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Systematic reviews and meta-analyses suggest that behaviour change interventions have modest effect sizes, struggle to demonstrate effect in the long term and that there is high heterogeneity between studies. Such interventions take huge effort to design and run for relatively small returns in terms of changes to behaviour.
So why do behaviour change interventions not work and how can we make them more effective? This article offers some ideas about what may underpin the failure of behaviour change interventions. We propose three main reasons that may explain why our current methods of conducting behaviour change interventions struggle to achieve the changes we expect: 1) our current model for testing the efficacy or effectiveness of interventions tends to a mean effect size. This ignores individual differences in response to interventions; 2) our interventions tend to assume that everyone values health in the way we do as health professionals; and 3) the great majority of our interventions focus on addressing cognitions as mechanisms of change. We appeal to people’s logic and rationality rather than recognising that much of what we do and how we behave, including our health behaviours, is governed as much by how we feel and how engaged we are emotionally as it is with what we plan and intend to do.
Drawing on our team’s experience of developing multiple interventions to promote and support health behaviour change with a variety of populations in different global contexts, this article explores strategies with potential to address these issues.
Clinical diagnostics in sudden onset disasters have historically been limited. We set out to design, implement, and evaluate a mobile diagnostic laboratory accompanying a type 2 emergency medical team (EMT) field hospital.
Available diagnostic platforms were reviewed and selected against in field need. Platforms included HemoCue301/WBC DIFF, i-STAT, BIOFIRE FILMARRAY multiplex rt-PCR, Olympus BX53 microscopy, ABO/Rh grouping, and specific rapid diagnostic tests. This equipment was trialed in Katherine, Australia, and Dili, Timor-Leste.
During the initial deployment, an evaluation of FilmArray tests was successful using blood culture identification, gastrointestinal, and respiratory panels. HemoCue301 (n = 20) hemoglobin values were compared on Sysmex XN 550 (r = 0.94). HemoCue WBC DIFF had some variation, dependent on the cell, when compared with Sysmex XN 550 (r = 0.88-0.16). i-STAT showed nonsignificant differences against Vitros 250. Further evaluation of FilmArray in Dili, Timor-Leste, diagnosed 117 pathogens on 168 FilmArray pouches, including 25 separate organisms on blood culture and 4 separate cerebrospinal fluid pathogens.
This mobile laboratory represents a major advance in sudden onset disaster. Setup of the service was quick (< 24 hr) and transport to site rapid. Future deployment in fragmented health systems after sudden onset disasters with EMT2 will now allow broader diagnostic capability.
We designed, developed, and implemented a new hospital-based health technology assessment (HB-HTA) program called Smart Innovation. Smart Innovation is a decision framework that reviews and makes technology adoption decisions. Smart Innovation was meant to replace the fragmented and complex process of procurement and adoption decisions at our institution. Because use of new medical technologies accounts for approximately 50 percent of the growth in healthcare spending, hospitals and integrated delivery systems are working to develop better processes and methods to sharpen their approach to adoption and management of high cost medical innovations.
The program has streamlined the decision-making process and added a robust evidence review for new medical technologies, aiming to balance efficiency with rigorous evidence standards. To promote system-wide adoption, the program engaged a broad representation of leaders, physicians, and administrators to gain support.
To date, Smart Innovation has conducted eleven HB-HTAs and made clinician-led adoption decisions that have resulted in over $5 million dollars in cost avoidance. These are comprised of five laboratory tests, three software-assisted systems, two surgical devices, and one capital purchase.
Smart Innovation has achieved cost savings, avoided uncertain or low-value technologies, and assisted in the implementation of new technologies that have strong evidence. The keys to its success have been the program's collaborative and efficient decision-making systems, partnerships with clinicians, executive support, and proactive role with vendors.
Clinical diagnostics in sudden-onset disasters (SOD) has historically been limited. With poor supply routes, lack of a cold chain, and challenging environmental conditions, many diagnostic platforms are unsuitable.
We set out to design, implement, and evaluate a mobile diagnostic laboratory accompanying a type II emergency medical team (EMT) field hospital.
Available diagnostic platforms were reviewed and selected against infield need. Platforms included HemoCue301/WBC DIFF, i-STAT, BioFire multiplex RT-PCR, Olympus BX53 microscopy, ABO/Rh Grouping, and specific rapid diagnostic tests (RDT). This equipment was trialed in Katherine, Australia and Dili, Timor-Leste.
During the initial deployment, validation of FilmArray rt-PCR multiplex tests was successful on blood culture, gastrointestinal, and respiratory panels. HemoCue301 (n = 20) haemoglobin values were compared on Sysmex XN 550 (r = 0.94). Analysis of HemoCue WBC DIFF samples had some variation when compared to Sysmex XN 550, (neutrophils r = 0.88, lymphocytes r = 0.49, monocytes r = 0.16, eosinophils r = 0.70, basophils r = 0.16). i-STAT showed non-significant differences for CHEM4 (n=10), CG8 (n = 10), and TnI (n = 5) against Vitros 250. A further trial of BioFire rt-PCR testing in Dili, Timor-Leste diagnosed 117 causative pathogens on 168 FilmArray test cartridges.
This mobile laboratory represents a major advance in SOD. Setup of the service was quick (<24hr) and transport to site rapidly. Training was simple and performance consistent. Future deployment in fragmented health systems after sudden onset disasters with EMT2 will now allow broader diagnostics.
Following stage 1 palliation, delayed sternal closure may be used as a technique to enhance thoracic compliance but may also prolong the length of stay and increase the risk of infection.
We reviewed all neonates undergoing stage 1 palliation at our institution between 2010 and 2017 to describe the effects of delayed sternal closure.
During the study period, 193 patients underwent stage 1 palliation, of whom 12 died before an attempt at sternal closure. Among the 25 patients who underwent primary sternal closure, 4 (16%) had sternal reopening within 24 hours. Among the 156 infants who underwent delayed sternal closure at 4 [3,6] days post-operatively, 11 (7.1%) had one or more failed attempts at sternal closure. Patients undergoing primary sternal closure had a shorter duration of mechanical ventilation and intensive care unit length of stay. Patients who failed delayed sternal closure had a longer aortic cross-clamp time (123±42 versus 99±35 minutes, p=0.029) and circulatory arrest time (39±28 versus 19±17 minutes, p=0.0009) than those who did not fail. Failure of delayed sternal closure was also closely associated with Technical Performance Score: 1.3% of patients with a score of 1 failed sternal closure compared with 18.9% of patients with a score of 3 (p=0.0028). Among the haemodynamic and ventilatory parameters studied, only superior caval vein saturation following sternal closure was different between patients who did and did not fail sternal closure (30±7 versus 42±10%, p=0.002). All patients who failed sternal closure did so within 24 hours owing to hypoxaemia, hypercarbia, or haemodynamic impairment.
When performed according to our current clinical practice, sternal closure causes transient and mild changes in haemodynamic and ventilatory parameters. Monitoring of SvO2 following sternal closure may permit early identification of patients at risk for failure.
The optimal approach to unifocalisation in pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries (pulmonary artery/ventricular septal defect/major aortopulmonary collaterals) remains controversial. Moreover, the impact of collateral vessel disease burden on surgical decision-making and late outcomes remains poorly defined. We investigated our centre’s experience in the surgical management of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals.
Materials and methods
Between 1996 and 2015, 84 consecutive patients with pulmonary artery/ventricular septal defect/major aortopulmonary collaterals underwent unifocalisation. In all, 41 patients received single-stage unifocalisation (Group 1) and 43 patients underwent multi-stage repair (Group 2). Preoperative collateral vessel anatomy, branch pulmonary artery reinterventions, ventricular septal defect status, and late right ventricle/left ventricle pressure ratio were evaluated.
Median follow-up was 4.8 compared with 5.7 years for Groups 1 and 2, respectively, p = 0.65. Median number of major aortopulmonary collaterals/patient was 3, ranging from 1 to 8, in Group 1 compared with 4, ranging from 1 to 8, in Group 2, p = 0.09. Group 2 had a higher number of lobar/segmental stenoses within collateral vessels (p = 0.02). Group 1 had fewer catheter-based branch pulmonary artery reinterventions, with 5 (inter-quartile range from 1 to 7) per patient, compared with 9 (inter-quartile range from 4 to 14) in Group 2, p = 0.009. Among patients who achieved ventricular septal defect closure, median right ventricle/left ventricle pressure was 0.48 in Group 1 compared with 0.78 in Group 2, p = 0.03. Overall mortality was 6 (17%) in Group 1 compared with 9 (21%) in Group 2.
Single-stage unifocalisation is a promising repair strategy in select patients, achieving low rates of reintervention for branch pulmonary artery restenosis and excellent mid-term haemodynamic outcomes. However, specific anatomic substrates of pulmonary artery/ventricular septal defect/major aortopulmonary collaterals may be better suited to multi-stage repair. Preoperative evaluation of collateral vessel calibre and function may help inform more patient-specific surgical management.
Truncus arteriosus and tetralogy of Fallot with pulmonary atresia may be difficult to differentiate prenatally. We present a case that, on newborn echocardiography, angiography, and intraoperative inspection, shared features of both diagnoses.
We report on an influenza B outbreak in an Ontario long-term care facility in which 2 immunized residents receiving oseltamivir prophylaxis for at least 5 days developed laboratory-confirmed influenza B infection. All isolates were tested for the most common oseltamivir resistance, and none of them had resistance identified.
No published information is available on the foraging ecology and choice of feeding habitat of New Zealand’s rarest breeding bird: the New Zealand Fairy Tern (NZFT) Sternula nereis davisae. To address this gap, we conducted an assessment of the largest remaining breeding population at Mangawhai Harbour, Northland, New Zealand, during the chick-rearing period of the 2010/2011 breeding season. We combined visual tracking of birds with prey surveys and stable isotope analyses, and we present the first quantitative assessment of NZFT foraging. We recorded 405 foraging dives that show NZFT foraging habitat includes the water edges, shallow channels, and pools on the tidal flats of mangrove-lined (Avicennia marina var. resinifera) parts of the estuary; tidal pools on mud- and sandflats in the mid-estuary and lower harbour; the shallow margins of the dredged main channel in the lower harbour; the oxbow lagoons on the sand spit; and coastal shallows. Our study identifies the mangrove-lined highly tidal and shallow mid-estuary and the lagoon on the sand spit as foraging hotspots for the Mangawhai breeding population of the NZFT. The prey survey employed a seine-net sampling method at identified NZFT foraging sites and yielded 4,367 prey-sized fish of 11 species, two of which had not previously been reported in Mangawhai Harbour, as well as numerous shrimps. The most abundant fish were gobies of the genus Favonigobius. Our stable isotope results highlight gobies as the most important prey for NZFT chick rearing, also indicating that flounder Rhombosolea sp. contribute to NZFT diet. We raise the possibility that shrimps may also constitute a substantial diet component for NZFT, potentially providing up to 21% of diet mass for adult birds. While our results provide a first basis to understanding the feeding ecology of NZFT during their breeding season in order to facilitate conservation planning, further research is required to address inter-annual variation and to identify key foraging grounds for this Critically Endangered bird at other breeding sites.
This study assessed the impact of Pinus radiata (D. Don) genetically modified (GM) by biolistic insertion of the LEAFY and nptII genes on rhizosphere microbial communities of field grown trees. Rhizosphere soil was sampled quarterly for two consecutive years. A culture-independent approach was used to characterise the microbial communities based on PCR and denaturing gradient gel electrophoresis (DGGE) of 16S/18S rDNA gene fragments, and internal transcribed spacer (ITS) fragments amplified from total rhizosphere DNA. Trees from two independent transformation events were sampled, together with non-modified control trees of the same parental genotype. DGGE profiles of rhizosphere general Bacteria did not differ between GM and control trees with one exception (summer 2006 sample). For Alphaproteo- and Actinobacteria, significant differences between treatments were detected in one out of eight samplings. Small seasonal shifts could be detected in all bacterial communities. General fungal and ectomycorrhizal communities did not differ significantly between GM and control trees with the exception of summer 2006, when ectomycorrhizal communities associated with GM trees from one transformation event differed from those associated with control trees. Small seasonal shifts of general fungal and ectomycorrhizal communities were seen over the two-year sampling period. More detailed analysis of microbial communities at one sampling date (using amplified rDNA restriction analysis (ARDRA) and 16S/18S rDNA sequencing) revealed significant differences in four ARDRA groups between one GM treatment and the control (bacteria), and significant differences in one ARDRA group between the two GM treatments (fungi). When data from all sampling dates are considered together, the low incidence of statistical differences in the microbial communities associated with the genetically modified and control trees suggests that there was no significant impact of this genetic modification on rhizosphere microbial communities.
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is curative for many pediatric diseases. Most children transplanted for cancer, severe combined immunodeficiency syndrome, aplastic anemia, sickle cell anemia, thalassemia, and certain metabolic disorders are expected to survive. This has led to an ever-increasing population of longterm survivors. Recent studies demonstrate the major impact that late effects have on the individual survivors and society as a whole.
Chronic Graft versus Host Disease
Chronic graft versus host disease (cGVHD) is the most significant nonrelapse cause of morbidity and mortality following stem cell transplantation (SCT) for malignancies. Although the rates of cGVHD are lower in children than adults, the incidence of cGVHD in children has increased in association with the use of peripheral blood and unrelated donors. The manifestations and mechanisms of cGVHD in children and adults appear similar, although the natural history and response to therapy are different. cGVHD and its current treatments have a spectrum of deleterious effects on normal growth and organ development in children. In addition, the impact of prolonged immunosuppression is of particular concern in childhood, a critical time of immunologic development in response to common infections and immunizations.
Data and research focused on cGVHD in pediatrics are limited. Most studies are small and are often grouped into larger adult series. In comparison to adults, relatively small numbers of children and adolescents undergo transplantation.
Screening instruments for autistic-spectrum disorders have not been compared in the same sample.
To compare the Social Communication Questionnaire (SCQ), the Social Responsiveness Scale (SRS) and the Children's Communication Checklist (CCC).
Screen and diagnostic assessments on 119 children between 9 and 13 years of age with special educational needs with and without autistic-spectrum disorders were weighted to estimate screen characteristics for a realistic target population.
The SCQ performed best (area under receiver operating characteristic curve (AUC)=0.90; sensitivity 0.86; specificity 0.78). The SRS had a lower AUC (0.77) with high sensitivity (0.78) and moderate specificity (0.67). The CCC had a high sensitivity but lower specificity (AUC=0.79; sensitivity 0.93; specificity 0.46). The AUC of the SRS and CCC was lower for children with IQ < 70. Behaviour problems reduced specificity for all three instruments.
The SCQ, SRS and CCC showed strong to moderate ability to identify autistic-spectrum disorder in this at-risk sample of school-age children with special educational needs.
Rat Basophilic Leukemia (RBL) cells are immobilized and stimulated on micro- and nanometer scale patterns of supported lipid bilayers. The patterns are realized as the photolithographically patterned polymer is mechanically peeled away in one contiguous piece in solution. The 0.36 μm2 to 4, 489 μm2 patches can contain both fluorescent lipids and lipid-linked antigen and provide a synthetic biological substrate for analysis of cell surface receptor-mediated events. 100-nm unilamellar lipid vesicles spread to form a supported lipid bilayer on a thermally oxidized silicon surface as confirmed by fluorescence recovery after photobleaching (FRAP). Aggregation of fluorescently labeled receptors is observed as their coincidence with the patterned antigen. Cell morphology is analyzed with scanning electron microscopy (SEM). Thus, a novel method has been developed for patterning antigen, capturing and immobilizing cells via specific receptors, and spatially controlling antigenic stimulus on the nanoscale.
Children with bilateral cerebral palsy (CP) born during 1989 to 1992 (n=346) to a geographically defined population were ascertained and followed up to age 5 years. The aims of the study were to monitor hip development by serial X-rays; to record gross locomotor development, aspects of physical management, and any hip-related orthotics or surgery; to learn more of the natural history of hip development in this condition; and to provide guidelines for a surveillance protocol for those clinically managing children with bilateral CP. Children were X-rayed at 18, 24, 30, 48, and 60 months. X-rays were taken in a standardized position and measured to record migration percentage, acetabular index, Sharp's angle, and Smith's diaphyseal ratios. Relationships between the measures were investigated and a natural history of the children's hip development suggested. At as early as 18 months, migration percentages were significantly greater than in the normally developing population, although no measured CP factor could be identified to be the cause of this early change. Two possible factors affecting early hip development are described, neither of which is clinically apparent: the first separates the bilateral CP population as a whole from the normal population; but there is an additional presdisposing factor affecting some children only which in the presence of the motor disorder, has a significant influence on early hip development and subsequent dysplasia. The study confirms that, when measured correctly, migration percentage is the best guide to hip surveillance and the need for treatment. It is suggested that all children with bilateral CP should be X-rayed in a standardized position at 30 months (corrected for gestational age).
Since the discovery of the structure and function of steroids over 60 years ago, it has long been recognized that synthetic antagonists of the natural hormones would have potential therapeutic uses. Antagonists of mineralocorticoids, androgens and oestrogens, for example spironolactine, cyproterone, flutamide and tamoxifen, have already found a place in the management of hormone dependent conditions. In 1982, chemists at Roussel UCLAF announced that they had synthesized mifepristone (RU486) 17β-hydroxy-11(p-(dimethylamino)phenyl)-17-(1-propynyl) estra-411, 9-dien-3-one) a derivative of norethindrone which had potent antiprogestogenic as well as antiglucocorticoid activity. Although it was immediately realised that this compound would potentially have wide clinical application, its development in the last 10 years has been dominated by its abortifacient action. In the original clinical report by Herrman and colleagues it was shown that bleeding occurred when it was given to female volunteers in the second half of the menstrual cycle. In addition, complete abortion occurred in eight of 11 women who took the drug in the early weeks of pregnancy. These findings, which demonstrated that mifepristone could be used as the basis of a medical method of inducing abortion, were immediately made the focus of groups opposed to abortion on moral grounds. Experience over the last 10 years has confirmed the promise of these early studies and mifepristone, in combination with a suitable prostaglandin, is now licensed in France, UK and Sweden for use as a medical method of inducing abortion in early pregnancy.
The hydrolysis of tetraethoxysilane was studied in an ethanol-water system with ammonium hydroxide catalyst. Reactions were carried out with water concentrations of 5M and 10M and ammonia concentrations up to 1.7M, and the products examined by electron optical methods. Variation of reagent concentrations lead to changes in the product morphology from small irregular particles, through roughly spherical and spherical particles to large fused particles. Within the range of particulate material the variations in size can be related to the effect of reagent concentrations by consideration of the reactions occurring. The effect on morphology of replacing ammonia with ethylamine was investigated and resembles that of the use of much higher ammonia concentrations.
The attitudes of women of reproductive age to IVF therapy and human embryo research were investigated. A questionnaire was given to 1920 consecutive women attending clinics for family planning (1050), ante-natal care (705) and infertility (165). This paper reports the analysis of 1701 returned questionnaires, all from women of reproductive age. The great majority (94%) were in favour of IVF treatment. Sixty-seven percent approved of research on human embryos up to 14 days to improve IVF treatment, and a further 10% supported research on embryos designed to avoid birth defects. The majority (79%) thought women should be allowed to donate ova for research. The social characteristics of the infertility group were similar to those of the ante-natal group except for lower parity. In the family planning and ante-natal groups attitudes were not related to age, social class or parity, but were influenced by religious beliefs.