Obstacles and Opportunities for Multi-disciplinary Working in Drug Misuse: a case study

This paper examines the lack of congruence between national policy documents and local practice in multi-disciplinary working with drug users, by reporting on a case study within one English county. It gives an analysis of the roles and responsibilities of generic service providers and a minority of specialists, based on 100 interviews and questionnaires with representatives from professional groups involved with drug issues. The respondents worked with a range of young people and adults. Whilst professionals worked well within broad disciplines such as health or education, they did not operate as well across disciplinary boundaries. Many of the respondents were unsure about the specific role of their own profession, and which group they should target for drug interventions. There was a lack of clarity about what approach was appropriate to their traditional target group in terms of drugs, and consequently many did not utilize their established approach for that group. When the reasons for the lack of co-working were examined, it was found that there were many misconceptions among professionals concerning what other professional groups actually did in response to drugs. The authors clarify the reasons for the apparent confusion and highlight the possibility that a traditional generic approach and target group may not provide an appropriate match in terms of drug intervention. They make recommendations for overcoming these obstacles to multi-disciplinary working and consider the implications for training.     

Comparison of the efficacy and safety of ciclesonide 160 μg once daily vs. budesonide 400 μg once daily in children with asthma

Ciclesonide is an onsite-activated inhaled corticosteroid (ICS) for the treatment of asthma. This study compared the efficacy, safety and effect on quality of life (QOL) of ciclesonide 160 microg (ex-actuator; nominal dose 200 microg) vs. budesonide 400 microg (nominal dose) in children with asthma. Six hundred and twenty-one children (aged 6-11 yr) with asthma were randomized to receive ciclesonide 160 microg (ex-actuator) once daily (via hydrofluoroalkane metered-dose inhaler and AeroChamber Plus spacer) or budesonide 400 microg once daily (via Turbohaler) both given in the evening for 12 wk. The primary efficacy end-point was change in forced expiratory volume in 1 s (FEV1). Additional measurements included change in daily peak expiratory flow (PEF), change in asthma symptom score sum, change in use of rescue medication, paediatric and caregiver asthma QOL questionnaire [PAQLQ(S) and PACQLQ, respectively] scores, change in body height assessed by stadiometry, change in 24-h urinary cortisol adjusted for creatinine and adverse events. Both ciclesonide and budesonide increased FEV1, morning PEF and PAQLQ(S) and PACQLQ scores, and improved asthma symptom score sums and the need for rescue medication after 12 wk vs. baseline. The non-inferiority of ciclesonide vs. budesonide was demonstrated for the change in FEV1 (95% confidence interval: -75, 10 ml, p = 0.0009, one-sided non-inferiority, per-protocol). In addition, ciclesonide and budesonide showed similar efficacy in improving asthma symptoms, morning PEF, use of rescue medication and QOL. Ciclesonide was superior to budesonide with regard to increases in body height (p = 0.003, two-sided). The effect on the hypothalamic-pituitary-adrenal axis was significantly different in favor of ciclesonide treatment (p < 0.001, one-sided). Both ciclesonide and budesonide were well tolerated. Ciclesonide 160 microg once daily and budesonide 400 microg once daily were effective in children with asthma. In addition, in children treated with ciclesonide there was significantly less reduction in body height and suppression of 24-h urinary cortisol excretion compared with children treated with budesonide after 12 wk.     

Calcification and ossification of chronic encapsulated intracerebral haematoma: case report.

We report a case of calcified chronic encapsulated intracerebral haematoma (ICH) in a 29-year-old female who presented with progressive left sided weakness and intermittent seizures since childhood. The preoperative magnetic resonance (MR) imaging of the head initially suggested that a partially thrombosed aneurysm or vascular malformation was present. However, no vascular stain was found on the digital subtraction angiography (DSA) of both the carotid and vertebral arteries. The excised mass was histologically diagnosed as a chronic ICH. We traced the patient's medical history and found that at the age of one she sustained a head injury after a fall. So far, to our knowledge, no case of epilepsy secondary to a calcified chronic encapsulated ICH occurring 28 years after head injury has been reported. Calcified chronic encapsulated ICH concomitant with new bone formation within is even rarer. The possible pathogenesis of this case is discussed.     

Expression profiling identifies the CRH/CRH-R1 system as a modulator of neurovascular gene activity.

Corticotropin-releasing hormone receptor type 1 (CRH-R1)-deficient mice display reduced anxiety-like behavior, a chronic corticosterone deficit, and an impaired neuroendocrine stress response caused by disruption of the hypothalamic-pituitary-adrenocortical (HPA) axis. The molecular substrates and pathways of CRH/CRH-R1-dependent signaling mechanisms underlying the behavioral phenotype as well as the consequences of lifelong glucocorticoid deficit remain largely obscure. To dissect involved neuronal circuitries, we performed comparative expression profiling of brains of CRH-R1 mutant and wild-type mice using our custom made MPIP (Max Planck Institute of Psychiatry) 17k cDNA microarray. Microarray analysis yielded 107 genes showing altered expression levels when comparing CRH-R1 knockout mice with wild-type littermates. A significant proportion of differentially expressed genes was related to control of HPA and hypothalamic-pituitary-thyroid (HPT) axes reflecting not only the disturbance of the HPA axis in CRH-R1 mutant mice but also the interplay of both neuroendocrine systems. The spatial analysis of regulated genes revealed a prevalence for genes expressed in the cerebral microvasculature. This phenotype was confirmed by the successful cross-validation of regulated genes in CRH overexpressing mice. Analysis of the cerebral vasculature of CRH-R1 mutant and CRH overexpressing mice revealed alterations of functional rather than structural properties. A direct role of the CRH/CRH-R1 system was supported by demonstrating Crhr1 expression in the adult murine cerebral vasculature. In conclusion, these data suggest a novel, previously unknown role of the CRH/CRH-R1 system in modulating neurovascular gene expression and function.     

Impact of randomized trials comparing conventional and endovascular abdominal aortic aneurysm repair on clinical practice.

PURPOSE: To report a retrospective study into the effects of trials on clinical decision-making regarding abdominal aortic aneurysm (AAA) patients suitable for both conventional open (OR) and endovascular aneurysm repair (EVAR). METHODS: A questionnaire was sent to 1400 Dutch surgeons and trainees. Interviewees had to choose between OR and EVAR for AAA patients with and without comorbidity. Specifically, their preferences before and after the publication of 2 randomized trials (EVAR-1 and DREAM) were polled. RESULTS: Of the 524 (37%) questionnaires returned, 223 (43%) respondents treated AAA patients. Before publication of the trials, 160 (72%) preferred OR for the patient without comorbidity and 169 (76%) preferred EVAR for the patient with comorbidity. In total, 72 (32%) respondents changed their preference after the trials were published; however, there was no overall major shift. Focusing on the different cases revealed that the OR preference was significantly enhanced for the patient without comorbidity (p<0.01), while the EVAR preference was significantly enhanced for the patient with comorbidity (p<0.05). CONCLUSION: The randomized trials have not induced major overall changes in surgical decision-making for AAA patients suitable for both EVAR and OR.     

Satisfaction with Team Midwifery Care for Low‐ and High‐Risk Women: A Randomized Controlled Trial

ABSTRACT:Background: In 1996 a new model of maternity care characterized by continuity of midwifery care from early pregnancy through the postpartum period was implemented for women attending Monash Medical Centre, a tertiary level obstetric service, in Melbourne, Australia. This study's purpose was to assess the impact of this model on women's views and experiences of care during the antenatal, intrapartum, and postpartum periods compared with views of women receiving standard maternity care. Methods: One thousand low‐ and high‐risk women who booked at the antenatal clinic and met the eligibility criteria were randomly allocated to continuity of midwifery care from a group of seven midwives in collaboration with medical staff, or to standard care from a variety of midwives and medical staff. Women's views of care were measured by means of a postal questionnaire at four months after the birth. Results: Team midwifery care was associated with increased satisfaction with antenatal, intrapartum, and some aspects of postpartum care. The differences were most obvious for antenatal care. Conclusions: Continuity of midwifery care is realistically achievable in a tertiary obstetric referral service and is associated with increased satisfaction. (BIRTH 30:1 March 2003)