The art and science of priority-setting: assessing the value of Public Health England’s Prioritization Framework

Background Findings are presented from the evaluation of Public Health England’s (PHE) Prioritization Framework (PF) aimed to assist local authority commissioners with their public health investment and disinvestment decisions. The study explored the take up of the PF in three early adopter local authority settings. Methods Semi-structured interviews (n = 30) across three local authorities supplemented by participant observation of workshops. Results Participants acknowledged that the PF provided a systematic means of guiding priority-setting and one that encouraged transparency over investment and disinvestment decisions. The role performed by PHE and its regional teams in facilitating the process was especially welcomed and considered critical to the adoption process. However, uptake of the PF required a significant investment of time and commitment from public health teams at a time when resources were stretched. The impact of the political environment in the local government was a major factor determining the likely uptake of the PF. Ensuring committed leadership and engagement from senior politicians and officers was regarded as critical to success. Conclusions The study assessed the value and impact of PHE’s PF tool in three early adopter local authorities. Further research could explore the value of the tool in aiding investment and disinvestment decisions and its impact on spending

Analysis of the hippocampal proteome in ME7 prion disease reveals a predominant astrocytic signature and highlights the brain-restricted production of clusterin in chronic neurodegeneration

Prion diseases are characterized by accumulation of misfolded protein, gliosis, synaptic dysfunction, and ultimately neuronal loss. This sequence, mirroring key features of Alzheimer disease, is modeled well in ME7 prion disease. We used iTRAQ(TM)/mass spectrometry to compare the hippocampal proteome in control and late-stage ME7 animals. The observed changes associated with reactive glia highlighted some specific proteins that dominate the proteome in late-stage disease. Four of the up-regulated proteins (GFAP, high affinity glutamate transporter (EAAT-2), apo-J (Clusterin), and peroxiredoxin-6) are selectively expressed in astrocytes, but astrocyte proliferation does not contribute to their up-regulation. The known functional role of these proteins suggests this response acts against protein misfolding, excitotoxicity, and neurotoxic reactive oxygen species. A recent convergence of genome-wide association studies and the peripheral measurement of circulating levels of acute phase proteins have focused attention on Clusterin as a modifier of late-stage Alzheimer disease and a biomarker for advanced neurodegeneration. Since ME7 animals allow independent measurement of acute phase proteins in the brain and circulation, we extended our investigation to address whether changes in the brain proteome are detectable in blood. We found no difference in the circulating levels of Clusterin in late-stage prion disease when animals will show behavioral decline, accumulation of misfolded protein, and dramatic synaptic and neuronal loss. This does not preclude an important role of Clusterin in late-stage disease, but it cautions against the assumption that brain levels provide a surrogate peripheral measure for the progression of brain degeneration

Use of prescribed contraception in Northern Ireland 2010-2016

Background The risk of an unintended, potentially unwanted, pregnancy is related to whether or not a woman uses any method of contraception and which method she uses. We do not know if, or how, contraceptive use in Northern Ireland (NI) varies by age or deprivation. If, as in the rest of the United Kingdom, the younger and most disadvantaged are least likely to use contraception, or to use effective methods of contraception, they will be at increased risk of having an unintended pregnancy. Objectives To describe the use of prescribed contraceptives in NI and explore how this varies based on a woman’s age and the deprivation in the area in which she lives. As the prescriber plays a critical role in determining medication use we will also explore how the use of prescribed contraceptives varies based on characteristics of the woman’s general practice (GP) such as size of practice, urban/rural practice location and practice area deprivation. Method A population based cohort study, is being conducted through the Honest Broker Service, linking the GP Register to the Enhanced Prescribing database and 2017 NI Multiple Deprivation Measure for all females of reproductive age 2010-2016. Research based on administrative data is free from recall and social desirability bias, which may be present in surveys of contraceptive use. Administrative data cannot however identify use of over-the-counter contraceptives. Findings This project is still in progress and results will be available by the time of the conference. Based on the NI Statistics and Research Agency Mid-Year Population Estimates and the Business Services Organisation Pharmaceutical statistics there were an estimated 472,875 females between the ages of 12 and 49 living in NI 2010-2016 with 2,316,075 prescriptions for a contraceptive. Conclusions Administrative data should be regularly analysed to understand contraceptive use patterns, and address inequalities

Genetic, environmental and gender influences on attachment disorder behaviours

Background Despite current interest in attachment disorder, there is concern about its discrimination from other disorders and an unproven assumption of an environmental aetiology. Aims To test whether behaviours suggestive of attachment disorder are distinct from other childhood behavioural and emotional problems and are solely environmentally determined. Method In a community sample of 13 472 twins, we carried out factor analysis of questionnaire items encompassing behaviours indicative of attachment disorder, conduct problems, hyperactivity and emotional difficulties. We used behavioural genetic model-fitting analysis to explore the contribution of genes and environment. Results Factor analysis showed clear discrimination between behaviours suggestive of attachment disorder, conduct problems, hyperactivity and emotional problems. Behavioural genetics analysis suggested a strong genetic influence to attachment disorder behaviour, with males showing higher heritability. Conclusions Behaviours suggestive of attachment disorder can be differentiated from common childhood emotional and behavioural problems and appear to be strongly genetically influenced, particularly in boys. INTRODUCTION TOP ABSTRACT INTRODUCTION METHOD RESULTS DISCUSSION REFERENCES There have been recent attempts to codify behaviours associated with early neglect and institutionalisation (Chisolm et al, 1995; Zeanah et al, 2004) into a psychiatric category. Both DSM–IV and ICD–10 describe reactive attachment disorder, with two subtypes encompassing inhibited and disinhibited behaviour (World Health Organization, 1992; American Psychiatric Association, 1994). Questions remain about the nosology of the syndrome beyond age 5 years (American Academy of Child and Adolescent Psychiatry, 2005), therefore we simply refer to ‘attachment disorder behaviours’. We seek to extend the extant literature by testing two hypotheses: first, that the two subtypes are distinct from one another and from other common behavioural and emotional problems in young children, and second that these behavioural patterns are environmentally mediated. We capitalise on a twin study, a design that provides particular leverage in testing environmental hypotheses

Older UK sheltered housing tenants’ perceptions of wellbeing and their usage of hospital services

The aim of this study was to examine sheltered housing tenants’ views of health and wellbeing, the strategies they adopted to support their wellbeing and their use of health and social care services through a Health Needs Assessment. Sheltered housing in the UK is a form of service-integrated housing for people, predominantly over 60. The study used a parallel, three-strand mixed method approach to encompass the tenants’ perceptions of health and wellbeing (n=96 participants), analysis of the service’s health and wellbeing database and analysis of emergency and elective hospital admissions (n= 978 tenant data sets for the period January to December 2012). Tenants’ perceptions of wellbeing were seen to reinforce much of the previous work on the subject with strategies required to sustain social, community, physical, economic, environmental, leisure, emotional and spiritual dimensions. Of the tenants’ self-reported chronic conditions, arthritis, heart conditions and breathing problems were identified as their most common health concerns. Hospital admission data indicated that 43% of the tenant population was admitted to hospital (886 admissions) with 53% emergency and 47% elective admissions. The potential cost of emergency as opposed to elective admissions was substantial. The mean length of stay for emergency admissions was 8.2 days (median 3.0 days). While elective hospital admission had a mean length of stay of 1.0 day (median 0.0 days). These results suggest the need for multi-professional health, social care and housing services interventions to facilitate sheltered housing tenants’ aspirations and support their strategies to live well and independently in their own homes. Equally there is a need to increase tenants’ awareness of health conditions and their management; the importance of services which offer facilitation, resources and support and the key role played by prevention and reablement

Programas internacionais de capacitação em pesquisa para enfermeiros no estudo do fenómeno das drogas na América Latina: desafios e perspectivas

The First International Research Capacity-Building Program for Nurses to Study the Drug Phenomenon in the Americas is a result of a partnership between the Inter-American Drug Abuse Control Commission (CICAD) of the Organization of American States (OAS) and the Faculty of Nursing in the University of Alberta, with financial support from the Government of Canada. The program was divided into two parts. The first part of the program was held at the University of Alberta in Edmonton, Alberta, Canada. It involved capacity-building in research methodologies at the Faculty of Nursing, which lead to the preparation of four multi-centric research proposals for drug demand reduction in the home countries of the eleven participants in the program. The second part of the program was related to the implementation of multi-centric research proposals in seven countries in Latin America and in Canada. This program presented expertise in research methodology to members of Latin American Schools of Nursing and introduced Latin American expertise to members of a Canadian Faculty of Nursing. The International Research Capacity-Building Program for Nurses to Study the Drug Phenomenon in the Americas has fostered the kind of inter-cultural respect and mutual appreciation necessary to confront the global health problem of the abuse of both licit and illicit drugs.El Primer Programa Internacional de Capacitación en Investigación para Enfermeros en el Estudio del Fenómeno de las Drogas en las Américas resultó de una colaboración entre la Comisión Interamericana para el Control del Abuso de Drogas (CICAD) de la Organización de los Estados Americanos (OEA) y la Facultad de Enfermería en la Universidad de Alberta, con apoyo financiero del Gobierno de Canadá. El programa fue dividido en dos partes. La primera parte del programa se organizó en la Universidad de Alberta en Edmonton, Alberta, Canadá. Abarcó la capacitación en metodologías de investigación en la Facultad de Enfermería, que llevó a la preparación de cuatro propuestas de investigación multicéntrica con vistas a la reducción de la demanda de drogas en los países de origen de los once participantes en el programa. La segunda parte del programa estaba relacionada a la implementación de propuestas de investigación multicéntrica en siete países de América Latina y en Canadá. Este programa presentó conocimientos especializados en metodologías de investigación a miembros de Escuelas de Enfermería latinoamericanas e introdujo los conocimientos especializados latinoamericanos a miembros de una Facultad de Enfermería canadiense. El Programa Internacional de Capacitación en Investigación para Enfermeros en el Estudio del Fenómeno de las Drogas en las Américas estimuló el tipo de respecto intercultural y apreciación mutua necesario para confrontar el problema de salud global del abuso de drogas lícitas e ilícitas.O Primeiro Programa Internacional de Capacitação para Enfermeiros no Estudo do Fenômeno das Drogas nas Américas é resultado de uma parceria entre a Comissão Interamericana para o Controle do Abuso das Drogas (CICAD) da Organização dos Estados Americanos (OEA) e a Faculdade de Enfermagem da Universidade de Alberta, com apoio financeiro do Governo do Canadá. O programa foi dividido em duas partes. A primeira parte do programa foi realizada na Universidade de Alberta em Edmonton, Alberta, Canadá. Compreendeu a capacitação em metodologias de pesquisa na Faculdade de Enfermagem, que levou à preparação de quatro propostas de pesquisas multicêntricas para a redução da demanda de drogas nos países de origem dos onze participantes no programa. A segunda parte do programa estava relacionada à implementação de propostas de pesquisa multicêntricas em sete países da América Latina e no Canadá. Este programa apresentou expertise em metodologias de pesquisa a membros de Escolas de Enfermagem latino-americanas e introduziu expertise latino-americana a membros de uma Faculdade de Enfermagem canadense. O Primeiro Programa Internacional de Capacitação para Enfermeiros no Estudo do Fenômeno das Drogas nas Américas estimulou o tipo de respeito intercultural e apreço mútuo necessário para confrontar o problema de saúde global do abuso das drogas lícitas e ilícitas

Morphine for elective endotracheal intubation in neonates: a randomized trial [ISRCTN43546373]

BACKGROUND: Elective endotracheal intubations are still commonly performed without premedication in many institutions. The hypothesis tested in this study was that morphine given prior to elective intubations in neonates would decrease fluctuations in vital signs, shorten the duration of intubation and reduce the number of attempts. METHODS: From December 1999 to September 2000, infants of all gestations admitted to a level III neonatal intensive care unit and requiring an elective endotracheal intubation were randomly assigned to receive morphine 0.2 mg/kg IV or placebo 5 minutes before intubation. Duration of severe hypoxemia (HR< 90/min and Sp0(2)<85%), duration of procedure, duration of hypoxemia (Sp0(2)<85%), number of attempts and change in mean blood pressure were compared between groups. RESULTS: 34 infants (median 989 g and 28 weeks gestation) were included. The duration of severe hypoxemia was similar between groups. Duration of procedure, duration of hypoxemia, number of attempts and increases in mean blood pressure were also similar between groups. 94% of infants experienced bradycardia during the procedure. CONCLUSION: We failed to demonstrate the effectiveness of morphine in reducing the physiological instability or time needed to perform elective intubations. Alternatives, perhaps with more rapid onset of action, should be considered

Rapid Evaluation for health and social care innovations: Challenges for “quick wins” using interrupted time series.

Background: Rapid evaluation was at the heart of National Health Service England’s evaluation strategy of the new models of care vanguard programme. This was to facilitate the scale and spread of successful models of care throughout the health & social care system. The aim of this paper is to compare the findings of the two evaluations of the Enhanced health in Care Homes (EHCH) vanguard in Gateshead, one using a smaller data set for rapidity and one using a larger longitudinal data set and to investigate the implications of the use of rapid evaluations using interrupted time series (ITS) methods. Methods: A quasi-experimental design study in the form of an ITS was used to evaluate the impact of the vanguard on secondary care use. Two different models are presented differing by timeframes only. The short-term model consisted of data for 11 months data pre and 20 months post vanguard. The long-term model consisted of data for 23 months pre and 34 months post vanguard. Results: The cost consequences, including the cost of running the EHCH vanguard, were estimated using both a single tariff non-elective admissions methodology and a tariff per bed day methodology. The short-term model estimated a monthly cost increase of £73,408 using a single tariff methodology. When using a tariff per bed day, there was an estimated monthly cost increase of £14,315. The long-term model had, using a single tariff for non-elective admissions, an overall cost increase of £7576 per month. However, when using a tariff per bed-days, there was an estimated monthly cost reduction of £57,168. Conclusions: Although it is acknowledged that there is often a need for rapid evaluations in order to identify “quick wins” and to expedite learning within health and social care systems, we conclude that this may not be appropriate for quasi-experimental designs estimating effect using ITS for complex interventions. Our analyses suggests that care must be taken when conducting and interpreting the results of short-term evaluations using ITS methods, as they may produce misleading results and may lead to a misallocation of resources