makeup of their patient base. Nearly two-thirds of orthodontists had a branch practice. Over 50 percent of the 10- to 14-year-old population resided within 5 km of an orthodontist, and nearly three-quarters within 10 km. Disparities between regions existed in the supply of specialist orthodontic services. The catchment areas of main urban areas had more than three times the supply of orthodontists to 12-year-olds than did the secondary and minor urban areas combined. The mean average active patient load was 371, and the mean number of full upper and lower fixed appliances placed was 130.3 during the year of the study. Nearly half of all patients had been referred from dentists, approximately one-quarter were self-referred, and a quarter had been referred by dental therapists. Adults comprised 12.1 percent of the patient load of orthodontists; 60 percent were female.

Economic evaluation of a community based exercise programme to prevent falls.

OBJECTIVE: To assess the incremental costs and cost effectiveness of implementing a home based muscle strengthening and balance retraining programme that reduced falls and injuries in older women. DESIGN: An economic evaluation carried out within a randomised controlled trial with two years of follow up. Participants were individually prescribed an exercise programme (exercise group, n=116) or received usual care and social visits (control group, n=117). SETTING: 17 general practices in Dunedin, New Zealand. PARTICIPANTS: Women aged 80 years and older living in the community and invited by their general practitioner to take part. MAIN OUTCOME MEASURES: Number of falls and injuries related to falls, costs of implementing the intervention, healthcare service costs resulting from falls and total healthcare service costs during the trial. Cost effectiveness was measured as the incremental cost of implementing the exercise programme per fall event prevented. MAIN RESULTS: 27% of total hospital costs during the trial were related to falls. However, there were no significant differences in health service costs between the two groups. Implementing the exercise programme for one and two years respectively cost $314 and $265 (1995 New Zealand dollars) per fall prevented, and $457 and $426 per fall resulting in a moderate or serious injury prevented. CONCLUSIONS: The costs resulting from falls make up a substantial proportion of the hospital costs for older people. Despite a reduction in falls as a result of this home exercise programme there was no significant reduction in healthcare costs. However, the results reported will provide information on the cost effectiveness of the programme for those making decisions on falls prevention strategies.

Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: Randomised controlled trial.

OBJECTIVES: To assess the effectiveness of a trained district nurse individually prescribing a home based exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme. DESIGN: Randomised controlled trial with one year's follow up. SETTING: Community health service at a New Zealand hospital. PARTICIPANTS: 240 women and men aged 75 years and older. INTERVENTION: 121 participants received the exercise programme (exercise group) and 119 received usual care (control group); 90% (211 of 233) completed the trial. MAIN OUTCOME MEASURES: Number of falls, number of injuries resulting from falls, costs of implementing the programme, and hospital costs as a result of falls. RESULTS: Falls were reduced by 46% (incidence rate ratio 0.54, 95% confidence interval 0.32 to 0.90). Five hospital admissions were due to injuries caused by falls in the control group and none in the exercise group. The programme cost $NZ1803 (523 pound sterling) (at 1998 prices) per fall prevented for delivering the programme and $NZ155 per fall prevented when hospital costs averted were considered. CONCLUSION: A home exercise programme, previously shown to be successful when delivered by a physiotherapist, was also effective in reducing falls when delivered by a trained nurse from within a home health service. Serious injuries and hospital admissions due to falls were also reduced. The programme was cost effective in participants aged 80 years and older compared with younger participants.

Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 2: Controlled trial in multiple centres.

OBJECTIVES: To assess the effectiveness of trained nurses based in general practices individually prescribing a home exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme. DESIGN: Controlled trial with one year's follow up. SETTING: 32 general practices in seven southern New Zealand centres. PARTICIPANTS: 450 women and men aged 80 years and older. INTERVENTION: 330 participants received the exercise programme (exercise centres) and 120 received usual care (control centres); 87% (371 of 426) completed the trial. MAIN OUTCOME MEASURES: Number of falls, number of injuries resulting from falls, costs of implementing the programme, and hospital costs as a result of falls. RESULTS: Falls were reduced by 30% in the exercise centres (incidence rate ratio 0.70, 95% confidence interval 0.59 to 0.84). The programme was equally effective in men and women. The programme cost $NZ418 (121 pound sterling) (at 1998 prices) per person to deliver for one year or $NZ1519 (441 pound sterling) per fall prevented. Fewer participants had falls resulting in injuries, but there was no difference in the number who had serious injuries and no difference in hospital costs resulting from falls in exercise centres compared with control centres. CONCLUSIONS: An individually tailored exercise programme, delivered by trained nurses from within general practices, was effective in reducing falls in three different centres. This strategy should be combined with other successful interventions to form part of home programmes to prevent falls in elderly people.

The delivery of orthodontic care in New Zealand. Part II: Analysis of a census of dentists.

Part I of this study reported the level and distribution of the supply of specialist orthodontic services in New Zealand. This paper focuses on the amount and variety of orthodontic services supplied by dentists. A questionnaire sent to all dentists in New Zealand sought information on the amount and type of orthodontic treatment carried out between 1 July 1998 and 30 June 1999. The reply rate was 80.9 percent. The majority of dentists carried out some form of orthodontic treatment, predominantly of a minor nature. A small number provided significant amounts of treatment, both simple and complex. The majority of orthodontic treatment and the majority of comprehensive fixed-appliance treatment were undertaken by orthodontists. One-quarter of all orthodontic patients in New Zealand were treated by dentists, irrespective of the complexity of treatment. Nearly a fifth of all full fixed upper and lower appliances, and nearly a third of all single-arch fixed appliances were placed by dentists during the study period. In general, male dentists, dentists over the age of 40, those who had attended an orthodontic continuing education course in the previous 5 years, and those who referred fewer patients to an orthodontist carried out more procedures, including those of a complex nature; they also had a higher average active orthodontic patient load. Wanting to be more or less busy had little influence on the amount or complexity of treatment performed. Dentists in regions with a low supply of specialist orthodontic services provided more comprehensive fixed appliance treatment and had a higher orthodontic patient load. However, the presence or absence of an orthodontist in an urban area seemed to have little impact on the complexity of treatment or the orthodontic patient load of dentists. Despite fewer orthodontists in secondary and minor urban areas, dentists in these areas did not have a higher orthodontic patient load, but carried out a wider range of procedures and more complex procedures than those in main urban areas.

Priority-setting in New Zealand: translating principles into practice.

In May 1998 the New Zealand Health Funding Authority released a discussion paper which proposed a principles-based approach to setting purchasing priorities that incorporates the economic methods of programme budgeting and marginal analysis, and cost-utility analysis. The principles upon which the process was to be based are effectiveness, cost, equity of health outcomes, Maori health and acceptability. This essay describes and critiques issues associated with translating the principles into practice, most particularly the proposed methods for evaluating the effectiveness and measuring the cost of services. It is argued that the proposals make an important contribution towards the development of a method for prioritizing services which challenges our thinking about those services and their goals, and which is systematic, explicit, and transparent. The shift towards 'thinking at the margin' and systematically reviewing the value for money of competing claims on resources is likely to improve the quality of decision-making compared with the status quo. This does not imply that prioritization can, or should, be undertaken by means of any simple formula. Any prioritization process should always be guided by informed judgement. The approach is more appropriate for some services than for others. Key methodological issues that need further consideration include the choice of instrument for measuring health gains, the identification of marginal services, how to combine qualitative and quantitative information, and how to ensure consistency across different levels of decision-making.