Barriers and facilitators to implementation of an exercise and education programme for osteoarthritis: a qualitative study using the consolidated framework for implementation research.

Targeted efforts to better understand the barriers and facilitators of stakeholders and healthcare settings to implementation of exercise and education self-management programmes for osteoarthritis (OA) are needed. This study aimed to explore the barriers and facilitators to the implementation of Good Life with osteoArthritis in Denmark (GLA:D), a supervised group guideline-based OA programme, across Irish public and private healthcare settings. Interviews with 10 physiotherapists (PTs; 8 public) and 9 people with hip and knee OA (PwOA; 4 public) were coded by the Consolidated Framework for Implementation Research (CFIR) constructs in a case memo (summary, rationale, quotes). The strong positive/negative implementation determinants were identified collaboratively by rating the valence and strength of CFIR constructs on implementation. Across public and private settings, PTs and PwOA strongly perceived GLA:D Ireland as evidence-based, with easily accessible education and modifiable marketing/training materials that meet participants' needs, improve skills/confidence and address exercise beliefs/expectations. Despite difficulties in scheduling sessions (e.g., work/caring responsibilities), PTs in public and private settings perceived advantages to implementation over current clinical practice (e.g., shortens waiting lists). Only PTs in public settings reported limited availability of internal/external funding, inappropriate space, marketing/training tools, and inadequate staffing. Across public and private settings, PwOA reported adaptability, appropriate space/equipment and coaching/supervision, autonomy, and social support as facilitators. Flexible training and tailored education for stakeholders and healthcare settings on guideline-based OA management may promote implementation. Additional support on organising (e.g., scheduling clinical time), planning (e.g., securing appropriate space, marketing/training tools), and funding (e.g., accessing dedicated internal/external grants) may strengthen implementation across public settings.

Older adults experience of transition to the community from the emergency department: a qualitative evidence synthesis.

AIM: Older adults comprise a growing proportion of Emergency Department (ED) attendees and are vulnerable to adverse outcomes following an ED visit including ED reattendance within 30 days. Interventions to reduce older adults' risk of adverse outcomes following an ED attendance are proliferating and often focus on improving the transition from the ED to the community. To optimise the effectiveness of interventions it is important to determine how older adults experience the transition from the ED to the community. This study aims to systematically review and synthesise qualitative studies reporting older adults' experiences of transition to the community from the ED. METHODS: Six databases (Academic Search Complete, CINAHL, MEDLINE, PsycARTICLES, PsycINFO, and Social Science Full Text) were searched in March 2022 and 2023. A seven-step approach to meta-ethnography, as described by Noblit and Hare, was used to synthesise findings across included studies. The methodological quality of the included studies was appraised using the 10-item Critical Appraisal Skills Programme (CASP) checklist for qualitative research. A study protocol was registered on PROSPERO (Registration: CRD42022287990). FINDINGS: Ten studies were included, and synthesis led to the development of five themes. Unresolved symptoms reported by older adults on discharge impact their ability to manage at home (theme 1). Limited community services and unresolved symptoms drive early ED reattendance for some older adults (theme 2). Although older adults value practical support and assistance transporting home from the ED this is infrequently provided (theme 3). Accessible health information and interactions are important for understanding and self-managing health conditions on discharge from the ED (theme 4). Fragmented Care between ED and community is common, stressful and impacts on older adult's ability to manage health conditions (theme 5). A line of argument synthesis integrated these themes into one overarching concept; after an ED visit older adults often struggle to manage changed, complex, health and care needs at home, in the absence of comprehensive support and guidance. DISCUSSION/ CONCLUSION: Key areas for consideration in future service and intervention development are identified in this study; ED healthcare providers should adapt their communication to the needs of older adults, provide accessible information and explicitly address expectations about symptom resolution during discharge planning. Concurrently, community health services need to be responsive to older adults' changed health and care needs after an ED visit to achieve care integration. Those developing transitional care interventions should consider older adults needs for integration of care, symptom management, clear communication and information from providers and desire to return to daily life.

Exploring the Impact of COVID-19 on Home Care Workers: A Qualitative Study.

This qualitative study aimed to gain insight into the impact of COVID-19 on Home Care Workers (HCWs). During COVID-19 HCWs provided a lifeline for home care clients to support older people remaining living in their own homes. With a high-risk client base, HCWs were one of the few (Health and Social Care Professional) HSCPs to continue providing home-based care throughout COVID-19. Despite these contributions HCWs provided for aging in place during COVID-19, a paucity of research exists in relation to the challenges and impact of the pandemic on HCWs. Three in-person focus groups were conducted (n = 23). Two main themes were produced guided by a Reflexive Thematic Analysis approach to enable the researchers to best represent the participants experiences: Challenges and concerns to the personal and private lives of HCWs and Navigating home-based complexities of HCWs workplace during COVID-19. health care challenges to minimize impact to HCWs issues to create a safe workplace for HCWs.

Exploring stakeholders' experiences of comprehensive geriatric assessment in the community and out-patient settings: a qualitative evidence synthesis.

BACKGROUND: Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary process that addresses an older adult's biopsychosocial capabilities to create an integrated and co-ordinated plan of care. While quantitative evidence that demonstrates the positive impacts of CGA on clinical and process outcomes has been synthesised, to date qualitative research reporting how older adults and service providers experience CGA has not been synthesised. This study aimed to systematically review and synthesise qualitative studies reporting community-dwelling older adults', caregivers' and healthcare professionals' (HCP) experiences of CGA in the primary care and out-patient (OPD) setting. METHOD: We systematically searched five electronic databases including MEDLINE, CINAHL, PsycINFO, PsycARTICLES and Social Sciences Full Text targeting qualitative or mixed methods studies that reported qualitative findings on older adults', caregivers' and HCPs' experiences of CGA in primary care or out-patient settings. There were no language or date restrictions applied to the search. The protocol was registered with the PROSPERO database (Registration: CRD42021283167). The methodological quality of the included studies was appraised using the Critical Appraisal Skills Programme checklist for qualitative research. Results were synthesised according to Noblit and Hare's seven-step approach to meta-ethnography, which involves an iterative and inductive process of data synthesis. RESULTS: Fourteen studies were included where CGA was completed in the home, general practice, out-patient setting in acute hospitals and in hybrid models across the community and hospital-based OPD settings. Synthesis generated four key themes: (1) CGA is experienced as a holistic process, (2) The home environment enhances CGA, (3) CGA in the community is enabled by a collaborative approach to care, and (4) Divergent experiences of the meaningful involvement of older adults, caregivers and family in the CGA process. CONCLUSION: Findings demonstrate that CGA in a home-based or OPD setting allows for a holistic and integrated approach to care for community-dwelling older adults while increasing patient satisfaction and accessibility of healthcare. Healthcare professionals in the community should ensure meaningful involvement of older adults and their families or caregivers in the CGA process. Further robustly designed and well reported trials of different models of community-based CGA informed by the findings of this synthesis are warranted.

Stakeholders' experiences of comprehensive geriatric assessment in an inpatient hospital setting: a qualitative systematic review and meta-ethnography.

BACKGROUND: Comprehensive geriatric assessment (CGA) is considered the gold standard approach to improving a range of outcomes for older adults living with frailty admitted to hospital. To date, research has predominantly focused on quantitative syntheses of the international evidence with limited focus on qualitative synthesis of stakeholder perspectives. This review aims to resolve this research gap by identifying and synthesising qualitative studies reporting multiple stakeholders' experiences of inpatient CGA. METHODS: A systematic search of five electronic databases was conducted. Qualitative or mixed methods studies that included qualitative findings on the experiences of CGA in an inpatient hospital setting from the perspective of healthcare professionals (HCP), older adults, and those important to them were included. The protocol was registered on PROSPERO (Registration: CRD42021283167) and the 10-item Critical Appraisal Skills Programme checklist was used to appraise the methodological quality of included studies. Results were synthesised as a meta-ethnography. RESULTS: Eleven studies, which reported on the experiences of 153 HCPs, 91 older adults and 57 caregivers were included. The studies dated from 2011 to 2021 and three key themes were identified: (1) HCPs, older adults and caregivers report conflicting views on CGA as a holistic process, (2) most HCPs, but only some older adults and caregivers view CGA goalsetting and care planning as collaborative, and (3) all stakeholders value care continuity during the transition from hospital to home but often fail to achieve it. CONCLUSION: While HCPs, older adults, and caregivers' values and ambitions related to CGA broadly align, their experiences often differ. The identified themes highlight organisational and relational factors, which positively and negatively influence CGA practices and processes in an inpatient hospital setting.

Establishing the core elements of a frailty at the front door model of care using a modified real-time Delphi technique.

BACKGROUND: Innovations in models of care for older adults living with frailty presenting to the emergency department (ED) have become a key priority for clinicians, researchers and policymakers due to the deleterious outcomes older adults experience due to prolonged exposure to such an environment. This study aimed to develop a set of expert consensus-based statements underpinning operational design, outcome measurement and evaluation of a Frailty at the Front Door (FFD) model of care for older adults within an Irish context. METHODS: A modified real-time Delphi method was used. Facilitation of World Café focus groups with an expert panel of 86 members and seperate advisory groups with a Public and Patient Involvement panel of older adults and members of the Irish Association of Emergency Medicine generated a series of statements on the core elements of the FFD model of care. Statements were analysed thematically and incorporated into a real-time Delphi survey, which was emailed to members of the expert panel. Members were asked to rank 70 statements across nine domains using a 9-point Likert scale. Consensus criteria were defined a priori and guided by previous research using 9-point rating scales. RESULTS: Fifty members responded to the survey representing an overall response rate of 58%. Following analyses of the survey responses, the research team reviewed statements for content overlap and refined a final list of statements across the following domains: aims and objectives of the FFD model of care; target population; screening and assessment; interventions; technology; integration of care; evaluation and metrics; and research. CONCLUSION: Development of a consensus derived FFD model of care represents an important step in generating national standards, implementation of a service model as intended and enhances opportunities for scientific impact. Future research should focus on the development of a core outcome set for studies involving older adults in the ED.

A qualitative evidence synthesis (QES) exploring the barriers and facilitators to screening in emergency departments using the theoretical domains framework.

BACKGROUND: Validated screening tools can be utilised to detect early disease processes and risk factors for disease and adverse outcomes. Consequently, identifying individuals in need of early intervention and targeted assessment can be achieved through the implementation of screening in the ED. Successful implementation can be impacted by a lack of resources and ineffective integration of screening into the clinical workflow. Tailored implementation processes and staff training, which are contextually specific to the ED setting, are facilitators to effective implementation. This review will assist in the identification of barriers and facilitators to screening in the ED using a QES to underpin implementation processes. Healthcare workers engage in screening in the ED routinely. Consequently, this review focused on synthesizing the experience of healthcare workers (HCWs) who are involved in this process. This synthesis is informed by a QES protocol published by the lead author in 2021 (Barry et al., HRB Open Res 3:50, 2021). METHODOLOGY: A comprehensive literature search, inclusive of grey literature sources, was undertaken. Initially, an a priori framework of themes was formed to facilitate the interpretation and organisation of search results. A context specific conceptual model was then formulated using "Best fit" framework synthesis which further assisted in the interpretation of data that was extracted from relevant studies. Dual blind screening of search results was undertaken using RAYYAN as a platform. Thirty studies were identified that met the inclusion criteria. Dual appraisal of full text articles was undertaken using CASP, GRADE CERQual assessed confidence of findings and data extraction was performed by two reviewers collaboratively. FINDINGS: This is the first known synthesis of qualitative research on HCW's experiences of screening in the ED. Predominantly, the findings illustrate that staff experience screening in the ED as a complex challenging process. The barriers and facilitators identified can be broadly categorised under preconditions to screen, motivations to screen and knowledge and skills to screen. Competing interests in the ED, environmental stressors such as overcrowding and an organisational culture that resists screening were clear barriers. Adequate resources and tailored education to underpin the screening process were clear facilitators. TRIAL REGISTRATION: PROSPERO: CRD42020188712 05/07/20.

Clinical research stakeholders' experiences of clinical research during COVID-19: a qualitative study.

BACKGROUND: The COVID-19 pandemic created a complex high-risk clinical research environment with clinical research activities significantly impacted. Clinical research stakeholders adapted rapidly to new clinical practices; PPE, infection control policies, all while engaging with a more unwell patient demographic. The aim of this study is to explore the experiences of conducting clinical research during COVID-19 with clinical research stakeholders. METHODS: This qualitative study of semi-structured interviews conducted with clinical research stakeholders in an acute Hospital setting across a variety of disciplines; Consultant Geriatrician, Clinical Research Nurse, Occupational Therapy, Physiotherapy. Interviews were fully transcribed prior to reflexive thematic analysis. NVivo software was used to support data management and analysis. RESULTS: Three main themes were produced; (1) The challenging COVID-19 clinical research landscape, (2) COVID-19 clinical research communication barriers, and (3) Adaptations and learnings from clinical research during COVID-19. CONCLUSIONS: This study explored the experiences of conducting clinical research during COVID-19 with clinical research stakeholders examining challenges faced and adaptations required. The findings inform, equip and support clinical research stakeholders in the event of future adverse public health events.

Effectiveness of community-based multidisciplinary integrated care for older people: a protocol for a systematic review.

INTRODUCTION: The increasing number of older adults with multiple complex care needs has placed increased pressure on healthcare systems internationally to reorientate healthcare delivery. For many older adults, their first point of contact with the health service is with their general practitioner (GP) and GP participation with integrated care models is the foundation of a population-based approach. A knowledge gap remains in relation to the effectiveness of GP participation in community-based integrated health and social care approaches for older adults. This systematic review aims to examine the effectiveness of multidisciplinary-integrated care for community-dwelling older adults with GP participation. METHODS AND ANALYSIS: This systematic review will include randomised controlled trials (RCTs), quasi and cluster RCTs focusing on integrated care interventions for community-dwelling older adults by multidisciplinary teams including health and social care professionals and GPs. The databases PUBMED, EMBASE, CINAHL, Central Register of Controlled Trials in the Cochrane Library and MEDLINE will be searched. The primary outcome measure will be functional status. Secondary outcomes will include: primary healthcare utilisation, secondary healthcare utilisation, participant satisfaction with care, health-related quality of life, nursing home admission and mortality. The methodological quality of the studies will be assessed using the Cochrane Risk of Bias Tool V.2. The elements of care integration will be mapped in the individual studies using the Rainbow Model of Integrated Care taxonomy. A meta-analysis will be completed, depending on the uniformity of the data. Grading of Recommendations, Assessment, Development and Evaluation will be used to assess the certainty of evidence. ETHICS AND DISSEMINATION: Formal ethical approval is not required as all data included are anonymous secondary data. Scientific outputs will be presented at relevant conferences and in collaboration with our public and patient involvement stakeholder panel of older adults at the Ageing Research Centre at the University of Limerick. PROSPERO REGISTRATION NUMBER: CRD42022309744.

The experiences of homecare workers in navigating the COVID-19 pandemic: a protocol for a qualitative study.

Background: Globally, there have been over 400 million confirmed cases of coronavirus disease 2019 (COVID-19), including over 6 million deaths, reported to the World Health Organization. Older adults have been disproportionally affected by COVID-19 in terms of morbidity and mortality. Homecare workers continue to play a key role in supporting vulnerable people to live in their own homes. Unlike other health professionals, whose interactions with patients are relatively brief, homecare workers sometimes spend hours with clients assisting with caregiving and functional tasks. In addition, these workers frequently provide companionship and emotional support. The COVID-19 pandemic has resulted in many challenges to this caregiving role given the risk of virus transmission to both clients and homecare workers in the community. Despite the vital role homecare workers have played, qualitative research exploring perspectives of homecare workers experiences' of providing help and care to older adults during the pandemic is sparse. This study aims to explore the experiences of homecare workers in navigating the COVID-19 pandemic. Methods: A qualitative interpretative approach will be applied in this study through the facilitation of focus groups with homecare workers. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) guidelines will be used to standardise the conduct and reporting of the research. Homecare workers will be recruited from a provider of homecare services in the Mid-West of Ireland (Clarecare) by a gatekeeper. Focus groups will be transcribed and analysed using a reflexive thematic approach supported by the use of NVIVO software package (Version 12). Conclusion: This study represents a necessary first step in the development of an evidence base for clinical, education, and support needs of homecare workers.

Formative evaluation of a community-based approach to reduce the incidence of Strep A infections and acute rheumatic fever.

OBJECTIVES: To explore the acceptability of a novel, outreached-based approach to improve primary and primordial prevention of Strep A skin sores, sore throats and acute rheumatic fever in remote Aboriginal communities. METHODS: A comprehensive prevention program delivered by trained Aboriginal Community Workers was evaluated using approximately fortnightly household surveys about health and housing and clinical records. RESULTS: Twenty-seven primary participants from three remote Aboriginal communities in the Northern Territory consented, providing 37.8 years of retrospective baseline data and 18.5 years of prospective data during the study period. Household members were considered to be secondary participants. Five Aboriginal Community Workers were trained and employed, delivering a range of supports to households affected by acute rheumatic fever including environmental health support and education. Clinical record audit and household self-report of Strep A infections were compared. No association between clinical- and self-report was identified. CONCLUSIONS: Ongoing participation suggests this outreach-based prevention program was acceptable and associated with improved reporting of household maintenance issues and awareness of prevention opportunities for Strep A infections. Implications for public health: Biomedical, clinic-based approaches to the management of Strep A infections in remote communities can be usefully augmented by outreach-based supports delivered by Aboriginal Community Workers responding to community needs.

Family carers' perspectives of the Alzheimer Café in Ireland.

Background: The Alzheimer Café is a psychosocial intervention shown to have benefits for family carers of people with dementia. Family carers experience a period of change across all aspects of their lives following the dementia diagnosis, and require new skills and tools to navigate these new landscapes. The objective of this research was to investigate family carers' perspectives of the Alzheimer Café in Ireland, and explore how attendance may translate into broader benefits in their lives. This paper also provides an overview of Alzheimer Café models, which exist internationally. Methods: Semi-structured interviews were conducted with nine family carers of people with dementia who were currently attending or had attended an Alzheimer Café in the preceding six months. The research was conducted in three Alzheimer Cafés in Ireland. Data analysis was conducted using Braun and Clarke's six step thematic analysis framework. Results: Community, atmosphere, activity and information were described as core features of the Alzheimer Café in Ireland. The Alzheimer Café was described as a community with a good atmosphere encompassing emotional support, friendship, equality and inclusion. Family carer also highlighted Alzheimer Cafés could potentially facilitate wider community awareness and engagement. The Alzheimer Café was shown to provide an activity which facilitated relationship building within care dyads as well as with other attendees. Several information streams were identified, including guest speaker input, attendees' shared experiences, and specific advice from healthcare professionals. Conclusion: The Alzheimer Café offers strong personal support to family carers of people with dementia. Our findings suggest that Alzheimer Cafés can build family carers' capacity to manage new social, environmental and cultural challenges associated with dementia. While it is important the Alzheimer Café is enjoyable, has useful information and is supportive, it is equally important that these features generate sustained improvements for family carers external to the Alzheimer Café.

Resource allocation decision-making in dementia care with and without budget constraints: a qualitative analysis.

Introduction: Health systems in many different countries have increasingly been reorienting the delivery of dementia care to home and community care settings. This paper provides information on how health and social care professionals (HSCPs) in Ireland make decisions on resource allocation for people with dementia living at home and how resource constraints affect their decisions and choices. Methods: A balance of care approach was used to assess resource allocation across six dementia case types, from low to high needs. Workshops were held with 24 HSCPs from multiple disciplines. Participants allocated services in two scenarios: allocation with and without a budget constraint. Nominal group technique was used to structure discussions around resource allocation in both scenarios. Thematic analysis was applied to analyse the qualitative data using a general inductive approach. Results: The following themes influenced allocative deliberations: whose needs are being met; what needs are identified; decision making context; decision making process; and allocation outcomes. Participants were proficient in making decisions, using 'decision rules' or heuristics to help them make decisions under fixed budget rules and sticking to conventional provision when constraints were in place. Conclusions: Freedom from a budget constraint allowed HSCPs to consider a broader range of services and to take a more expansive view on what needs should be considered, with a particular emphasis on adopting a proactive, preventative approach to the allocation of resources. The effect of the budget constraint overall was to narrow all considerations, using heuristics to limit the type of needs addressed and the range of services and supports provided. The consequences were a largely reactive, less personalised system of care. The findings emphasise the need for an integrated and comprehensive assessment process that is more concerned with individualised responses rather than relying on existing models of care alone.

GPs' attitudes towards the diagnosis and treatment of male urinary tract infections: a qualitative interview study in Ireland.

BACKGROUND: In general practice, males represent around 20% of the total number of urinary tract infection (UTI) consultations. The majority of UTI research focuses on the diagnosis and treatment of women with UTIs but there is little evidence on how male UTIs are treated. AIM: To better understand GPs' attitudes towards the diagnosis and treatment of male UTIs. This research aimed to support future investigations to determine best practice in diagnosis and treatment of male UTI. DESIGN AND SETTING: A qualitative interview study was carried out with 15 GPs across Ireland. METHOD: A topic guide was created to ensure consistency in interviews. The interviews were audiorecorded and transcribed verbatim. Transcripts were analysed using thematic analysis. RESULTS: Fifteen interviews with GPs were completed. Analysis indicated that GPs' knowledge of guidelines and implementation of them varied widely when deciding a treatment plan for a male presenting with UTI symptoms. There was clear consensus that male UTIs were uncommon and complicated to diagnose. Three GPs reported never treating a male UTI, while others reported treating <5 patients in their careers. There was an assumption that sexually transmitted infections (STI) take precedence in young males when presenting with similar symptoms. The use of antimicrobial treatment guidelines varied widely, in line with the interpretation of the origin and severity of symptoms. CONCLUSION: Male UTIs are perceived by GPs as rare and complicated. GPs expressed that patient age, resources, and guidelines available limited their confidence in diagnosing and treating male UTIs.

Modernising patient clothing: a Florence Nightingale Foundation project.

Christine Fitzgerald, Matron at The Hillingdon Hospitals NHS Foundation Trust (currently on secondment) discusses a project to boost patient self-esteem and dignity through the clothing provided for them to wear.

Online analysis of single cyanobacteria and algae cells under nitrogen-limited conditions using aerosol time-of-flight mass spectrometry.

Metabolomics studies typically perform measurements on populations of whole cells which provide the average representation of a collection of many cells. However, key mechanistic information can be lost using this approach. Investigating chemistry at the single cell level yields a more accurate representation of the diversity of populations within a cell sample; however, this approach has many analytical challenges. In this study, an aerosol time-of-flight mass spectrometer (ATOFMS) was used for rapid analysis of single algae and cyanobacteria cells with diameters ranging from 1 to 8 µm. Cells were aerosolized by nebulization and directly transmitted into the ATOFMS. Whole cells were determined to remain intact inside the instrument through a combination of particle sizing and imaging measurements. Differences in cell populations were observed after perturbing Chlamydomonas reinhardtii cells via nitrogen deprivation. Thousands of single cells were measured over a period of 4 days for nitrogen-replete and nitrogen-limited conditions. A comparison of the single cell mass spectra of the cells sampled under the two conditions revealed an increase in the dipalmitic acid sulfolipid sulfoquinovosyldiacylglycerol (SQDG), a chloroplast membrane lipid, under nitrogen-limited conditions. Single cell peak intensity distributions demonstrate the ability of the ATOFMS to measure metabolic differences of single cells. The ATOFMS provides an unprecedented maximum throughput of 50 Hz, enabling the rapid online measurement of thousands of single cell mass spectra.

Generic substitution of levetiracetam resulting in increased incidence of breakthrough seizures.

OBJECTIVE: We report on 4 patients having an increased incidence of seizures when treatment was switched from brand name levetiracetam (Keppra) to generic levetiracetam formulations. CASE SUMMARY: Patients reported an increase in seizure activity to their neurologists after treatment was switched from Keppra to generic levetiracetam formulations. To confirm the timeline of increased seizure activity with use of the generic drug and report these adverse events to MedWatch, we made a telephone call to each patient's pharmacy to collect information on dispensing dates and the generic formulations' manufacturers. Subsequent to the increase in seizure frequency with generic levetiracetam, treatment in all 4 patients was switched back to Keppra. Seizure frequency in all patients returned to baseline when Keppra was reinstituted. DISCUSSION: The Food and Drug Administration (FDA) considers generic medications to be therapeutically equivalent to their corresponding brand name formulation when the generic meets bioequivalence criteria. Considering the linear pharmacokinetic profile of levetiracetam, loss of seizure control or fluctuations of serum concentrations are unexpected if the patient remains on a consistent dose. However, there is growing evidence to support the concept that brand name antiepileptic drugs (AEDs) are not clinically equivalent to their generic counterparts. Because the FDA relies on voluntary reporting of adverse events from health-care professionals and consumers to their MedWatch program, underreporting makes it difficult to quantify the significance of brand to generic switches, and, equally important, generic to generic switches. CONCLUSIONS: Until the use of generic AEDs can be evaluated in a large randomized blinded controlled study, clinicians must be vigilant in their efforts to report to MedWatch adverse events resulting from the switch from an AED brand to generic formulation of an AED.

Young incarcerated men's perceptions of and experiences with HIV testing.

We analyzed incarcerated men's perceptions of and experiences with HIV testing. Interviews were conducted with 105 men, aged 18 to 29 years, in 4 states. Most men had received an HIV test while incarcerated because it was convenient or free or because they thought it was mandatory. At most sites, men believed they were HIV-negative because they never received test results. Some men did not know the diseases for which they had been tested. Some men avoided HIV testing outside prison because they lacked time, lacked resources, feared knowing the results, or perceived themselves to not be at risk. HIV testing programs for young men inside or outside prison should address barriers to HIV testing, communicate the meaning and extent of testing, and improve notification of those with HIV-negative results.

Melanopsin-dependent persistence and photopotentiation of murine pupillary light responses.

PURPOSE: To determine the relative contributions of inner and outer retinal photoreception to the pupillary light response. METHODS: Wild-type, retinal degenerate (rd/rd), and melanopsin mutant (opn4(-/-)) mice were tested for pupillary light responsiveness by video pupillometry before, during, and after exposure to supersaturating light intensities. Similar lighting protocols were used to probe responses of intrinsically photosensitive retinal ganglion cells (ipRGCs) recorded with multielectrode arrays ex vivo. RESULTS: Both outer retinal photoreceptors (rods and cones) and inner retinal photoreceptors (intrinsically photosensitive retinal ganglion cells [ipRGCs]) are sufficient to drive the pupillary light response in mice. After supersaturating light exposure, rather than bleaching or adapting, rd/rd mice showed paradoxical potentiation of responses to subsaturating light exposure. opn4(-/-) mice, in contrast, could not sustain pupillary constriction under continuous bright illumination, and showed desensitization after bright-light exposure. Both the intensity of light necessary to induce potentiation and the spectral sensitivity for sustained and potentiated responses differed from that necessary to trigger pupillary constriction, suggesting that photopotentiation is dependent on a pigment-state distinct from that triggering the pupillary light response itself. Multielectrode array recordings of ipRGCs from rd/rd retinas demonstrated persistent cell firing under continuous light exposure but did not show potentiation. CONCLUSIONS: Unique photoreceptive properties of intrinsically photosensitive RGCs confer resistance to bleaching and/or adaptation under continuous bright illumination to the pupillary light response and suggest the presence of a photopigment with multiple absorption states.

HIV and STD testing in prisons: perspectives of in-prison service providers.

Because individuals at risk for HIV and STDs are concentrated in prisons and jails, incarceration is an opportunity to provide HIV and STD testing. We interviewed 72 service providers working in U.S. prisons in four states about their experiences with and perceptions regarding HIV and STD testing in prison. Providers' job duties represented administration, education, security, counseling, and medical care. Providers' knowledge of prison procedures and programs related to HIV and STD testing was narrowly limited to their specific job duties, resulting in many missed opportunities for prevention counseling and referral. Suggestions include increasing health care and counseling staff so posttest counseling can be provided for those with negative as well as positive test results, providing additional prevention programs for incarcerated persons, improving staff training about HIV and STD testing, and improving communication among in-prison providers as well as between corrections and public health staff.