Medicine Goes to School: Teachers as Sickness Brokers for ADHD

Christine Phillips explores the roles of teachers as brokers for ADHD and its treatment, and the strategies used by the pharmaceutical industry to frame educators' responses to ADHD

Impact of interprofessional education about psychological and medical comorbidities on practitioners’ knowledge and collaborative practice: mixed method evaluation of a national program

BACKGROUND Many patients with chronic physical illnesses have co-morbid psychological illnesses, which may respond to interprofessional collaborative care. Continuing education programs frequently focus on skills and knowledge relevant for individual illnesses, and unidisciplinary care. This study evaluates the impact of “Mind the Gap”, an Australian interprofessional continuing education program about management of dual illnesses, on practitioners’ knowledge, use of psychological strategies and collaborative practice. METHODS A 6-h module addressing knowledge and skills needed for patients with physical and psychological co-morbid illnesses was delivered to 837 practitioners from mixed health professional backgrounds, through locally-facilitated workshops at 45 Australian sites. We conducted a mixed-methods evaluation, incorporating observation, surveys and network analysis using data collected, before, immediately after, and three months after training. RESULTS Six hundred forty-five participants enrolled in the evaluation (58 % GPs, 17 % nurses, 15 % mental health professionals, response rate 76 %). Participants’ knowledge and confidence to manage patients with psychological and physical illnesses improved immediately. Among the subset surveyed at three months (response rate 24 %), referral networks had increased across seven disciplines, improvements in confidence and knowledge were sustained, and doctors, but no other disciplines, reported an increase in use of motivational interviewing (85.9 % to 96.8 %) and mindfulness (58.6 % to 74 %). CONCLUSIONS Interprofessional workshops had an immediate impact on the stated knowledge and confidence of participants to manage patients with physical and psychological comorbidities, which appears to have been sustained. For some attendees, there was a sustained improvement in the size of their referral networks and their use of some psychological strategies.This project was funded by the Australian Medicare Local Alliance, through a grant from the Department of Veterans Affairs

Using qualitative mixed methods to study small health care organizations while maximising trustworthiness and authenticity

BACKGROUND The primary health care sector delivers the majority of health care in western countries through small, community-based organizations. However, research into these healthcare organizations is limited by the time constraints and pressure facing them, and the concern by staff that research is peripheral to their work. We developed Q-RARA-Qualitative Rapid Appraisal, Rigorous Analysis-to study small, primary health care organizations in a way that is efficient, acceptable to participants and methodologically rigorous. METHODS Q-RARA comprises a site visit, semi-structured interviews, structured and unstructured observations, photographs, floor plans, and social scanning data. Data were collected over the course of one day per site and the qualitative analysis was integrated and iterative. RESULTS We found Q-RARA to be acceptable to participants and effective in collecting data on organizational function in multiple sites without disrupting the practice, while maintaining a balance between speed and trustworthiness. CONCLUSIONS The Q-RARA approach is capable of providing a richly textured, rigorous understanding of the processes of the primary care practice while also allowing researchers to develop an organizational perspective. For these reasons the approach is recommended for use in small-scale organizations both within and outside the primary health care sector.This research was funded by the Australian Government Department of Health and Ageing, through the Australian Primary Health Care Research Institute (APHCRI)

Variable Magnitude and Frequency Financial Reinforcement is Effective at Increasing Adults’ Free-Living Physical Activity

Financial rewards can increase health behaviors, but little research has quantified the effects of different reinforcement schedules on this process. This analysis compares the average moderate-to-vigorous physical activity (MVPA) associated with six distinct positive reinforcement schedules implemented within a physical activity promotion clinical trial. In this trial, participants (N = 512) wore an accelerometer for 1 year and were prescribed one of two types of MVPA goals: a static 30-min goal or an adaptive goal based on the MVPA produced over the previous 9 days. As participants met goals, they transitioned through a sequence of reinforcement stages, beginning with a continuous-fixed magnitude (CRF-FM), then CRF-variable magnitude (CRF-VM), followed by a series of variable ratio-VM (VR-VM) schedules. The average accumulation of MVPA bouts over the last 24 days of each stage was compared to each other. Average MVPA during stage transitions was also examined. The results indicated that immediate reinforcement resulted in more MVPA relative to a comparison group and that the relative effectiveness of adaptive versus static goals was dependent on the magnitude of daily MVPA goals. Schedule effects were qualitatively different for individuals who frequently met their daily goals (Large Intervention Effect subgroup) versus those who did not (Small Intervention Effect subgroup). For the Large Intervention Effect group, the CRF-VM schedule produced the most MVPA, in particular within the adaptive goal condition, with increases observed immediately upon encountering this schedule. In contrast, the CRF-FM schedule produced small amounts of MVPA. This pattern was reversed for the Small Intervention Effect subgroup, where the most MVPA was associated with the CRF-FM stage. Future interventions should focus on discriminating small versus large intervention effects as quickly as possible so that the optimal reinforcement schedule can be used

Correction to: Variable Magnitude and Frequency Financial Reinforcement is Effective at Increasing Adults’ Free-Living Physical Activity

The original article has been corrected to update figures 1, 4, and 5 captions. Original article available on Springer\u27s website or in Chapman University Digital Commons

Perspectives of US private payers on insurance coverage for pediatric and prenatal exome sequencing: Results of a study from the Program in Prenatal and Pediatric Genomic Sequencing (P3EGS).

PurposeExome sequencing (ES) has the potential to improve management of congenital anomalies and neurodevelopmental disorders in fetuses, infants, and children. US payers are key stakeholders in patient access to ES. We examined how payers view insurance coverage and clinical utility of pediatric and prenatal ES.MethodsWe employed the framework approach of qualitative research to conduct this study. The study cohort represented 14 payers collectively covering 170,000,000 enrollees.ResultsSeventy-one percent of payers covered pediatric ES despite perceived insufficient evidence because they saw merit in available interventions or in ending the diagnostic odyssey. None covered prenatal ES, because they saw no merit. For pediatric ES, 50% agreed with expanded aspects of clinical utility (e.g., information utility), and 21% considered them sufficient for coverage. For prenatal ES, payers saw little utility until in utero interventions become available.ConclusionThe perceived merit of ES is becoming a factor in payers' coverage for serious diseases with available interventions, even when evidence is perceived insufficient. Payers' views on ES's clinical utility are expanding to include informational utility, aligning with the views of patients and other stakeholders. Our findings inform clinical research, patient advocacy, and policy-making, allowing them to be more relevant to payers

Gender Differences in Bed Rest: Preliminary Analysis of Vascular Function

Orthostatic intolerance is a recognized consequence of spaceflight. Numerous studies have shown that women are more susceptible to orthostatic intolerance following spaceflight as well as bed rest, the most commonly used ground-based analog for spaceflight. One of the possible mechanisms proposed to account for this is a difference in vascular responsiveness between genders. We hypothesized that women and men would have differing vascular responses to 90 days of 6-degree head down tilt bed rest. Additionally, we hypothesized that vessels in the upper and lower body would respond differently, as has been shown in the animal literature. Thirteen subjects were placed in bedrest for 90 days (8 men, 5 women) at the Flight Analogs Unit, UTMB. Direct arterial and venous measurements were made with ultrasound to evaluate changes in vascular structure and function. Arterial function was assessed, in the arm and leg, during a reactive hyperemia protocol and during sublingual nitroglycerin administration to gauge the contributions of endothelial dependent and independent dilator function respectively. Venous function was assessed in dorsal hand and foot veins during the administration of pharmaceuticals to assess constrictor and dilator function. Both gender and day effects are seen in arterial dilator function to reactive hyperemia, but none are seen with nitroglycerin. There are also differences in the wall thickness in the arm vs the leg during bed rest, which return toward pre-bed rest levels by day 90. More subjects are required, especially females as there is not sufficient power to properly analyze venous function. Day 90 data are most underpowered

Effects of Goal Type and Reinforcement Type on Self-Reported Domain-Specific Walking Among Inactive Adults: 2×2 Factorial Randomized Controlled Trial

Background: WalkIT Arizona was a 2×2 factorial trial examining the effects of goal type (adaptive versus static) and reinforcement type (immediate versus delayed) to increase moderate to vigorous physical activity (MVPA) among insufficiently active adults. The 12-month intervention combined mobile health (mHealth) technology with behavioral strategies to test scalable population-health approaches to increasing MVPA. Self-reported physical activity provided domain-specific information to help contextualize the intervention effects. Objective: The aim of this study was to report on the secondary outcomes of self-reported walking for transportation and leisure over the course of the 12-month WalkIT intervention. Methods: A total of 512 participants aged 19 to 60 years (n=330 [64.5%] women; n=425 [83%] Caucasian/white, n=96 [18.8%] Hispanic/Latinx) were randomized into interventions based on type of goals and reinforcements. The International Physical Activity Questionnaire-long form assessed walking for transportation and leisure at baseline, and at 6 months and 12 months of the intervention. Negative binomial hurdle models were used to examine the effects of goal and reinforcement type on (1) odds of reporting any (versus no) walking/week and (2) total reported minutes of walking/week, adjusted for neighborhood walkability and socioeconomic status. Separate analyses were conducted for transportation and leisure walking, using complete cases and multiple imputation. Results: All intervention groups reported increased walking at 12 months relative to baseline. Effects of the intervention differed by domain: a significant three-way goal by reinforcement by time interaction was observed for total minutes of leisure walking/week, whereas time was the only significant factor that contributed to transportation walking. A sensitivity analysis indicated minimal differences between complete case analysis and multiple imputation. Conclusions: This study is the first to report differential effects of adaptive versus static goals for self-reported walking by domain. Results support the premise that individual-level PA interventions are domain- and context-specific and may be helpful in guiding further intervention refinement

SHARC II: a Caltech Submillimeter Observatory facility camera with 384 pixels

SHARC II is a background-limited 350 μm and 450 μm facility camera for the Caltech Submillimeter Observatory undergoing commissioning in 2002. The key component of SHARC II is a 12×32 array of doped silicon 'pop-up' bolometers developed at NASA/Goddard. Each 1 mm × 1 mm pixel is coated with a 400 Ω/square bismuth film and located λ/4 above a reflective backshort to achieve >75% absorption efficiency. The pixels cover the focal plane with >90% filling factor. At 350 μm, the SHARC II pixels are separated by 0.65 λ/D. In contrast to the silicon bolometers in the predecessor of SHARC II, each doped thermistor occupies nearly the full area of the pixel, which lowers the 1/f knee of the detector noise to <0.03 Hz, under load, at the bath temperature of 0.36 K. The bolometers are AC-biased and read in 'total power' mode to take advantage of the improved stability. Each bolometer is biased through a custom ~130 MΩ CrSi load resistor at 7 K and read with a commercial JFET at 120 K. The JFETs and load resistors are integrated with the detectors into a single assembly to minimize microphonic noise. Electrical connection across the 0.36 K to 4 K and 4 K to 120 K temperature interfaces is accomplished with lithographed metal wires on dielectric substrates. In the best 25% of winter nights on Mauna Kea, SHARC II is expected to have an NEFD at 350 μm of 1 Jy Hz-1/2 or better. The new camera should be at least 4 times faster at detecting known point sources and 30 times faster at mapping large areas compared to the prior instrument

The Impact of HAART on the Respiratory Complications of HIV Infection: Longitudinal Trends in the MACS and WIHS Cohorts

Objective: To review the incidence of respiratory conditions and their effect on mortality in HIV-infected and uninfected individuals prior to and during the era of highly active antiretroviral therapy (HAART). Design: Two large observational cohorts of HIV-infected and HIV-uninfected men (Multicenter AIDS Cohort Study [MACS]) and women (Women's Interagency HIV Study [WIHS]), followed since 1984 and 1994, respectively. Methods: Adjusted odds or hazards ratios for incident respiratory infections or non-infectious respiratory diagnoses, respectively, in HIV-infected compared to HIV-uninfected individuals in both the pre-HAART (MACS only) and HAART eras; and adjusted Cox proportional hazard ratios for mortality in HIV-infected persons with lung disease during the HAART era. Results: Compared to HIV-uninfected participants, HIV-infected individuals had more incident respiratory infections both pre-HAART (MACS, odds ratio [adjusted-OR], 2.4; 95% confidence interval [CI], 2.2-2.7; p<0.001) and after HAART availability (MACS, adjusted-OR, 1.5; 95%CI 1.3-1.7; p<0.001; WIHS adjusted-OR, 2.2; 95%CI 1.8-2.7; p<0.001). Chronic obstructive pulmonary disease was more common in MACS HIV-infected vs. HIV-uninfected participants pre-HAART (hazard ratio [adjusted-HR] 2.9; 95%CI, 1.02-8.4; p = 0.046). After HAART availability, non-infectious lung diseases were not significantly more common in HIV-infected participants in either MACS or WIHS participants. HIV-infected participants in the HAART era with respiratory infections had an increased risk of death compared to those without infections (MACS adjusted-HR, 1.5; 95%CI, 1.3-1.7; p<0.001; WIHS adjusted-HR, 1.9; 95%CI, 1.5-2.4; p<0.001). Conclusion: HIV infection remained a significant risk for infectious respiratory diseases after the introduction of HAART, and infectious respiratory diseases were associated with an increased risk of mortality. © 2013 Gingo et al