Collaboration in maternity care: A randomised controlled trial comparing community-based continuity of care with standard hospital care

Objective: To test whether a new community-based model of continuity of care provided by midwives and obstetricians improved maternal clinical outcomes, in particular a reduced caesarean section rate. Design: Randomised controlled trial. Setting: A public teaching hospital in metropolitan Sydney, Australia. Sample: 1089 women randomised to either the community-based model (n = 550) or standard hospital-based care (n = 539) prior to their first antenatal booking visit at an Australian metropolitan public hospital. Main outcome measures: Data were collected on onset and outcomes of labour, antenatal, intrapartum and postnatal complications, antenatal admissions to hospital and neonatal mortality and morbidity. Results: There was a significant difference in the caesarean section rate between the groups, 13.3% (73/550) in the community-based group and 17.8% in the control group (96/539). This difference was maintained after controlling for known contributing factors to caesarean section (OR = 0.6, 95% CI 0.4-0.9, P = 0.02). There were no other significant differences in the events during labour and birth. Eighty babies (14.5%) from the community-based group and 102 (18.9%) from the control group were admitted to the special care nursery, but this difference was not significant (OR 0.75, 95% CI 0.5-1.1, P = 0.12). Eight infants died during the perinatal period (four from each group), for an overall perinatal mortality rate of 7.3 per 1000 births. Conclusion: Community-based continuity of maternity care provided by midwives and obstetricians resulted in a significantly reduced caesarean section rate. There were no other differences in clinical outcomes

Inequity in exercise-based interventions for adults with rheumatoid arthritis: a systematic review

Objectives This systematic review describes the extent to which PROGRESS-Plus equity factors were considered in the eligibility criteria of trials of exercise interventions for adults with RA. Methods Electronic databases were searched for published (Cinahl, Embase, Medline, Physiotherapy Evidence Database), unpublished (Opengrey) and registered ongoing (International Standard Randomized Controlled Trial Number registry) randomized controlled trials (RCTs) of exercise interventions for adults with RA. Two authors independently performed study selection and quality assessment (Cochrane risk of bias tool). Results A total of 9696 records were identified. After screening, 50 trials were included. All trials had either some concerns or high risk of bias and reported at least one PROGRESS-Plus equity factor within the eligibility criteria; this included place of residence, personal characteristics (age and disability), language, sex, social capital, time-dependent factors or features of relationship factors. Where reported, this equated to exclusion of 457 of 1337 potential participants (34%) based on equity factors. Conclusion This review identified the exclusion of potential participants within exercise-based interventions for people with RA based on equity factors that might affect health-care opportunities and outcomes. This limits the generalizability of results, and yet this evidence is used to inform management and service design. Trials need to optimize participation, particularly for people with cardiovascular conditions, older adults and those with cognitive impairments. Reasons for exclusions need to be justified. Further research needs to address health inequalities to improve treatment accessibility and the generalizability of research findings

The restoration potential of offshore mussel farming on degraded seabed habitat

The United Kingdom's first large-scale, offshore, long-line mussel farm deployed its first ropes in 2013 in Lyme Bay, southwest United Kingdom, located in an area of seabed that was heavily degraded due to historic bottom-towed fishing. It was hypothesised that due to the artificial structures that accumulate mussels and exclude destructive fishing practices, the seabed could be restored. To assess the restoration potential of the farm and its ecosystem interactions over time, a multi-method, annual monitoring approach was undertaken. Here, we tested the effects of the farm trial stations on the seabed habitat, epifauna and demersal species over 5 years. Responses of % mussel cover, sessile and sedentary, and mobile taxa were measured using three video methods. Within 2 years of infrastructure deployment, mussel clumps and shells were detected below the headlines, increasing the structural complexity of the seabed. After 4 years, there was a significantly greater abundance of mobile taxa compared to the Controls that remained open to trawling. Commercial European lobster and edible crab were almost exclusively recorded within the farm. We discuss whether these findings can be considered a restoration of the seabed and how these data can be used to inform the future management of offshore mariculture globally

Quetiapine augmentation of SRIs in treatment refractory obsessive-compulsive disorder: a double-blind, randomised, placebo-controlled study [ISRCTN83050762]

BACKGROUND: Although serotonin reuptake inhibitors are effective in the treatment of OCD, many patients fail to respond to these agents. Growing evidence from open-label and placebo-controlled trials suggests a role for augmentation of SRIs with atypical antipsychotics in OCD. Quetiapine is generally well tolerated and previous open-label data has produced mixed results in OCD and additional controlled data is needed. METHODS: We undertook a double-blind, randomised, parallel-group, flexible-dose, placebo-controlled study of quetiapine augmentation in subjects who had responded inadequately to open-label treatment with an SRI for 12 weeks. Following informed consent and screening, forty-two subjects were randomised to either placebo or quetiapine for six weeks. RESULTS: There was significant improvement from baseline to endpoint on the Yale-Brown Obsessive-Compulsive Scale in both the quetiapine and placebo groups (quetiapine, n = 20, p < 0.0001; placebo, n = 21, p = 0.001) with 40% (n = 8) of quetiapine and 47.6% (n = 10) of placebo treated subjects being classified as responders. Quetiapine did not demonstrate a significant benefit over placebo at the end of the six-week treatment period (p = .636). Similarly quetiapine failed to separate from placebo in the subgroup of subjects (n = 10) with co-morbid tics. Quetiapine was generally well tolerated. CONCLUSIONS: In this study, quetiapine augmentation was no more effective than placebo augmentation of SRIs. A number of limitations in study design make comparisons with previous studies in this area difficult and probably contributed to our negative findings. Future work in this important clinical area should address these limitations

Trypanosoma cruzi CYP51 Inhibitor Derived from a Mycobacterium tuberculosis Screen Hit

Enzyme sterol 14α-demethylase (CYP51) is a well-established target for anti-fungal therapy and is a prospective target for Chagas' disease therapy. We previously identified a chemical scaffold capable of delivering a variety of chemical structures into the CYP51 active site. In this work the binding modes of several second generation compounds carrying this scaffold were determined in high-resolution co-crystal structures with CYP51 of Mycobacterium tuberculosis. Subsequent assays against CYP51 in Trypanosoma cruzi, the agent of Chagas' disease, demonstrated that two of the compounds bound tightly to the enzyme. Both were tested for inhibitory effects against T. cruzi and the related protozoan parasite Trypanosoma brucei. One of the compounds had potent, selective anti–T. cruzi activity in infected mouse macrophages. This compound is currently being evaluated in animal models of Chagas' disease. Discrimination between T. cruzi and T. brucei CYP51 by the inhibitor was largely based on the variability of a single amino acid residue at a critical position in the active site. Our work is aimed at rational design of potent and highly selective CYP51 inhibitors with potential to become therapeutic drugs. Drug selectivity to prevent host–pathogen cross-reactivity is pharmacologically important, because CYP51 is present in human host

Cost-utility of a visiting service for older widowed individuals: Randomised trial

Background. Despite a growing understanding of the effectiveness of bereavement interventions and the groups that benefit most from them, we know little about the cost-effectiveness of bereavement interventions. Methods. We conducted a cost-utility analysis alongside a randomized clinical trial on a visiting service for older widowed individuals (n = 110) versus care as usual (CAU; n = 106). The visiting service is a selective bereavement intervention that offers social support to lonely widows and widowers by a trained volunteer. Participants were contacted 6-9 months post-loss. Eleven percent of all contacted persons responded and eight percent participated in the trial. The primary outcome measure was quality adjusted life years (QALYs) gained (assessed with the EQ-5D), which is a generic measure of health status. Costs were calculated from a societal perspective excluding costs arising from productivity losses. Using the bootstrap method, we obtained the incremental cost utility ratio (ICUR), projected these on a cost-utility plane and presented as an acceptability curve. Results. Overall, the experimental group demonstrated slightly better results against slightly higher costs. Whether the visiting service is acceptable depends on the willingness to pay: at a willingness to pay equal to zero per QALY gained, the visiting service has a probability of 31% of being acceptable; beyond €20,000, the visiting service has a probability of 70% of being more acceptable than CAU. Conclusion. Selective bereavement interventions like the visiting service will not produce large benefits from the health economic point of view, when targeted towards the entire population of all widowed individuals. We recommend that in depth analyses are conducted to identify who benefits most from this kind of interventions, and in what subgroups the incremental cost-utility is best. In the future bereavement interventions are then best directed to these groups. Trial registration. Controlled trials ISRCTN17508307. © 2008 Onrust et al; licensee BioMed Central Ltd

Bullying of medical students in Pakistan: a cross-sectional questionnaire survey.

Background: Several studies from other countries have shown that bullying, harassment, abuse or belittlement are a regular phenomenon faced not only by medical students, but also junior doctors, doctors undertaking research and other healthcare professionals. While research has been carried out on bullying experienced by psychiatrists and psychiatry trainees in Pakistan no such research has been conducted on medical students in this country. Methodology/Principal Findings: We conducted a cross-sectional questionnaire survey on final year medical students in six medical colleges of Pakistan. The response rate was 63%. Fifty-two percent of respondents reported that they had faced bullying or harassment during their medical education, about 28% of them experiencing it once a month or even more frequently. The overwhelming form of bullying had been verbal abuse (57%), while consultants were the most frequent (46%) perpetrators. Students who were slightly older, males, those who reported that their medical college did not have a policy on bullying or harassment, and those who felt that adequate support was not in place at their medical college for bullied individuals, were significantly more likely to have experienced bullying. Conclusion: Bullying or harassment is faced by quite a large proportion of medical students in Pakistan. The most frequent perpetrators of this bullying are consultants. Adoption of a policy against bullying and harassment by medical colleges, and providing avenues of support for students who have been bullied may help reduce this phenomenon, as the presence of these two was associated with decreased likelihood of students reporting having being bullied

(Cost)effectiveness of life review for Older Adults: Design of a randomized controlled trial

Background Depression in older adults is a serious health problem with a poor prognosis. There is a need for indicated preventive psychological interventions for older adults, that show to be promising in preventing depressive disorders. Methods/design This manuscript describes the design of a study evaluating 'Looking for Meaning', a newly developed prevention course for older adults with depressive symptoms, based on life-review. Both clinical and economic effectiveness are evaluated in a pragmatic randomized controlled trial. The control condition of this 12-session preventive intervention is a 20-minute video movie. The primary outcome is symptoms of depression at post-treatment and follow-up (6 months after post-treatment). Secondary outcomes are symptoms of anxiety, satisfaction with life, mastery, reminiscence styles, quality of life, and health care costs. An additional result of this study is the insight into the working elements of the course, provided by the qualitative study. The qualitative data, mainly based on 20 open-ended interviews with participants, are to be analyzed with an emphasis on newly emerging insight. Discussion This study will add to the existing scientific knowledge in several ways, especially by also including an economic evaluation and a qualitative study to gain insight into the working mechanisms of the course, both rather new in the field of life review. Positive results of this study will make an evidence-based intervention to improve public health among older people available

Smart Tourism Destinations: Can the Destination Management Organizations Exploit Benefits of the ICTs? Evidences from a Multiple Case Study

Recent developments of ICTs enable new ways to experience tourism and conducted to the concept of smart tourism. The adoption of cutting-edge technologies and its combination with innovative organizational models fosters cooperation, knowledge sharing, and open innovation among service providers in tourism destination. Moreover, it offers innovative services to visitors. In few words, they become smart tourism destinations. In this paper, we report first results of the SMARTCAL project aimed at conceiving a digital platform assisting Destination Management Organizations (DMOs) in providing smart tourism services. A DMO is the organization charged with managing the tourism offer of a collaborative network, made up of service providers acting in a destination. In this paper, we adopted a multiple case studies approach to analyze five Italian DMOs. Our aims were to investigate (1) if, and how, successful DMOs were able to offer smart tourism services to visitors; (2) if the ICTs adoption level was related to the collaboration level among DMO partners. First results highlighted that use of smart technologies was still in an embryonic stage of development, and it did not depend from collaboration levels

Prevalence and predictors of 6-month exclusive breastfeeding among Canadian women: a national survey

<p>Abstract</p> <p>Background</p> <p>In spite of the evidence supporting the importance of breastfeeding during the first year of life, data on breastfeeding practices remain limited in Canada. The study aimed to examine the prevalence and predictors of 6-month exclusive breastfeeding among Canadian women.</p> <p>Methods</p> <p>The analysis was based on the Maternity Experience Survey targeting women aged ≥ 15 years who had singleton live births between February 2006 - May 2006 in the Canadian provinces and November 2005 - February 2006 in the territories. The main outcome was exclusive breastfeeding based on the World Health Organization definition. Socioeconomic, demographic, maternal, pregnancy and delivery related variables were considered for a multivariate logistic regression using stepwise modeling. Bootstrapping was performed to account for the complex sampling design.</p> <p>Results</p> <p>The sample size in this study was 5,615 weighted to represent 66,810 Canadian women. While ever breastfeeding was 90.3%, the 6-month exclusive breastfeeding rate was 13.8%. Based on the regression model, having higher years of education, residing in the Northern territories and Western provinces, living with a partner, having had previous pregnancies, having lower pre-pregnancy body mass index and giving birth at older age were associated with increased likelihood of 6-month exclusive breastfeeding. Moreover, smoking during pregnancy, Caesarean birth, infant's admission to the intensive care unit and maternal employment status before 6 months of infant's age were negatively associated with exclusive breastfeeding. Mothers choosing to deliver at home were more likely to remain exclusively breastfeeding for 6 months (Odds Ratio: 5.29, 95% Confidence Interval: 2.95-9.46).</p> <p>Conclusions</p> <p>The 6-month exclusive breastfeeding rate is low in Canada. The study results constitute the basis for designing interventions that aim to bridge the gap between the current practices of breastfeeding and the World Health Organization recommendation.</p