Fidelity and influencing factors in the Systemic Practice Model of children's social care in Finland

Given that multiple countries have recently adopted social work practice models in children’s services, it is striking that only a few studies have systematically analysed both the level of fidelity and potential implementation barriers and facilitators. The aim of this study is to provide an in-depth analysis of how and why the Reclaiming Social Work (RSW) model works in different settings. The study context was the implementation in Finland of an adaptation of the model, the Systemic Practice Model (SPM). This mixed-methods study evaluates 1) fidelity to the SPM and 2) the possible influencing factors. The results reveal high variability in the extent of fidelity in 23 implementation sites, and even among individual teams within the same site. A lack of clarity concerning systemic social work practice, insufficient training, and inadequate resources and leadership hindered the implementation, whereas coaching and positive experiences of the SPM were facilitating factors. In particular, the involvement of a clinician qualified in systemic family therapy was crucial in embedding the new approach. The relationship between the level of fidelity and the influencing factors worked both ways (e.g., low coverage was associated with a decrease in participant responsiveness, and vice versa). Given the complexity of children’s social care as an implementation environment, careful preparation and ongoing support are crucial in the implementation of practice models.Peer reviewe

Non-alcoholic fatty liver disease : studies on pathogenesis and diagnosis

Non-alcoholic fatty liver disease (NAFLD) often coexists with obesity and metabolic syndrome and is characterised by insulin resistance (IR). NAFLD may also be due to common gene variants in PNPLA3 at rs738409 and TM6SF2 at rs58542926. It is unclear whether these forms of NAFLD are related to IR. Liver fat content may be assessed using liver histology, imaging tools or biomarkers. This thesis was undertaken to better understand the pathogenesis of NAFLD and to improve currently available diagnostic tools. Subcutaneous (SC) adipocyte hypertrophy is related to IR, but it is unknown whether SC adipocyte size is independently associated with liver fat content. In study I, mean adipocyte size was determined from SC adipose tissue obtained from 119 non-diabetic subjects, whose liver fat content was measured using proton magnetic resonance spectroscopy (1H-MRS). SC adipocyte size significantly associated with liver fat content independent of age, gender, body composition and PNPLA3 genotype (R2=54%, p<0.0001). In study II, a systematic review was performed to investigate whether ‘PNPLA3 NAFLD’ and ‘TM6SF2 NAFLD’ are associated with IR. In 12 of 14 studies, the carriers of the PNPLA3 I148M variant had higher liver fat content than the non-carriers without an increase in IR, while in 5 of 7 studies, the carriers of the TM6SF2 E167K variant had higher liver fat content than the non-carriers without an increase in IR. A systematic review was also performed to compare how normal liver fat content is defined by liver histology and currently available imaging tools. These definitions were found to be variable and not inter-relatable. In study III, a reference value for HOMA-IR, a surrogate marker of IR, was determined, its use in the diagnosis of NAFLD evaluated and inter-laboratory variation determined. The study cohorts included two population-based studies, the FINRISK 2007 (n=5024) and the FIN-D2D (n=2849), and 368 non-diabetic subjects who underwent measurement of liver fat content (1H-MRS). In the healthy subjects of FINRISK (n=1167) and FIN-D2D (n=459), the upper reference limits of HOMA-IR (95th percentile [95% CI]) were 1.9 (1.8–2.0) and 2.0 (1.9–2.1), respectively. The former corresponded to the optimal HOMA-IR cut-off for diagnosing NAFLD (AUROC 0.88). The latter matched with a HOMA-IR corresponding to normal liver fat content (5.56%). Inter-laboratory variation of HOMA-IR was determined by simultaneously analysing samples from 10 subjects in 7 European laboratories. The coefficient of variation of HOMA-IR was high, 25%. In study IV, we determined whether serum pIGFBP-1, produced mainly by the liver, helps in the estimation of liver fat content independent of other known predictors. Fasting serum pIGFBP-1 was measured in 378 subjects who underwent measurement of liver fat content (1H-MRS). Serum pIGFBP-1 significantly associated with liver fat content independent of age, waist-to-hip ratio, and fasting ALT, glucose and insulin. This ‘% Liver fat equation' was significantly worse if pIGFBP-1 was removed (p<0.05) and significantly better than liver enzymes ALT and AST (p<0.0001). SC adipocyte size contributes independently to variation in liver fat content.‘Genetic NAFLD’ seems not to be characterised by IR despite higher liver fat content. Definitions of normal liver fat depend on the diagnostic imaging method used and are not inter-related. The upper reference limit of HOMA-IR corresponds to normal liver fat, but high inter-laboratory variation must be considered. Measurement of pIGFBP-1 may help in non-invasive diagnosis of NAFLD.Alkoholiin liittymätön rasvamaksatauti (non-alcoholic fatty liver disease, NAFLD) on yleisin krooninen maksasairaus länsimaissa. Maksan rasvoittuminen liittyy tiiviisti lihavuuteen, insuliiniherkkyyden heikentymiseen, tyypin 2 diabetekseen ja metaboliseen oireyhtymään. Lisäksi viime vuosina on löydetty yleisiä geneettisiä syitä rasvamaksalle, kuten PNPLA3–geenin I148M-geenivariantti tai TM6SF2-geenin E167K-geenivariantti, joiden aiheuttaman rasvamaksataudin yhteys insuliiniherkkyyteen on epäselvä. Maksan rasvoittumista voidaan arvioida maksan koepalasta, kuvantamismenetelmillä tai laboratoriomäärityksillä. Tämän väitöskirjatutkimuksen tavoitteena oli ymmärtää paremmin rasvamaksataudin kehittymistä sekä arvioida diagnoosimenetelmiä. Lihavuudessa ihonalaisten rasvasolujen koko suurenee, mutta ei kuitenkaan tiedetä, onko rasvasolujen koon kasvu yhteydessä maksan rasvoittumiseen. Ensimmäisessä osatyössä 119 tutkimushenkilön ihonalaisten rasvasolujen koko määritettiin rasvakudoskoepalasta ja heidän maksan rasvapitoisuus magneettiresonanssispektroskopialla (1H-MRS). Ihonalaisen rasvasolun koko oli itsenäinen maksan rasvapitoisuutta selittävä tekijä riippumatta iästä, sukupuolesta, kehonkoostumuksesta sekä PNPLA3-genotyypistä. Toisessa osatyössä selvitettiin systemaattisessa kirjauskatsauksessa, että PNPLA3 I148M- tai TM6SF2 E167K-geenivarianttien kantajilla ei ollut suurentuneesta maksan rasvapitoisuudesta huolimatta heikentynyttä insuliiniherkkyyttä. Lisäksi systemaattisessa kirjallisuuskatsauksessa selvitettiin, miten maksan normaali rasvapitoisuus määritellään maksan koepalasta sekä käytössä olevin kuvantamismenetelmin. Määritelmät vaihtelivat menetelmästä riippuen, eivätkä olleet toisiinsa suoraan verrattavissa. Kolmannessa osajulkaisussa määritettiin viitearvot laajasti käytetylle insuliiniherkkyyttä kuvastavalle HOMA-IR:lle kahden väestötutkimuksen (FINRISK 2007, n=5024 ja FIN-D2D, n=2849) terveillä henkilöillä. Määritetyt viitearvot vastasivat normaalia maksan rasvapitoisuutta 368 tutkimushenkilön aineistossa. HOMA-IR toimi myös hyvin rasvamaksan diagnosoinnissa (AUROC 0.88). Lisäksi havaittiin, että 7 eurooppalaisessa laboratoriossa HOMA-IR-määrityksissä oli suuri vaihtelu, mikä tulee ottaa huomioon sitä käyttäessä. IGFBP-1 on pääosin maksan tuottama proteiini, jonka pitoisuus verenkierrossa laskee insuliiniherkkyyden heikentyessä ja joka on verenkierrossa pääosin fosforyloituna. Neljännessä osajulkaisussa tavoitteena oli selvittää, onko seerumin fosforyloitu (p)IGFBP-1 itsenäinen tekijä maksan rasva-pitoisuutta ennustavassa mallissa. 378 koehenkilöltä määritettiin seerumin pIGFBP-1 sekä mitattiin maksan rasvapitoisuus 1H-MRS:lla. pIGFBP-1 oli itsenäinen maksan rasvapitoisuutta selittävä tekijä riippumatta iästä, vyötärön ja lantion suhteesta, sekä ALAT-, glukoosi- ja insuliinipitoisuuksista. Mallin ennustama maksan rasvapitoisuus vastasi 1H-MRS:llä mitattua maksan rasvapitoisuutta. Malli ennusti maksan rasvapitoisuutta paremmin kuin maksaentsyymit tai aiemmin maksan rasvapitoisuuden arviointiin kehitetyt mallit. Tutkimus osoittaa, että ihonalaisten rasvasolujen koon kasvu liittyy maksan rasvoittumiseen. ’Geneettisessä rasva-maksassa’ maksan rasvoittumiseen ei nykykirjallisuuden mukaan liity insuliiniherkkyyden heikentyminen. Rasvamaksan diagnostiikkaan liittyy vaihtelua, mutta tulevaisuudessa laboratoriomääritykset HOMA-IR tai pIGFBP-1 saattavat auttaa tässä

Effectiveness of child protection practice models : a systematic review

Background: Attempts to improve child protection outcomes by implementing social work practice models embedded in a particular theory and practice approach, have increased internationally over the past decade. Objective: To assess the evidence of the effectiveness of child protection practice models in improving outcomes for children and families. Participants and setting: Children <18 years and their families involved in child protection services. Methods: A systematic review was conducted to synthesize evidence regarding the effectiveness of child protection practice models. Systematic searches across 10 electronic databases and grey literature were conducted to identify quasi-experimental studies minimally. Included studies were critically appraised and the findings summarized narratively. Results: Five papers, representing six studies, focusing on three practice models (Solution-Based Casework; Signs of Safety; and Reclaiming Social Work) met the inclusion criteria. All studies applied a quasi-experimental design. Overall, the quality of the evidence was rated as being poor, with studies suffering from a risk of selection bias, small sample sizes and short-term follow up. Conclusions: Despite the popularity of practice models, the evidence base for their effectiveness is still limited. The results suggest that high-quality studies are urgently needed to evaluate the impact of practice models in improving the outcomes of child-protection-involved families. The findings also illustrate the difficulties of conducting high-quality outcome evaluations in children's social care, and these challenges and future directions for research, are discussed.Peer reviewe

Lastensuojelun tutkimusperustan ­vahvistamisen haasteita ja mahdollisuuksia

Peer reviewe

Ensimmäinen vaihe lastensuojelun tilannearviointiin kehitetyn ARVOA© -menetelmän validoinnissa – laadullinen arvio menetelmän sisällöstä ja soveltuvuudesta

Lastensuojelun tilannearviointiin Suomessa käytettyjen välineiden ja menetelmien pätevyydestä ei ole tutkittua tietoa Strukturoituja arviointivälineitä eli lomakkeita, joissa lapsen tilannetta koskeviin kysymyksiin annetaan vastaus valmiista vastausvaihtoehdoista, on lastensuojelun tilannearviointiin kehitetty Suomessa tiettävästi yksi, ARVOA© -menetelmä Tutkimuksessa tarkasteltiin ARVOA© -menetelmän sisältövaliditeettia analysoimalla sen kattavuutta, kysymysten sanoitusta, vastausvaihtoehtoja, soveltuvuutta eri asiakasryhmille ja suhdetta lapsen edun määritelmään Tutkimus on ensimmäinen avaus tuottaa tutkittua tietoa Suomessa kehitetyistä lastensuojelun tilannearviointivälineistä ARVOA© -menetelmän lomakkeiden kysymyksissä, vastausvaihtoehdoissa ja rakenteessa havaittiin kehittämistarpeita Suomessa olisi hyvä muodostaa käytännön työtä ja arviointivälineiden arviointia hyödyntävä jäsennys niistä konkreettisista tekijöistä, jotka tutkimuksen ja arvojen perusteella ovat keskeisimpiä lastensuojelun tilannearvioinniss

Natural Course of Nonalcoholic Fatty Liver Disease and Type 2 Diabetes in Patients With Human Immunodeficiency Virus With and Without Combination Antiretroviral Therapy-associated Lipodystrophy : A 16-Year Follow-up Study

Background: Abnormal glucose metabolism and nonalcoholic fatty liver disease (NAFLD) are common in patients with human immunodeficiency virus (HIV+ patients), but longitudinal data are lacking. We determined the natural course of NAFLD (liver fat [LFAT]) and type 2 diabetes mellitus (T2DM) in HIV+ patients with and without lipodystrophy (LD+ and LD-, respectively) during a 16-year longitudinal study. Methods: LFAT (by proton magnetic resonance spectroscopy) and clinical characteristics were measured in 41 HIV+ patients at baseline and after 16 years. Liver fibrosis was estimated by measuring liver stiffness using transient elastography (TE) and magnetic resonance elastography (MRE) at 16 years. We also longitudinally studied 28 healthy subjects. Results: During follow-up, the HIV+ patients gained more body fat (8.6% 0.7%) than the control patients (4.5% 0.6%, P <.001). Features of insulin resistance increased significantly in the HIV+ patients but not the control patients. A significant proportion (20%, P <.01 vs 0% at baseline) of the HIV+ but none of the control patients developed T2DM. LFAT was significantly higher at baseline in the LD+ (4.3 [1.9-11.8]) than the LD- (1.0 [0.5-1.5]; P <.001) HIV+ patients. LFAT remained stable during follow-up in all groups. At follow-up, liver stiffness measured with TE was similar among all HIV, LD+, LD-, and control patients and between the LD+ and LD- patients measured with MRE. Advanced fibrosis by MRE was observed in 3 of LD+ and none of LD- patients. Conclusions: During 16 years of follow-up, progression of NAFLD is rare compared to development of T2DM in HIV+ patients.Peer reviewe

Expanding excitation wavelengths for azobenzene photoswitching into the near-infrared range via endothermic triplet energy transfer

Developing azobenzene photoswitches capable of selective and efficient photoisomerization by long-wavelength excitation is an enduring challenge. Herein, rapid isomerization from the Z- to E-state of two ortho-functionalized bistable azobenzenes with near-unity photoconversion efficiency was driven by triplet energy transfer upon red and near-infrared (up to 770 nm) excitation of porphyrin photosensitizers in catalytic micromolar concentrations. We show that the process of triplet-sensitized isomerization is efficient even when the sensitizer triplet energy is substantially lower (>200 meV) than that of the azobenzene used. This makes the approach applicable for a wide variety of sensitizer-azobenzene combinations and enables the expansion of excitation wavelengths into the near-infrared spectral range. Therefore, indirect excitation via endothermic triplet energy transfer provides efficient and precise means for photoswitching upon 770 nm near-infared light illumination with no chemical modification of the azobenzene chromophore, a desirable feature in photocontrollable biomaterials.Peer reviewe

Obesity/insulin resistance rather than liver fat increases coagulation factor activities and expression in humans

Increased liver fat may be caused by insulin resistance and adipose tissue inflammation or by the common I148M variant in PNPLA3 at rs738409, which lacks both of these features. We hypothesised that obesity/insulin resistance rather than liver fat increases circulating coagulation factor activities. We measured plasma prothrombin time (PT, Owren method), activated partial thromboplastin time (APTT), activities of several coagulation factors, VWF:RCo and fibrinogen, and D-dimer concentration in 92 subjects divided into groups based on insulin sensitivity [insulin-resistant ('IR') versus insulin-sensitive ('IS')] and PNPLA3 genotype (PNPLA3(148MM/MI) vs PNPLA3(148II)). Liver fat content (H-1-MRS) was similarly increased in 'IR' (13 +/- 1%) and PNPLA3(148MM/MI) (12 +/- 2%) as compared to 'IS' (6 +/- 1%, pPeer reviewe

Human PNPLA3-I148M variant increases hepatic retention of polyunsaturated fatty acids

The common patatin-like phospholipase domain-containing protein 3 (PNPLA3) variant I148M predisposes to nonalcoholic liver disease but not its metabolic sequelae. We compared the handling of labeled polyunsaturated fatty acids (PUFAs) and saturated fatty acids (SFA) in vivo in humans and in cells harboring different PNPLA3 genotypes. In 148M homozygous individuals, triglycerides (TGs) in very low-density lipoproteins (VIOL) were depleted of PUFAs both under fasting and postprandial conditions compared with 148I homozygotes, and the PUFA/SFA ratio in VLDL-TGs was lower relative to the chylomicron precursor pool. In human PNPLA3-148M and PNPLA3-KO cells, PUFA but not SFA incorporation into TGs was increased at the expense of phosphatidylcholines, and under lipolytic conditions, PUFA-containing diacylglycerols (DAGs) accumulated compared with PNPLA3-148I cells. Polyunsaturated TGs were increased, while phosphatidylcholines (PCs) were decreased in the human liver in 148M homozygous individuals as compared with 148I homozygotes. We conclude that human PNPLA3-I148M is a loss-of-function allele that remodels liver TGs in a polyunsaturated direction by impairing hydrolysis/transacylation of PUFAs from DAGs to feed phosphatidylcholine synthesis.Peer reviewe