Evaluation of knowledge, attitude, practices and effectiveness of menstrual hygiene interventions in rural schools from Lilongwe, Malawi.

BACKGROUND: Menstrual hygiene management (MHM) is associated with the menstrual process in women and adolescent girls who face cultural and financial challenges in rural areas of many developing countries. As part of the pilot study, we assessed the sustainability and effectiveness of the approaches and lessons learned from the MHM project intervention in rural areas of Lilongwe, Malawi. METHODS: Rural primary schools (n = 4) were purposively selected where an MHM intervention was implemented in Lilongwe, Malawi. The study employed a mixed-method research design. Assessments and data collection were performed through surveys of learners, literature reviews, key informant interviews (KIIs) (n = 90), and 20 focus group discussions (FGDs). The study participants included boys and adolescent girls (n = 100, 11-19 years; grades 5-8), teachers, mother groups, and community leaders from the selected schools. RESULTS: All the schools had water sanitation and hygiene facilities and latrines (45% improved, 54% ventilated improved pit latrines - VIPs) that promoted menstrual hygiene for adolescent girls. However, two of the schools studied (50%, n = 4) did not have separate washrooms for changing sanitary materials. There was a slight increase in latrine coverage in Kabuthu zone communities (90% at baseline versus 93.4% at midterm). However, the coverage dropped to 85.7% at the final evaluation, which was attributed to too much rain received in the area that damaged most of the latrines. There was a significant reduction (p < 0.05) in the number of girls failing to attend classes due to menstruation (70% at baseline versus 14% at final evaluation). Furthermore, the project resulted in the majority of girls (94.4%) having access to school. There was a strong uptake and adoption of sanitary products (reusable pads and menstrual cups) among adolescent girls of all age groups. The study has demonstrated that the inclusion of key stakeholders such as health workers, parents, mother groups and community leaders promoted the uptake and sustainability of reusable pads and menstrual cups and MHM interventions and programs. CONCLUSION: The MHM project implementation improved adolescent girls' education in the area. The inclusion of boys and other key stakeholders in the health education talks addressed issues of stigma and discrimination. The study, therefore, calls for comprehensive training on MHM and hygiene education to remove discrimination and harmful cultural practices.

Committee Opinion No. 399: Management of Tick Bites and Lyme Disease During Pregnancy.

OBJECTIVE: Lyme disease is an emerging infection in Canada caused by the bacterium belonging to the Borrelia burgdorferi sensu lato species complex, which is transmitted via the bite of an infected blacklegged tick. Populations of blacklegged ticks continue to expand and are now established in different regions in Canada. It usually takes more than 24 hours of tick attachment to transfer B. burgdorferi to a human. The diagnosis of early localized Lyme disease is made by clinical assessment, as laboratory tests are not reliable at this stage. Most patients with early localized Lyme disease will present with a skin lesion (i.e., erythema migrans) expanding from the tick bite site and/or non-specific "influenza-like" symptoms (e.g., arthralgia, myalgia, and fever). Signs and symptoms may occur from between 3 and 30 days following the tick bite. The care of pregnant patients with a tick bite or suspected Lyme disease should be managed similarly to non-pregnant adults, including the consideration of antibiotics for prophylaxis and treatment. The primary objective of this committee opinion is to inform practitioners about Lyme disease and provide an approach to managing the care of pregnant women who may have been infected via a blacklegged tick bite. INTENDED USERS: Health care providers who care for pregnant women or women of reproductive age. TARGET POPULATION: Women of reproductive age. EVIDENCE: In November 2018, Medline, EMBASE, PubMed, and CENTRAL databases were searched for 2 main categories: (1) Lyme disease and (2) other tick-borne diseases. Because the main focus was Lyme disease, and considering the limited number of the articles, no further filters were applied for publication time or type of study. For other tick-borne diseases, the results were restricted to a publication date within the last 10 years (2008-2018). The search terms were developed using MeSH terms and keywords including Lyme Disease, Pregnancy, Pregnant Women, Pregnancy Complications, Ehrlichiosis, Anaplasmosis, Rocky Mountain Spotted Fever, Babesiosis, Tularemia, Powassan Virus, Encephalitis Viruses, Tick-Borne, Tick-Borne Diseases, Colorado Tick Fever, Q Fever, Relapsing Fever, and Southern Tick-Associated Rash Illness. All articles on Lyme disease and other tick-borne diseases with a target population of pregnant women were included; other groups and populations were excluded. VALIDATION METHODS: The content and recommendations of this committee opinion were drafted and agreed upon by the authors. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication.

Diagnostic Performance of High Sensitivity Compared with Contemporary Cardiac Troponin I for the Diagnosis of Acute Myocardial Infarction.

BACKGROUND: We examined the diagnostic performance of high-sensitivity cardiac troponin I (hs-cTnI) vs contemporary cTnI with use of the 99th percentile alone and with a normal electrocardiogram (ECG) to rule out acute myocardial infarction (MI) and serial changes (deltas) to rule in MI. METHODS: We included consecutive patients presenting to a US emergency department with serial cTnI onclinical indication. Diagnostic performance for acute MI, including MI subtypes, and 30-day outcomes were examined. RESULTS: Among 1631 patients, MI was diagnosed in 12.9% using the contemporary cTnI assay and in 10.4% using the hs-cTnI assay. For ruling out MI, contemporary cTnI ≤99th percentile at 0, 3, and 6 h and a normal ECG had a negative predictive value (NPV) of 99.5% (95% CI, 98.6-100) and a sensitivity of 99.1% (95% CI, 97.4-100) for diagnostic and safety outcomes. Serial hs-cTnI measurements ≤99th percentile at 0 and 3 h and a normal ECG had an NPV and sensitivity of 100% (95% CI, 100-100) for diagnostic and safety outcomes. For ruling in MI, contemporary cTnI measurements had specificities of 84.4% (95% CI, 82.5-86.3) at presentation and 78.7% (95% CI, 75.4-82.0) with serial testing at 0, 3, and 6 h, improving to 89.2% (95% CI, 87.1-91.3) by using serial cTnI changes (delta, 0 and 6 h) >150%. hs-cTnI had specificities of 86.9% (95% CI, 85.1-88.6) at presentation and 85.7% (95% CI, 83.5-87.9) with serial testing at 0 and 3 h, improving to 89.3% (95% CI, 87.3-91.2) using a delta hs-cTnI (0 and 3 h) >5 ng/L. CONCLUSIONS: hs-cTnI and contemporary cTnI assays are excellent in ruling out MI following recommendations predicated on serial testing and the 99th percentile with a normal ECG. For ruling in MI, deltas improve the specificity. ClinicalTrials.gov Identifier: NCT02060760.

Occupational Therapy Interventions for Adults With Cancer.

This Evidence Connection describes a case report of a man with non-Hodgkin's lymphoma who underwent an allogenic stem cell transplant. The occupational therapy assessment and treatment processes for an outpatient rehabilitation setting are described. Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Project.

Incidence of Undetectable, Measurable, and Increased Cardiac Troponin I Concentrations Above the 99th Percentile Using a High-Sensitivity vs a Contemporary Assay in Patients Presenting to the Emergency Department.

INTRODUCTION: We compared the incidence of undetectable [below the limit of detection (LoD)], measurable (LoD to 99th percentile), and increased cardiac troponin I (cTnI) concentrations above the 99th percentile between Abbott high-sensitivity cTnI (hs-cTnI) and contemporary cTnI assays in a US emergency department population. METHODS: Patients (n = 2100) presenting to the emergency department who had serial cTnI (0, 3, 6, 9 h) measurements ordered on clinical indication were enrolled. Contemporary cTnI [Abbott Architect used clinically; 99th percentile: 0.030 µg/L (30 ng/L)] and hs-cTnI [Abbott investigational; sex-specific 99th percentiles: female (F) 16 ng/L, male (M) 34 ng/L] assays simultaneously measured fresh EDTA plasma. RESULTS: The hs-cTnI assay measured fewer undetectable cTnI concentrations compared to the contemporary cTnI assay across baseline (F: 31% vs 47%, M: 22% vs 40%) and serial (F: 21% vs 46%; M: 19% vs 54%) measurements. Conversely, the proportion of measurable cTnI concentrations was higher using hs-cTnI compared to contemporary cTnI assay across both baseline (F: 46% vs 31%; M: 60% vs 33%) and serial (F: 48% vs 28%; M: 83% vs 40%) measurements. The overall proportion of patients with increased cTnI concentrations above the 99th percentile was not significantly different between the contemporary (31%) and hs-cTnI (26%) assays (P = 0.09). CONCLUSIONS: In patients presenting to the emergency department, the use of the Abbott hs-cTnI assay provides clinicians with more numeric cTnI concentrations. This occurs via a shift from results below the LoD to those between the LoD and the 99th percentile and does not increase in the number of cTnI concentrations above the 99th percentile.

Application of the World Health Organization Programmatic Assessment Tool for Risk of Measles Virus Transmission-Lessons Learned from a Measles Outbreak in Senegal.

The World Health Organization (WHO) African Region set a goal for regional measles elimination by 2020; however, regional measles incidence was 125/1,000,000 in 2012. To support elimination efforts, the WHO and U.S. Centers for Disease Control and Prevention developed a tool to assess performance of measles control activities and identify high-risk areas at the subnational level. The tool uses routinely collected data to generate district-level risk scores across four categories: population immunity, surveillance quality, program performance, and threat assessment. To pilot test this tool, we used retrospective data from 2006 to 2008 to identify high-risk districts in Senegal; results were compared with measles case-based surveillance data from 2009 when Senegal experienced a large measles outbreak. Seventeen (25%) of 69 districts in Senegal were classified as high or very high risk. The tool highlighted how each of the four categories contributed to the total risk scores for high or very high risk districts. Measles case-based surveillance reported 986 cases during 2009, including 368 laboratory-confirmed, 540 epidemiologically linked, and 78 clinically compatible cases. The seven districts with the highest numbers of laboratory-confirmed or epidemiologically linked cases were within the capital region of Dakar. All except one of these seven districts were estimated to be high or very high risk, suggesting that districts identified as high risk by the tool have the potential for measles outbreaks. Prospective use of this tool is recommended to help immunization and surveillance program managers identify high-risk areas in which to strengthen specific programmatic weaknesses and mitigate risk for potential measles outbreaks.

Diagnosis of type 1 and type 2 myocardial infarction using a high-sensitivity cardiac troponin I assay with sex-specific 99th percentiles based on the third universal definition of myocardial infarction classification system.

BACKGROUND: The frequency and characteristics of myocardial infarction (MI) subtypes per the Third Universal Definition of MI (TUDMI) classification system using high-sensitivity (hs) cardiac troponin assays with sex-specific cutoffs is not well known. We sought to describe the diagnostic characteristics of type 1 (T1MI) and type 2 (T2MI) MI using an hs-cardiac troponin I (hs-cTnI) assay with sex-specific cutoffs. METHODS: A total of 310 consecutive patients with serial cTnI measurements obtained on clinical indication were studied with contemporary and hs-cTnI assays. Ninety-ninth percentile sex-specific upper reference limits (URLs) for the hs-cTnI assay were 16 ng/L for females and 34 ng/L for males. The TUDMI consensus recommendations were used to define and adjudicate MI based on each URL. RESULTS: A total of 127 (41%) patients had at least 1 hs-cTnI exceeding the sex-specific 99th percentiles, whereas 183 (59%) had hs-cTnI within the reference interval. Females had more myocardial injury related to supply/demand ischemia than males (39% vs 18%, P = 0.01), whereas males had more multifactorial or indeterminate injury (52% vs 33%, P = 0.05). By hs-cTnI, there were 32 (10%) acute MIs, among which 10 (3%) were T1MI and 22 (7%) were T2MI. T2MI represented 69% (22 out of 32) of all acute MIs, whereas T1MI represented 31% (10 out of 32). Ninety-five patients (31%) had an increased hs-cTnI above the 99th percentile but did not meet criteria for acute MI. The most common triggers for T2MI were tachyarrhythmias, hypotension/shock, and hypertension. By contemporary cTnI, more MIs (14 T1MI and 29 T2MI) were diagnosed. By contemporary cTnI, there were 43 MIs, 14 T1MI, and 29 T2MI. CONCLUSIONS: Fewer MI diagnoses were found with the hs-cTnI assay, contrary to the commonly accepted idea that hs-cTnI will lead to excessive false-positive diagnoses.

Opinion du comité No 399 : Prise en charge des morsures de tiques et de la maladie de Lyme pendant la grossesse.

Objectif: La maladie de Lyme est une infection émergente au Canada. Causée par une bactérie appartenant au complexe d'espèces Borrelia burgdorferi sensu lato, elle est transmise par la morsure d'une tique à pattes noires infectée. Les populations de tiques à pattes noires continuent de se propager et sont maintenant établies dans différentes régions du Canada. Il faut habituellement plus de 24 heures de temps d'attachement de la tique pour que la B. burgdorferi soit transmise à l'humain. Le diagnostic de la maladie de Lyme au stade localisé précoce est posé au moyen d'une évaluation clinique, puisque les analyses de laboratoire ne sont pas fiables à ce stade. La plupart des patients atteints de la maladie de Lyme au stade localisé précoce manifestent une lésion cutanée (c.-à-d. érythème migrant) qui s'étend à partir du site de la morsure et/ou des symptômes non spécifiques qui rappellent l'influenza (p. ex. arthralgie, myalgie et fièvre). Les signes et symptômes peuvent se manifester de 3 à 30 jours après la morsure de tique. Il y a lieu de prendre en charge les patientes enceintes qui présentent une morsure de tique ou une maladie de Lyme soupçonnée en leur prodiguant des soins semblables à ceux de la population adulte non enceinte, ce qui implique d'envisager le recours aux antibiotiques pour la prophylaxie et le traitement. L'objectif principal de la présente opinion du comité est de renseigner les praticiens sur la maladie de Lyme et de fournir une façon d'aborder la prise en charge des soins prodigués aux femmes enceintes qui pourraient avoir été infectées par une morsure de tique à pattes noires. Utilisateurs concernés: Les fournisseurs de soins de santé qui prodiguent des soins aux patientes enceintes ou aux femmes en âge de procréer. Population cible: Les femmes en âge de procréer. Données probantes: En novembre 2018, des recherches ont été effectuées dans les bases de données Medline, EMBASE, PubMed et CENTRAL relativement à deux catégories principales : (1) maladie de Lyme, (2) autres maladies transmises par les tiques. Puisque la recherche était principalement axée sur la maladie de Lyme et compte tenu du nombre limité d'articles à ce sujet, aucun filtre supplémentaire n'a été appliqué pour la date de publication ou le type d'étude. Pour ce qui est des autres maladies transmises par les tiques, les résultats ont été restreints à une date de publication qui s'inscrit dans les 10 dernières années (2008­2018). Les termes de recherche ont été déterminés au moyen des termes de recherche MeSH et de mots clés : Lyme Disease, Pregnancy, Pregnant Women, Pregnancy Complications, Ehrlichiosis, Anaplasmosis, Rocky Mountain Spotted Fever, Babesiosis, Tularemia, Powassan Virus, Encephalitis Viruses, Tick-Borne, Tick-Borne Diseases, Colorado Tick Fever, Q Fever, Relapsing Fever, et Southern Tick-Associated Rash Illness. Tous les articles portant sur la maladie de Lyme et autres maladies transmises par les tiques comprenant une population cible de femmes enceintes ont été inclus; les autres groupes et populations ont été exclus. Méthodes de validation: Le contenu et les recommandations de la présente opinion du comité ont été rédigés et acceptés par les auteurs. Le conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version définitive aux fins de publication.

Young adults and the Affordable Care Act of 2010.

The Patient Protection and Affordable Care Act includes several provisions that promise to stem the rapidly rising tide of uninsured young adults, one of the largest uninsured segments of the population. These include the ability to enroll in a parent's health plan up to age 26, beginning in September 2010; significant expansion in eligibility for Medicaid, beginning in 2014; and the creation of health insurance exchanges with subsidized private insurance for people with low and moderate incomes, also beginning in 2014. Of the 14.8 million uninsured young adults, up to 12.1 million may gain subsidized insurance once all the law's provisions go into effect in 2014: 7.2 million may gain coverage under Medicaid and 4.9 million may gain subsidized private coverage through the insurance exchanges. In addition, about 1 million uninsured young adults are expected to join their parents' policies over the next three years.

Rite of passage: young adults and the Affordable Care Act of 2010.

Young adults between the ages of 19 and 29 represent one of the largest segments of the uninsured; approximately 13.7 million were uninsured in 2008. The problem is linked to critical transition points in young adults' lives: aging off parents' coverage when they graduate from either high school or college, and losing eligibility for public programs like Medicaid and the Children's Health Insurance Program when they turn 19. Health reform, however, has the potential to cover millions of uninsured young people. This issue brief describes critical provisions in the new law that will help, including the ability to enroll in a parent's health plan up to age 26 beginning in September 2010; significant expansion in eligibility for Medicaid, beginning in 2014; and the creation of state or regional health insurance exchanges with subsidized private insurance for people with low and moderate incomes, also beginning in 2014.

Small businesses and the Affordable Care Act of 2010.

The Patient Protection and Affordable Care Act (ACA) includes several short- and long-term provisions designed to help small businesses pay for and maintain health insurance for their workers, and to allow workers without employer coverage to gain access to affordable, comprehensive health insurance. Provisions include a small business tax credit to offset premium costs for firms that offer coverage starting this taxable year, establishment of state-based insurance exchanges that promise to lower administrative costs and pool risk more broadly, and creation of new market rules and an essential benefit standard to protect small firms and their workers. Analysis shows that up to 16.6 million workers are in firms that would be eligible for the tax credit in 2010 to 2013. Over the next 10 years, small businesses and organizations could receive an estimated $40 billion in federal support through the premium credit program.

Young, uninsured, and seeking change: health coverage of young adults and their views on health reform. Findings from the Commonwealth fund Survey of Young Adults (2009).

Young adults are one of the largest uninsured segments of the population. This analysis of new survey data from The Commonwealth Fund finds almost half are without insurance at some time during the year. As they hit milestones like high school or college graduation, they face loss of coverage as they are dropped from parents' plans or public insurance programs. In the current economic climate, young adults are less likely to find jobs, and when they do, are frequently offered positions that come without benefits. Provisions in the health reform bills could help young adults by expanding Medicaid eligibility, creating a health insurance exchange with premium subsidies, and requiring insurers and employers to allow young adults to remain on parents' plans up to age 26 or 27. These provisions could help young adults obtain and keep affordable, comprehensive coverage through transitions from school to work and from job to job.

Out of options: why so many workers in small businesses lack affordable health insurance, and how health care reform can help. Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2007.

Although employer-sponsored health insurance forms the backbone of the health insurance system in the United States, small businesses are finding it increasingly difficult to provide their workers with comprehensive coverage. In 2007, only 25 percent of employees in small businesses had coverage through their own employers, compared with 74 percent of workers in large firms. Because there are few sources of affordable coverage outside the employer-based system, millions of employees in small businesses are uninsured or have inadequate health insurance. In 2007, 52 percent of workers in small businesses were uninsured or underinsured during the year, compared with half as many employees in large businesses. Congressional bills to reform the health system include provisions specifically aimed at helping small businesses and their employees gain access to affordable, comprehensive coverage.

Failure to protect: why the individual insurance market is not a viable option for most U.S. families: findings from the Commonwealth Fund Biennial Health Insurance Survey, 2007.

Between 2001 and 2007, an increasing share of adults with private insurance--whether employer-based coverage or individual market plans--spent a large amount of their income on premiums and out-of-pocket medical costs, were underinsured, and/or avoided needed health care because of costs. Those with coverage obtained in the individual market were the most affected. Over the last three years, nearly three-quarters of people who tried to buy coverage in this market never actually purchased a plan, either because they could not find one that fit their needs or that they could afford, or because they were turned down due to a preexisting condition. Even people enrolled in employer-based plans are spending larger amounts of their income on health care and curtailing their use of needed services to save money. The findings underscore the need for an expansion of affordable health insurance options, particularly during a time of mounting job losses.

Rite of passage? Why young adults become uninsured and how new policies can help, 2009 update.

Young adults ages 19 to 29 are one of the largest segments of the U.S. population without health insurance: 13.2 million, or 29 percent, lacked coverage in 2007. They often lose coverage at age 19 or upon high school or college graduation: nearly two of five (38%) high school graduates who do not enroll in college and one-third of college graduates are uninsured for a time during the first year after graduation. Twenty-six states have passed laws to expand coverage of dependents to young adults under parents' insurance policies. Congressional proposals to reform the health system could help uninsured young adults gain coverage and prevent others from losing it. This is the seventh edition of Rite of Passage, first published by The Commonwealth Fund in 2003.

Measles resurgence in southern Africa: challenges to measles elimination.

INTRODUCTION: In seven southern African countries (Botswana, Lesotho, Malawi, Namibia, South Africa, Swaziland and Zimbabwe), following implementation of a measles mortality reduction strategy starting in 1996, the number of annually reported measles cases decreased sharply to less than one per million population during 2006-2008. However, during 2009-2010, large outbreaks occurred in these countries. In 2011, a goal for measles elimination by 2020 was set in the World Health Organization (WHO) African Region (AFR). We reviewed the implementation of the measles control strategy and measles epidemiology during the resurgence in the seven southern African countries. METHODS: Estimated coverage with routine measles vaccination, supplemental immunization activities (SIA), annually reported measles cases by country, and measles surveillance and laboratory data were analyzed using descriptive analysis. RESULTS: In the seven countries, coverage with the routine first dose of measles-containing vaccine (MCV1) decreased from 80% to 65% during 1996-2004, then increased to 84% in 2011; during 1996-2011, 79,696,523 people were reached with measles vaccination during 45 SIAs. Annually reported measles cases decreased from 61,160 cases to 60 cases and measles incidence decreased to <1 case per million during 1996-2008. During 2009-2010, large outbreaks that included cases among older children and adults were reported in all seven countries, starting in South Africa and Namibia in mid-2009 and in the other five countries by early 2010. The measles virus genotype detected was predominantly genotype B3. CONCLUSION: The measles resurgence highlighted challenges to achieving measles elimination in AFR by 2020. To achieve this goal, high two-dose measles vaccine coverage by strengthening routine immunization systems and conducting timely SIAs targeting expanded age groups, potentially including young adults, and maintaining outbreak preparedness to rapidly respond to outbreaks will be needed.

Mortality amenable to health care in the United States: the roles of demographics and health systems performance.

This article examines associations of socio-demographic and health-care indicators, and the statistic 'mortality amenable to health care' (amenable mortality) across the US states. There is over two-fold variation in amenable mortality, strongly associated with the percentages of state populations that are poor or black. Controlling for poverty and race with bi- and multi-variate analyses, several indicators of health system performance, such as hospital readmission rates and preventive care for diabetics, are significantly associated with amenable mortality. A significant crude association of 'uninsurance' and amenable mortality rates is no longer statistically significant when poverty and race are controlled. Overall, there appear to be opportunities for states to focus on specific modifiable health system performance indicators. Comparative rates of amenable mortality should be useful for estimating potential gains in population health from delivering more timely and effective care and for tracking the health outcomes of efforts to improve health system performance.

Amplicon-plus targeting technology (APTT) for rapid production of a highly unstable vaccine protein in tobacco plants.

High-level expression of transgenes is essential for cost-effective production of valuable pharmaceutical proteins in plants. However, transgenic proteins often accumulate in plants at low levels. Low levels of protein accumulation can be caused by many factors including post-transcriptional gene silencing (PTGS) and/or rapid turnover of the transgenic proteins. We have developed an Amplicon-plus Targeting Technology (APTT), by using novel combination of known techniques that appears to overcome both of these factors. By using this technology, we have successfully expressed the highly-labile L1 protein of canine oral papillomavirus (COPV L1) by infecting transgenic tobacco plants expressing a suppressor of post-transcriptional gene silencing (PTGS) with a PVX amplicon carrying a gene encoding L1, and targeting the vaccine protein into the chloroplasts. Further, a scalable "wound-and-agrospray" inoculation method has been developed that will permit high-throughput Agrobacterium inoculation of Nicotiana tabacum, and a spray-only method (named "agrospray") for use with N. benthamiana to allow large-scale application of this technology. The good yield and short interval from inoculation to harvest characteristic of APTT, combined with the potential for high-throughput achieved by use of the agrospray inoculation protocol, make this system a very promising technology for producing high value recombinant proteins, especially those known to be highly labile, in plants for a wide range of applications including producing vaccines against rapidly evolving pathogens and for the rapid response needed to meet bio-defense emergencies.

Development of a group model of clinical supervision to meet the needs of a community mental health nursing team.

Clinical supervision is an important tool in the development of quality nursing care. It involves a process of reflection upon practice, the aim of which is to improve clinical practices and hence improve patient outcomes. The term 'clinical supervision' is itself problematic in that it implies an hierarchical, rather than a nurse-centred and reflective, process. In addition there are a variety of models of supervision which range from the purely managerial to the clinical. This gives rise to confusion and in some cases suspicion, in clinicians. This paper reports on the development, implementation and evaluation of a group model of clinical supervision developed by a small team of mental health nurses in a community mental health setting. This team recognised the need for a formal clinical supervision model but was unsure as to the model which best suited their practice situation and needs. Through collaboration with a university department of nursing, this group developed its own model of group clinical supervision. This paper reports on the development of the model and its evaluation. The model was developed with a small team of community nurses and hence may not be applicable to other teams and other settings. However, the methods described may be useful as a guide to other nurses who wish to plan, implement and evaluate a model of clinical supervision in their workplace.

Differences in insulin secretion and sensitivity of Caucasian and African American prepubertal children.

OBJECTIVE: To investigate whether differences in body composition of African American children (AA) and Caucasian children (C) explain differences in insulin sensitivity and secretion. STUDY DESIGN: Prepubertal nondiabetic children (31 AA and 54 C) were studied; 84% were overweight. Participants underwent a 2-hour hyperglycemic clamp, to estimate insulin sensitivity (SI(clamp)) and secretion, and dual energy x-ray absorptiometry, to assess body composition. RESULTS: AA had greater total body fat mass (P =.01), fasting, 1st phase, 2nd phase, and steady state insulin levels (P <.05). AA and C had similar glucose disposal rates, but AA had lower SI(clamp) (P <.05). Fasting, 1st phase, and steady state C-peptide were less in C (P <.05), whereas corresponding C-peptide/insulin ratios were higher (all P <.005). Insulin levels and SI(clamp) remained different in AA and C after adjustment for body fat or lean mass differences. Analyses restricted to only overweight AA and C showed similar trends. CONCLUSION: Prepubertal African American children have higher baseline and glucose-stimulated insulin and C-peptide levels, as well as reduced insulin sensitivity that is not entirely explained by differences in adiposity. The lower C-peptide/insulin molar ratio in AA suggests that they probably have lower hepatic insulin clearance than Caucasian children.