Can a Community-Led Intervention Offering Social Support and Health Education Improve Maternal Health? A Repeated Measures Evaluation of the PACT Project Run in a Socially Deprived London Borough.

Social adversity can significantly influence the wellbeing of mothers and their children. Maternal health may be improved through strengthened support networks and better health literacy. Health improvement at the population level requires optimizing of the collaboration between statutory health services, civic organizations (e.g., churches, schools), as well as community groups and parents. Two key elements in improving community engagement are co-production and community control. This study evaluated a co-produced and community-led project, PACT (Parents and Communities Together), for mothers in a deprived south London borough. The project offered social support and health education. Intended effects were improvements in mental health, health literacy, and social support, assessed by standardized measures in a pre-post design. Sixty-one mothers consented to take part in the evaluation. Significant improvements were found in mental health measures, in health literacy, for those with low literacy at baseline, and in overall and some specific aspects of social support. Satisfaction with the project was high. We found that the project engaged local populations that access statutory health services relatively less. We conclude that community-organized and community-led interventions in collaboration with statutory health services can increase accessibility and can improve mothers' mental health and other health-related outcomes.

Evaluation of a Community-Led Intervention in South London: How Much Standardization Is Possible?

It is widely recognized that public health interventions benefit from community engagement and leadership, yet there are challenges to evaluating complex, community-led interventions assuming hierarchies of evidence derived from laboratory experimentation and clinical trials. Particular challenges include, first, the inconsistency of the intervention across sites and, second, the absence of researcher control over the sampling frame and methodology. This report highlights these challenges as they played out in the evaluation of a community-organized health project in South London. The project aimed to benefit maternal mental health, health literacy, and social capital, and especially to engage local populations known to have reduced contact with statutory services. We evaluated the project using two studies with different designs, sampling frames, and methodologies. In one, the sampling frame and methodology were under community control, permitting a comparison of change in outcomes before and after participation in the project. In the other, the sampling frame and methodology were under researcher control, permitting a case-control design. The two evaluations led to different results, however: participants in the community-controlled study showed benefits, while participants in the researcher-controlled study did not. The principal conclusions are that while there are severe challenges to evaluating a community-led health intervention using a controlled design, the measurement of pre-/post-participation changes in well-defined health outcomes should typically be a minimum evaluation requirement, and confidence in attributing causation of any positive changes to participation can be increased by use of interventions in the project and in the engagement process itself that have a credible theoretical and empirical basis.

Enteral nutrition in critically ill adults: Literature review of protocols.

BACKGROUND: Managing nutrition in critically ill patients is an important intervention to promote healing. It is unknown whether the implementation of a protocol that guides enteral nutrition (EN) support is effective in improving the outcomes of critically ill patients. Furthermore, it is unknown whether a nurse-driven protocol is more or less effective than a protocol not managed by nurses. AIMS AND OBJECTIVES: The purpose of this literature review is to determine the current state of the science regarding evidence-based protocols for the administration and management of EN in critically ill patients. SEARCH STRATEGY, INCLUSION, AND EXCLUSION CRITERIA: Studies were identified by searching the Cumulative Index to Nursing and Allied Health Literature Plus database for the terms "enteral nutrition AND nursing." Studies with EN protocols for adult, critically ill patients published since 2011 were included. Studies without a protocol and those pertaining to paediatric, disease-specific, medical-surgical, or community-based populations were excluded. A total of 10 studies meeting the inclusion criteria were identified. CONCLUSIONS: Defining and implementing both early initiation of EN and adequate titration to goal are important for achieving the maximum nutritional advantage. The highest benefit is also derived from identifying and delivering an individualized caloric and/or protein goal. A protocol increases standardization of practice in relation to these themes as well as the management of gastric residual volume, complications, and potentially for managing feeding interruptions. Because of the significant effects of nursing care on nearly all aspects of the management and delivery of EN, a nurse-driven protocol may yield higher compliance and greater effectiveness than a protocol that is not nurse driven. RELEVANCE TO CLINICAL PRACTICE: Nurses are at the forefront of EN administration, although interprofessional collaboration remains paramount. Current practice must align with the best practice in the development and implementation of an EN protocol.

Clostridium difficile: More Challenging than Ever.

Clostridium difficile infection is not new, but it is posing more problems than ever before, described by the Centers for Disease Control and Prevention as an urgent threat. Its pathophysiology allows C difficile to be very difficult to manage, both within the hospital environment and in a patient's body. This article reviews clinical manifestations of the infection, outlines both medical and surgical treatment options, and discusses risk factors and predictors. Implications for nurses are thoroughly described. The epidemic proportion of C difficile infection gives cause for serious concern, especially for vulnerable populations, such as adults over age 65.

Nursing Student Perceptions of Structural Empowerment.

To meet role expectations for nurses, nurses must feel empowered. Faculty contributions to the learning environment for nursing students are critical. A descriptive analysis of student perceptions of empowerment within the learning environment was conducted using a form of Kanter's Conditions of Work Effectiveness Questionnaire; 203 participants from schools in 17 different states completed surveys. Subjects demonstrated moderate degrees of structural empowerment in their learning environment. This positive finding can be further investigated and used to fully prepare future nurses.

Staff nurses lead the way for improvement to shared governance structure.

The Magnet® model encompasses structural empowerment, transformational leadership, exemplary professional practice, and new knowledge, innovations, and improvements. As the American Nurses Credentialing Center reminds us, great leaders, structures, and nurses lead to great knowledge, innovation, and outcomes. One organization experienced the wisdom in this model through restructuring the systemwide staff nurse councils. The authors describe the steps by which this restructuring was accomplished and some of the positive effects on the work environment.

Identification of a novel cytosolic aldehyde dehydrogenase allele, ALDH1A1*4.

This paper reports the identification of a novel cytosolic aldehyde dehydrogenase 1 ( ALDH1A1 ) allele. One hundred and sixty-two Indo-Trinidadian and 85 Afro-Trinidadian individuals were genotyped. A novel ALDH1A1 allele, ALDH1A1*4 , was identified in an Indo-Trinidadian alcoholic with an A inserted at position -554 relative to the translational start site, +1. It was concluded that a wider cross-section of individuals needs to be evaluated in order to determine the representative frequency of the allele, and to see if it is associated with risk of alcoholism.

The clinical course of alcoholism in Trinidad and Tobago.

OBJECTIVE: The clinical course of alcoholism has been described as a series of distinct, alcohol-related life events that occur in an orderly sequence. However, whether that sequence differs, depending on ethnicity and country of origin, is less clear. The purposes of this study were to investigate the sequence and progression of alcohol-related life events in individuals of East Indian (Indo) and African (Afro) heritage on the islands of Trinidad and Tobago, and compare those results with data reported previously by the Collaborative study for the Genetics of Alcoholism (COGA). METHOD: Participants who were alcohol dependent (based on Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, criteria) and of Afro-Trinidadian and Tobagonian ancestry or Indo-Trinidadian ancestry were recruited from inpatient treatment facilities. A total of 148 alcohol-dependent men and women completed the Semi-Structured Assessment of the Genetics of Alcoholism, which assessed the physical, psychological, and social manifestations of alcohol dependence and other psychiatric disorders. RESULTS: A high degree of similarity in the sequence of alcohol-related life events was found between Indo-Trinidadian, Afro-Trinidadian and Tobagonian, and COGA participants. However, Trinidadian and Tobagonian alcoholics were more likely to endorse severe alcohol drinking in the form of binges (2 or more days of intoxication), blackouts, withdrawal, and medical consequences; however, they were less likely to endorse aggressive acts associated with drinking. Progression to alcohol dependence was significantly slower in Trinidadian and Tobagonian alcoholics than in the U.S. population of alcoholics, but severe alcohol symptoms were more commonly endorsed in Trinidadian and Tobagonians.

The clinical course of alcoholism in Trinidad and Tobago.

OBJECTIVE: The clinical course of alcoholism has been described as a series of distinct, alcohol-related life events that occur in an orderly sequence. However, whether that sequence differs, depending on ethnicity and country of origin, is less clear. The purposes of this study were to investigate the sequence and progression of alcohol-related life events in individuals of East Indian (Indo) and African (Afro) heritage on the islands of Trinidad and Tobago, and compare those results with data reported previously by the Collaborative study for the Genetics of Alcoholism (COGA). METHOD: Participants who were alcohol dependent (based on Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised, criteria) and of Afro-Trinidadian and Tobagonian ancestry or Indo-Trinidadian ancestry were recruited from inpatient treatment facilities. A total of 148 alcohol-dependent men and women completed the Semi-Structured Assessment of the Genetics of Alcoholism, which assessed the physical, psychological, and social manifestations of alcohol dependence and other psychiatric disorders. RESULTS: A high degree of similarity in the sequence of alcohol-related life events was found between Indo-Trinidadian, Afro-Trinidadian and Tobagonian, and COGA participants. However, Trinidadian and Tobagonian alcoholics were more likely to endorse severe alcohol drinking in the form of binges (2 or more days of intoxication), blackouts, withdrawal, and medical consequences; however, they were less likely to endorse aggressive acts associated with drinking. Progression to alcohol dependence was significantly slower in Trinidadian and Tobagonian alcoholics than in the U.S. population of alcoholics, but severe alcohol symptoms were more commonly endorsed in Trinidadian and Tobagonians. CONCLUSIONS: Identifying ethnic and country of origin differences in the clinical course of alcohol dependence may assist in the development of culturally sensitive intervention and prevention programs.

Developing leaders at every level: accountability and empowerment actualized through shared governance.

The shortage of frontline nursing staff and their managers in acute care organizations necessitates strategies to both use and recognize the unique knowledge and skills of these individuals. The authors describe one organization's successful implementation of a shared decision-making structure that promotes an empowering work environment in which professional fulfillment and personal satisfaction can flourish. With support and opportunity, leaders are developed across all levels of nursing.

Variations in alcohol-metabolizing enzymes in people of East Indian and African descent from Trinidad and Tobago.

The population of Trinidad and Tobago is composed mainly of people of East Indian (Indo-Trinidadians) and African (Afro-Trinidadians) ancestry. Differences in alcoholism rates exist between these two ethnic groups, and researchers have investigated whether these differences can be explained in part by variations in the genes encoding the alcohol-metabolizing enzymes alcohol dehydrogenase (ADH) 1B and 1C, and aldehyde dehydrogenase (ALDH) 1 and 2. Studies have demonstrated that a certain variant of the gene encoding ADH1B (ADH1B*3) is associated with a reduced risk of alcoholism in Afro-Trinidadians, as is a variant of the gene encoding ADH1C (i.e., ADH1C*1) in Indo-Trinidadians. An ALDH2 variant shown to have protective effects primarily in East Asians was not found in either Trinidadian ethnic group. However, a variant in the gene encoding cytosolic ALDH1A (i.e. ALDH1A1*1/*2) was found to be associated with an increase in alcohol dependence in Indo-Trinidadians.

ADH1C*2 allele is associated with alcohol dependence and elevated liver enzymes in Trinidad and Tobago.

Variants in alcohol dehydrogenase (ADH) genes differ between ethnic groups and have, in some studies, been found to be associated with alcohol dependence and alcoholic liver disease. This study sought to determine whether an association exists between ADH (ADH1C previously ADH3, ADH1B*2 previously ADH2*2) genotypes, alcohol dependence, drinking history, and liver function tests in the two major ethnic groups of Trinidad and Tobago (TT). One hundred and forty-five alcohol-dependent individuals of both East Indian (Indo-TT) and African (Afro-TT) ancestry, and 108 controls matched by age, sex, and education participated in the study. Serum levels of alanine and aspartate aminotransferase (ALT, AST), alkaline phosphatase (ALP), lactate dehydrogenase (LDH), and gamma-glutamyltransferase (GGT) as well as presence of HIV, hepatitis B surface antigen, and anti-hepatitis C virus antibody were determined. There was a significant difference in the distribution of ADH1C allele polymorphisms between the ethnic groups (P<.0001). Forty-three percent of the Indo-TT were found to have one ADH1C*2 allele and 5% were homozygous, whereas, only 23% of Afro-TT had one allele and one was homozygous. Only three individuals had an ADH1B*2 allele (one Indo-TT alcohol dependent, two Indo-TT controls). The ADH1C*2 allele was significantly associated with alcohol dependence overall and within Indo-TT ancestry, however, it was not associated with current or heaviest alcohol consumption levels. Individuals with at least one ADH1C*2 allele also had significantly elevated levels of ALP (P<.02) and GGT (P<.02) as compared to individuals homozygous for ADH1C*. Additionally, GGT levels were also found to be elevated (P<.02) within Indo-TT alcohol dependents with at least one ADH1C*2 allele but not within the Afro-TT alcohol dependents with that allele. A linear regression that included alcohol dependence and levels of alcohol consumption confirmed that levels of serum GGT were significantly associated with the ADH1C*2 genotype. These results suggest that ADH1C polymorphisms are associated with alcohol dependence and alcohol associated elevations of liver enzymes in a population with a low frequency of ADH1B2 alleles.

Diet-induced hyperphagia in the rat is influenced by sex and exercise.

Caloric intake is increased in rats fed a diet containing greater fat or sugar than that found in laboratory chow. Because such diet-induced hyperphagia has been studied primarily in sedentary male rats, our goal here was to investigate the effects of sex and exercise on caloric intake of a diet (chow supplemented with sweet milk) chosen for its ability to stimulate hyperphagia. Rats were housed individually in cages that provided access to running wheels, and daily caloric intake of chow alone and then chow plus sweet milk was monitored during sedentary and active conditions. In sedentary rats, chow intake was greater in males compared with females. Wheel running produced similar decreases in chow intake in both sexes. Availability of the chow plus milk diet increased caloric intake compared with that observed in chow-fed rats. This diet-induced hyperphagia was significantly greater in sedentary females (35.7 +/- 3.1% increase) relative to sedentary males (9.1 +/- 2.2% increase). In addition, 35% of sedentary females consuming the chow plus milk diet developed estrous cycle disruptions. Wheel running decreased intake of the chow plus milk diet in both sexes. In active males, diet-induced hyperphagia was abolished; caloric intake was reduced to that observed during chow feeding. In active female rats, diet-induced hyperphagia was attenuated but not abolished; caloric intake of the chow plus milk diet remained greater than that observed during chow feeding. We conclude that female rats are more vulnerable than male rats to this form of diet-induced hyperphagia.

The prescribing of psychotropic drugs in mental health services in Trinidad.

OBJECTIVE: To describe, analyze, and interpret patterns of psychotropic drug prescribing in new psychiatric patients attending psychiatric outpatient clinics in the Caribbean island of Trinidad. DESIGN AND METHODS: This was a cross-sectional study of psychotropic drug prescribing by psychiatrists for 132 new psychiatric outpatients who were seen at the outpatient clinics surveyed and who were entering the mental health system during the period of research, November 1998 through February 1999. RESULTS: A single patient could be prescribed more than one psychotropic drug. Antidepressant drugs were the class of psychotropic drugs most prescribed (79 of 132 patients, 59.8%), followed by antipsychotic drugs (67 of 132 patients, 50.8%). Tricyclic antidepressants (TCAs) were the antidepressants most prescribed (58 of the 79 patients), mainly amitriptyline (53 of the 58). Fluoxetine was the only selective serotonin reuptake inhibitor (SSRI) prescribed (21 of the 79 patients prescribed antidepressants). Of the 67 patients receiving antipsychotic drugs, phenothiazines accounted for 41 of those 67, including trifluoperazine (14 of the 41) and thioridazine (13 of the 41). The individual antipsychotic most prescribed was sulpiride (21 of the 67 patients). Anticholinergic drugs were prescribed to 20 of the 132 patients (15.1%). Eighty-three of the patients were prescribed more than one drug concomitantly (either more than one psychotropic or a combination of psychotropic(s) and nonpsychotropic(s)). Prescription by ethnicity, age, and gender coincided with the morbidity rates encountered in these patients. The prescribing of SSRIs to persons of African or East Indian ethnicity was significantly lower than it was for persons of mixed heritage. CONCLUSIONS: The prescription patterns of psychotropic drugs in Trinidad revealed the psychiatrists' preferences for traditional psychotropic drugs, the moderate use of anticholinergic drugs, and polypharmacy in some cases, with probable predisposition to adverse drug reactions. Given our results and based on the evaluation of individual patients, consideration should be given to a broader use of the newer antidepressants (SSRIs) and antipsychotics. Unless justified, polypharmacy should be avoided.

The prescribing of psychotropic drugs in mental health services in Trinidad

Objective: To describe, analyze, and interpret patterns of psychotropic drug prescribing in new psychiatric patients attending psychiatric outpatients clinics in the Caribbean island of Trinidad. Design and Methods: This was a cross-sectional study of psychotropic drug prescribing by psychiatrists for 132 new psychiatric outpatients who were seen at the outpatient clinics surveyed and who were entering the mental health system during the period of research, November 1998 through February 1999. Results: A single patient could be prescribed more than one psychotropic drug. Antidepressant drugs were the class of psychotropic drugs most prescribed (70 of 132 patients, 59.8 percent), followed by antipsychotropic drugs (67 of 132 patients, 50.8 percent). Tricyclic antidepressants (TCAs) were the antidepressants most prescribed (58 of the 79 patients), mainly amitriptyline (53 of the 58). Fluoxetine was the only selective serotonin reuptake inhibitor (SSRI) prescribed (21 of the 79 patients prescribed antidepressants). Of the 67 patients receiving antipsychotic drugs, phenothiazines accounted for 41 of those 67, including trifluoperazine (14 of the 41) and thioridazine (13 of the 41). The individual antipsychotic most prescribed was sulpiride (21 of the 67 patients). Anticholinergic drugs were prescribed to 20 of the 132 patients (15.1 percent). Eighty-three of the patients were prescribed more than one drug concomitantly (either more than one psychotropic or a combination of psychotropic(s) and nonpsychotropic(s). Prescription by ethnicity, age, and gender coincided with the morbidity rates encountered in these patients. The prescribing of SSRIs to persons of African or East Indian ethnicity was significantly lower than it was for persons of mixed heritage. Conclusions: The prescription patterns of psychotropic drugs in Trinidad revealed the psychiatrists' preferences for traditional psychotropic drugs, the moderate use of anticholinergic drugs, and polypharmacy in some cases, with probable predisposition to adverse drug reactions. Given our results and based on the evaluation of the individual patients, consideration should be given to a broader use of the newer antidepressants (SSRIs) and antipsychotics. Unless justified, polypharmacy should be avoided (AU)

The prescribing of psychotropic drugs in mental health services in Trinidad

Objective. To describe, analyze, and interpret patterns of psychotropic drug prescribing in new psychiatric patients attending psychiatric outpatient clinics in the Caribbean island of Trinidad. Design and Methods. This was a cross-sectional study of psychotropic drug prescribing by psychiatrists for 132 new psychiatric outpatients who were seen at the outpatient clinics surveyed and who were entering the mental health system during the period of research, November 1998 through February 1999. Results. A single patient could be prescribed more than one psychotropic drug. Antidepressant drugs were the class of psychotropic drugs most prescribed (79 of 132 patients, 59.8 percent), followed by antipsychotic drugs (67 of 132 patients, 50.8 percent). Tricyclic antidepressants (TCAs) were the antidepressants most prescribed (58 of the 79 patients), mainly amitriptyline (53 of the 58). Fluoxetine was the only selective serotonin reuptake inhibitor (SSRI) prescribed (21 of the 79 patients prescribed antidepressants). Of the 67 patients receiving antipsychotic drugs, phenothiazines accounted for 41 of those 67, including trifluoperazine (14 of the 41) and thioridazine (13 of the 41). The individual antipsychotic most prescribed was sulpiride (21 of the 67 patients). Anticholinergic drugs were prescribed to 20 of the 132 patients (15.1 percent). Eighty-three of the patients were prescribed more than one drug concomitantly (either more than one psychotropic or a combination of psychotropic(s) and nonpsychotropic(s)). Prescription by ethnicity, age, and gender coincided with the morbidity rates encountered in these patients. The prescribing of SSRIs to persons of African or East Indian ethnicity was significantly lower than it was for persons of mixed heritage. Conclusions. The prescription patterns of psychotropic drugs in Trinidad revealed the psychiatrists' preferences for traditional psychotropic drugs, the moderate use of anticholinergic drugs, and polypharmacy in some cases, with probable predisposition to adverse drug reactions. Given our results and based on the evaluation of individual patients, consideration should be given to a broader use of the newer antidepressants (SSRIs) and antipsychotics. Unless justified, polypharmacy should be avoided