Using implementation intentions to prevent relapse after remission from psychological treatment for depression: The SMArT intervention

Objective: To provide evidence of the effectiveness of a brief relapse prevention intervention using implementation intentions (Self-Management after Therapy, SMArT), following remission from depression and to identify effective relapse prevention strategies. Method: The SMArT intervention was provided to 107 patients who were recovered after psychological therapy for depression. Relapse events were calculated as reliable and clinically significant increases in PHQ-scores. Sixteen patients receiving the intervention and eight practitioners providing it were interviewed. Framework Analysis identified seven themes which highlighted effective relapse prevention strategies and effective implementation of the SMArT intervention. Results: Relapse rates at the final SMArT session (four months after the end of acute stage therapy) were 11%. Seven themes were identified that supported effective self-management: (1) Relationship with the practitioner—feeling supported; (2) Support networks; (3) Setting goals, implementing plans and routine; (4) Changing views of recovery; (5) The SMArT sessions—mode, content, timing, duration; (6) Suitability for the person; and (7) Suitability for the service. Conclusion: The study provides some support for the effectiveness of the SMArT intervention, although a randomized controlled trial is required; and identifies important relapse prevention strategies

Modulation of folic acid bioaccessibility by encapsulation in pH-responsive gated mesoporous silica particles

[EN] A study on the controlled release of folic acid (FA) from pH-responsive gated mesoporous silica particles (MSP) is reported. The MCM-41 support was synthesized using tetraethyl orthosilicate (TEOS) as hydrolytic inorganic precursor and the surfactant hexadecyltrimethylammonium bromide (CTAB) as porogen species. Calcination of the mesostructured phase resulted in the starting solid. This solid was loaded with FA to obtain the initial support S0. Moreover, this FA-loaded material was further functionalized with 3-[2-(2-aminoethylamino)ethylamino]propyltrimethoxysilane (N3) in order to obtain the gated polyamine-functionalised material S1. Solids S0 and S1 were characterized using standard solid state procedures. It was found that the functionalization process and the inclusion of FA on the pores did not modify the mesoporous structure of the starting material. FA delivery studies in water with solids S0 and S1 were carried out in water at pH 2 and 7.5. S0 was not able to completely inhibit FA delivery at acidic pH yet a rapid FA release at neutral pH was observed in few minutes. In contrast, S1 was tightly capped at pH 2 and displayed a sustained delivery of FA when the pH was switched to 7.5. In the second part of the study, FA loading and functionalization of S1-like supports was optimized. In particular, solids loaded with FA in phosphate buffered saline (PBS) and capped with N3 in acetate buffer at pH 2 exhibited a delivery capacity up to 95 μg FA/mg solid. Finally, FA release from the selected optimized supports was studied following an in vitro digestion procedure. The results showed that amine-capped MSP were not only able to hinder the release of the vitamin in gastric fluids (pH 2), but were also capable of deliver progressively the FA in presence of a simulated intestinal juice (pH 7.5) offering a suitable mechanism to control the bioaccessibility of the vitaminAuthors gratefully acknowledge the financial support from the Ministerio de Economia y Competitividad (Projects AGL201239597-C02 and MAT2012-38429-004-01) and the Generalitat Valenciana (project PROMETEO/2009/016). E.P. is grateful to the Ministerio de Ciencia e Innovacion for his Grant (AP2008-00620). C.C. thanks the Generalitat Valenciana for her post-doctoral contract VALi+D.Pérez-Esteve, É.; Fuentes López, A.; Coll Merino, MC.; Acosta, C.; Bernardos Bau, A.; Amoros Del Toro, PJ.; Marcos Martínez, MD.... (2015). Modulation of folic acid bioaccessibility by encapsulation in pH-responsive gated mesoporous silica particles. Microporous and Mesoporous Materials. 202:124-132. https://doi.org/10.1016/j.micromeso.2014.09.049S12413220

Nucleotide supplementation: a randomised double-blind placebo controlled trial of IntestAidIB in people with Irritable Bowel Syndrome [ISRCTN67764449]

BACKGROUND: Dietary nucleotide supplementation has been shown to have important effects on the growth and development of cells which have a rapid turnover such as those in the immune system and the gastrointestinal tract. Work with infants has shown that the incidence and duration of diarrhoea is lower when nucleotide supplementation is given, and animal work shows that villi height and crypt depth in the intestine is increased as a result of dietary nucleotides. Dietary nucleotides may be semi-essential under conditions of ill-health, poor diet or stress. Since people with Irritable Bowel Syndrome tend to fulfil these conditions, we tested the hypothesis that symptoms would be improved with dietary nucleotide supplementation. METHODS: Thirty-seven people with a diagnosis of Irritable Bowel gave daily symptom severity ratings for abdominal pain, diarrhoea, urgency to have a bowel movement, incomplete feeling of evacuation after a bowel movement, bloating, flatulence and constipation for 28 days (baseline). They were then assigned to either placebo (56 days) followed by experimental (56 days) or the reverse. There was a four week washout period before crossover. During the placebo and experimental conditions participants took one 500 mg capsule three times a day; in the experimental condition the capsule contained the nutroceutical substances. Symptom severity ratings and psychological measures (anxiety, depression, illness intrusiveness and general health) were obtained and analysed by repeated measures ANOVAs. RESULTS: Symptom severity for all symptoms (except constipation) were in the expected direction of baseline>placebo>experimental condition. Symptom improvement was in the range 4 – 6%. A feeling of incomplete evacuation and abdominal pain showed the most improvement. The differences between conditions for diarrhoea, bloating and flatulence were not significant at the p < .05 level. There were no significant differences between the conditions for any of the psychological measures. CONCLUSION: Dietary nucleotide supplementation improves some of the symptoms of irritable bowel above baseline and placebo level. As expected, placebo effects were high. Apart from abdominal pain and urgency to have a bowel movement, the improvements, while consistent, are modest, and were not accompanied by improvements in any of the psychological measures. We suggest that the percentage improvement over and above the placebo effect is a physiological effect of the nucleotide supplement on the gut. The mechanisms by which these effects might improve symptoms are discussed

Implementing peer support into practice in mental health services: a qualitative comparative case study

Background Peer workers are people with personal experience of mental distress, employed within mental health services to support others with similar experiences. Research has identified a range of factors that might facilitate or hinder the introduction of new peer worker roles into mental health services. While there is mixed evidence for the effectiveness of peer worker delivered interventions, there are no studies exploring how implementation might be associated with effect. Methods This was a qualitative comparative case study using data from interviews with 20 peer workers and their five supervisors. Peer workers delivered peer support for discharge from inpatient to community mental health care as part of a randomised controlled trial. In the trial, level of participant engagement with peer support was associated with better outcome (hospital readmission). Study sites with higher levels of engagement also had higher scores on a measure of fidelity to peer support principles. We compared data from sites with contrasting levels of engagement and fidelity using an analytical framework derived from implementation theory. Results In high engagement-high fidelity sites, there was regular work with clinical teams preparing for working alongside peer workers, and a positive relationship between staff on inpatient wards and peer workers. The supervisor role was well resourced, and delivery of peer support was highly consistent with the intervention manual. In low engagement-low fidelity sites peer workers were employed in not-for-profit organisations to support people using public mental health services and in rural areas. Supervisors faced constrained resources and experienced barriers to joint working between organisations. In these sites, peer workers could experience challenging relationships with ward staff. Issues of geography and capacity limited opportunities for supervision and team-building, impacting consistency of delivery. Conclusions This study provides clear indication that implementation can impact delivery of peer support, with implications for engagement and, potentially, outcomes of peer worker interventions. Resourcing issues can have knock-on effects on consistency of delivery, alongside challenges of access, authority and relationship with clinical teams, especially where peer workers were employed in not-for-profit organisations. Attention needs to be paid to the impact of geography on implementation

Folic acid fortification and public health: Report on threshold doses above which unmetabolised folic acid appear in serum

BACKGROUND: All flour in the USA is fortified with folic acid at a level of 140 μg/100 g which is estimated to supply an extra 100 μg daily to the average diet. Some researchers have advocated that this be increased to double and even four times this amount. Based on previous research these higher levels are likely to lead to the appearance of unmetabolised vitamin in the circulation, which may have safety implications for sub-groups of the population. The UK and the Republic of Ireland will likely introduce mandatory fortification also in the next year or so. The aim of this study was to capture the short-term effect of folic acid fortification on unmetabolised folic acid in serum after chronic consumption of folic acid. METHODS: After pre-saturation with 400 μg folic acid supplements daily for 14-weeks, healthy folate replete adults (n = 20) consumed folic acid fortified bread, at three different levels (400 μg, 200 μg, 100 μg) over a period of one week each. The dose was administered in two-equal sized slices consumed at 09.00 hrs and 13.00 hrs. Serum samples for total folate and folic acid were collected at baseline, after 14-weeks of supplementation, and pre and post (at 1, 2, 3 and 4 hours) each dose tested. RESULTS: Unmetabolised folic acid was detected after the 14-week supplementation period. Folic acid was not detected in either the 200 μg or 100 μg (current US regime) doses tested but was present at the highest level (400 μg) tested. CONCLUSION: Our findings suggest that persons exposed to the current US fortification programme supplying an average of 100 μg per day or less are unlikely to have unmetabolised folic acid in serum. It also seems that daily consumption of the higher level of 200 μg or less is unlikely to be problematic. Increasing the level however to 400 μg on the other hand is likely to lead to unmetabolised folic acid appearance

Self-Construal and Concerns Elicited by Imagined and Real Health Problems 1

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74826/1/j.1559-1816.2007.00283.x.pd

New Strategies for Research in Clinical Practice: A focus on self–harm.

This article suggests new ways of approaching clinical-based research in an era of evidence-based practice. Using the example of self-harm, we identify three distinct problems with current dominant approaches to research in this area. These include insufficient clarity about target issues, an overreliance on predetermined outcomes which prioritise behavioural measures (such as self-harm cessation) and an undue focus on treatment techniques. We argue that clinical research requires flexible, user-centred and practice-based methods, informed by a focus on principles instead of techniques. Therefore, we outline key practice-based principles that we argue need to be embedded within clinical research strategies. We then demonstrate how traditional behavioural approaches to research can be enriched with more qualitative cognitive and emotionally based data. We conclude that such strategies provide thickened, meaningful and context-specific research which is more relevant for service commissioners, clinicians and service users

The Role of Practice Research Networks (PRN) in the Development and Implementation of Evidence: The Northern Improving Access to Psychological Therapies PRN Case Study

Practice research networks (PRNs) can support the implementation of evidence based practice in routine services and generate practice based evidence. This paper describes the structure, processes and learning from a new PRN in the Improving Access to Psychological Therapies programme in England, in relation to an implementation framework and using one study as a case example. Challenges related to: ethics and governance processes; communications with multiple stakeholders; competing time pressures and linking outcome data. Enablers included: early tangible outputs and impact; a collaborative approach; engaging with local research leads; clarity of processes; effective dissemination; and committed leadership

Feasibility of familial PSA screening: psychosocial issues and screening adherence

This study examined factors that predict psychological morbidity and screening adherence in first-degree relatives (FDRs) taking part in a familial PSA screening study. Prostate cancer patients (index cases – ICs) who gave consent for their FDRs to be contacted for a familial PSA screening study to contact their FDRs were also asked permission to invite these FDRs into a linked psychosocial study. Participants were assessed on measures of psychological morbidity (including the General Health Questionnaire; Cancer Worry Scale; Health Anxiety Questionnaire; Impact of Events Scale); and perceived benefits and barriers, knowledge; perceived risk/susceptibility; family history; and socio-demographics. Of 255 ICs, 155 (61%) consented to their FDRs being contacted. Of 207 FDRs approached, 128 (62%) consented and completed questionnaires. Multivariate logistic regression revealed that health anxiety, perceived risk and subjective stress predicted higher cancer worry (P=0.05). Measures of psychological morbidity did not predict screening adherence. Only past screening behaviour reliably predicted adherence to familial screening (P=0.05). First-degree relatives entering the linked familial PSA screening programme do not, in general, have high levels of psychological morbidity. However, a small number of men exhibited psychological distress

Pemetrexed pharmacokinetics and pharmacodynamics in a phase I/II study of doublet chemotherapy with vinorelbine: implications for further optimisation of pemetrexed schedules

The purpose of this study was to investigate the utility of plasma pharmacokinetic and pharmacodynamic measures including plasma deoxynucleosides, homocysteine and methylmalonic acid concentrations in understanding the time course and extent of the inhibition of thymidylate synthase (TS) by pemetrexed in the context of a phase I/II combination study with vinorelbine. Eighteen patients received supplementation with folic acid and Vitamin B12 1 week before beginning treatment with pemetrexed and vinorelbine administered in a dose-escalating manner on a 21-day cycle. Heparinised blood samples were collected from consenting patients in the first cycle for pharmacokinetic analyses and in the first two cycles for determination of plasma thymidine, deoxyuridine, homocysteine and methylmalonic acid concentrations. These values were correlated with response and toxicity. Plasma deoxyuridine was used as a measure of TS inhibition, and concentrations of deoxyuridine were significantly elevated relative to baseline on days 1 (P<0.01), 2 (P<0.001) and 3 (P<0.05) after treatment at all pemetrexed dose levels (400–700 mg m−2). The magnitude of deoxyuridine elevation correlated with pemetrexed area under the plasma concentration–time curve (AUC) (r2=0.23, P<0.05). However, deoxyuridine concentrations returned to baseline between 8 and 15 days after treatment with pemetrexed, suggesting that inhibition of TS was not durable. Pemetrexed AUC correlated with the percentage decline (relative to baseline) in both platelets (r2=0.58, P<0.001) and leucocytes (r2=0.26, P<0.05) at day 8. Baseline homocysteine was also significantly correlated with these measures of haematological toxicity (r2=0.37, P<0.01 and r2=0.39, P<0.01, respectively). In addition, there was a significant reduction of plasma homocysteine on days 8 (P<0.005) and 15 (P<0.05) in cycle 1 compared to baseline values. The results suggest that the TS inhibitory effects of pemetrexed are short-lived and make the case for a more frequent schedule of administration such as every 2 weeks. The lack of protracted TS inhibition may be due to concomitant vitamin administration, and this may be the mechanism by which vitamins prevent life-threatening toxicity from pemetrexed. Baseline homocysteine concentration remains a predictive marker for haematological toxicity even following folate supplementation