Fidelity and moderating factors in complex interventions: a case study of a continuum of care program for frail elderly people in health and social care

<p>Abstract</p> <p>Background</p> <p>Prior studies measuring fidelity of complex interventions have mainly evaluated adherence, and not taken factors affecting adherence into consideration. A need for studies that clarify the concept of fidelity and the function of factors moderating fidelity has been emphasized. The aim of the study was to systematically evaluate implementation fidelity and possible factors influencing fidelity of a complex care continuum intervention for frail elderly people.</p> <p>Methods</p> <p>The intervention was a systematization of the collaboration between a nurse with geriatric expertise situated at the emergency department, the hospital ward staff, and a multi-professional team with a case manager in the municipal care services for older people. Implementation was evaluated between September 2008 and May 2010 with observations of work practices, stakeholder interviews, and document analysis according to a modified version of The Conceptual Framework for Implementation Fidelity.</p> <p>Results</p> <p>A total of 16 of the 18 intervention components were to a great extent delivered as planned, while some new components were added to the model. No changes in the frequency or duration of the 18 components were observed, but the dose of the added components varied over time. Changes in fidelity were caused in a complex, interrelated fashion by all the moderating factors in the framework, i.e., context, staff and participant responsiveness, facilitation, recruitment, and complexity.</p> <p>Discussion</p> <p>The Conceptual Framework for Implementation Fidelity was empirically useful and included comprehensive measures of factors affecting fidelity. Future studies should focus on developing the framework with regard to how to investigate relationships between the moderating factors and fidelity over time.</p> <p>Trial registration</p> <p>ClinicalTrials.gov, <a href="http://www.clinicaltrials.gov/ct2/show/NCT01260493">NCT01260493</a>.</p

A Genome-Wide Association Study of Diabetic Kidney Disease in Subjects With Type 2 Diabetes

dentification of sequence variants robustly associated with predisposition to diabetic kidney disease (DKD) has the potential to provide insights into the pathophysiological mechanisms responsible. We conducted a genome-wide association study (GWAS) of DKD in type 2 diabetes (T2D) using eight complementary dichotomous and quantitative DKD phenotypes: the principal dichotomous analysis involved 5,717 T2D subjects, 3,345 with DKD. Promising association signals were evaluated in up to 26,827 subjects with T2D (12,710 with DKD). A combined T1D+T2D GWAS was performed using complementary data available for subjects with T1D, which, with replication samples, involved up to 40,340 subjects with diabetes (18,582 with DKD). Analysis of specific DKD phenotypes identified a novel signal near GABRR1 (rs9942471, P = 4.5 x 10(-8)) associated with microalbuminuria in European T2D case subjects. However, no replication of this signal was observed in Asian subjects with T2D or in the equivalent T1D analysis. There was only limited support, in this substantially enlarged analysis, for association at previously reported DKD signals, except for those at UMOD and PRKAG2, both associated with estimated glomerular filtration rate. We conclude that, despite challenges in addressing phenotypic heterogeneity, access to increased sample sizes will continue to provide more robust inference regarding risk variant discovery for DKD.Peer reviewe

Cloning, structural characterization and functional expression of a zebrafish bradykinin B2-related receptor.

The actions of bradykinin (BK) in mammals are mediated through the activation of the B1 and B2 BK receptors. The only BK receptor that has been cloned from a non-mammalian species is a B2-like receptor from the chicken (termed the ornithokinin receptor). Pharmacological studies have demonstrated the presence of BK receptors in tissues of teleost fishes, such as trout and cod, but the ligand-binding properties of these receptors differ appreciably from those of the mammalian and chicken receptors. We report here the cloning of a B2-like receptor in zebrafish that shares 35% identity with human B2 and 30% identity with human B1. Phylogenetic analyses confirm a closer relationship with B2 than B1. The receptor gene was mapped to linkage group 17, which is syntenic to the human B2-B1 gene region. After functional expression of the zebrafish B2 receptor in mammalian cells, nanomolar concentrations of trout BK ([Arg0,Trp5,Leu8]-BK) and the derivative [des-Arg0,Trp5,Leu8]-BK (where 'des' indicates a missing amino acid) induced a significant transient rise in intracellular free Ca2+. The B1-selective analogue [Arg0,Trp5,Leu8,des-Arg9]-BK was inactive at nanomolar concentrations. Taken together, these results strongly support the gene's identity as a piscine orthologue of the mammalian B2 receptor

Cartilage oligomeric matrix protein associates with a vulnerable plaque phenotype in human atherosclerotic plaques

Background and Purpose- Extracellular matrix proteins are important in atherosclerotic disease by influencing plaque stability and cellular behavior but also by regulating inflammation. COMP (cartilage oligomeric matrix protein) is present in healthy human arteries and expressed by smooth muscle cells. A recent study showed that transplantation of COMP-deficient bone marrow to apoE-/- mice increased atherosclerotic plaque formation, indicating a role for COMP also in bone marrow-derived cells. Despite the evidence of a role for COMP in murine atherosclerosis, knowledge is lacking about the role of COMP in human atherosclerotic disease. Methods- In the present study, we investigated if COMP was associated with a stable or a vulnerable human atherosclerotic plaque phenotype by analyzing 211 carotid plaques for COMP expression using immunohistochemistry. Results- Plaque area that stained positive for COMP was significantly larger in atherosclerotic plaques associated with symptoms (n=110) compared with asymptomatic plaques (n=101; 9.7% [4.7-14.3] versus 5.6% [2.8-9.8]; P=0.0002). COMP was positively associated with plaque lipids (r=0.32; P=0.000002) and CD68 cells (r=0.15; P=0.036) but was negatively associated with collagen (r=-0.16; P=0.024), elastin (r=-0.14; P=0.041), and smooth muscle cells (r=-0.25; P=0.0002). COMP was positively associated with CD163 (r=0.37; P=0.00000006), a scavenger receptor for hemoglobin/haptoglobin and a marker of Mhem macrophages, and with intraplaque hemorrhage, measured as glycophorin A staining (r=0.28; P=0.00006). Conclusions- The present study shows that COMP is associated to symptomatic carotid atherosclerosis, CD163-expressing cells, and a vulnerable atherosclerotic plaque phenotype in humans

Death penalty: the political foundations of the global trend toward abolition

The death penalty is like no other punishment. Its continued existence in many countries of the world creates political tensions within these countries and between governments of retentionist and abolitionist countries. After the Second World War, more and more countries have abolished the death penalty. This article argues that the major determinants of this global trend toward abolition are political, a claim which receives support in a quantitative cross-national analysis from 1950 to 2002. Democracy, democratization, international political pressure on retentionist countries and peer group effects in relatively abolitionist regions all raise the likelihood of abolition. There is also a partisan effect as abolition becomes more likely if the chief executive’s party is left-wing oriented. Cultural, social and economic determinants receive only limited support. The global trend toward abolition will go on if democracy continues to spread around the world and abolitionist countries stand by their commitment to press for abolition all over the world.