Best interests decisions: professional practices in health and social care

This paper reports on data collected in 2011 from a national study about the operation of the best interests principle, a key feature of the Mental Capacity Act (MCA) 2005 for England and Wales. The objective was to provide a picture of current professional practices in best interests decision‐making. Four contrasting sample sites were selected, in which National Health Service trusts, social care and other organisations were recruited to participate. A multimethod design was followed, including an online survey with 385 participants, followed by qualitative research through a telephone survey of 68 participants, and face‐to‐face semi‐structured interviews following up 25 best interests cases, with different perspectives on the process in 12 of those cases. The current paper reports only on the qualitative findings. The findings indicate that the MCA was successful in providing a structure for these practitioners, and that the five principles of the MCA were in general adhered to. A variety of perceived risks led to best interests processes being undertaken, and a typical scenario was for a period of hospitalisation or ill health to trigger a best interests decision process about a social care and or a life decision. The study supported previous research in finding the notion of capacity the most difficult aspect of the MCA, and it provides evidence of some specific capacity assessment practices, including problematic ones relating to ‘insight’. Best interests decisions were often made by consensus, with practitioners taking on different roles within the process. Meetings played a key part, but other ways of involving people lacking capacity and significant others were also important. It was recommended that the issues highlighted in this research could be clarified further in the Code of Practice, or within risk guidance.     

Exposure to injecting drug use and hepatitis C knowledge among an online sample of young people

Aim: Young people who are socially engaged with people who inject drugs are at higher risk of transitioning to injecting drug use. We aimed to examine rates of exposure to injecting among young people in an online survey, and whether exposure to injecting was related to hepatitis C (HCV) knowledge. Methods: A cross-sectional, online survey was completed by 827 young people (aged 16–26 years) in New South Wales, Australia. Exposure to injecting in the preceding 12 months was measured by asking participants whether close friends and romantic/sexual partners had injected, and whether somebody had offered them an injection. HCV knowledge was measured using items adapted from a survey of Australian secondary school students. Findings: Eleven percent of participants reported recent exposure to injecting. Participants exposed to injecting were significantly more likely than other participants to report use of injectable drugs. Some aspects of HCV transmission were poorly understood, and exposure to injecting was not significantly associated with higher HCV knowledge. Conclusions: While online methods were only moderately successful in recruiting people exposed to injecting, higher rates of use of injectable drugs and HCV knowledge deficits in this group suggests that they are an important target for HCV education and prevention.     

Collaborative population health planning between Australian primary health care organisations and local government: lost opportunity

Objective: To examine the strength and extent of collaborations between primary health care organisations and local government in population health planning. Methods: Methods included: a) online surveys with Medicare Locals (n=210) and Primary Health Networks (n=66), comparing the two using two‐level mixed models; b) interviews with Medicare Local (n=50) and Primary Health Network (n=55) executives; c) interviews with members of local government associations and Primary Health Network board members with local government experience (n=7); and d) review of 54 Medicare Local and 31 Primary Health Network publicly available annual reports. Results: Despite partnership being a policy objective for Medicare Locals/ Primary Health Networks, they reported limited time and financial support for collaboration with local government. Organisational capacity and resources, supportive governance and public health legislation mandating a role for local governments were critical to collaborative planning. Conclusions: Local government has the potential to tackle social factors affecting health; therefore, their inclusion in population health planning is valuable. Legislative mandates would help to achieve this, and PHNs require a stronger Federal Government mandate backed by sufficient resources and a governance structure that supports collaboration. Implications for public health: Improving primary health care and local government collaboration has great potential to improve the quality of health planning and action on social determinants, thus advancing population health and health equity.     

The GRADE approach is reproducible in assessing the quality of evidence of quantitative evidence syntheses

ObjectiveWe evaluated the inter-rater reliability (IRR) of assessing the quality of evidence (QoE) using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.Study Design and SettingOn completing two training exercises, participants worked independently as individual raters to assess the QoE of 16 outcomes. After recording their initial impression using a global rating, raters graded the QoE following the GRADE approach. Subsequently, randomly paired raters submitted a consensus rating.ResultsThe IRR without using the GRADE approach for two individual raters was 0.31 (95% confidence interval [95% CI] = 0.21–0.42) among Health Research Methodology students (n = 10) and 0.27 (95% CI = 0.19–0.37) among the GRADE working group members (n = 15). The corresponding IRR of the GRADE approach in assessing the QoE was significantly higher, that is, 0.66 (95% CI = 0.56–0.75) and 0.72 (95% CI = 0.61–0.79), respectively. The IRR further increased for three (0.80 [95% CI = 0.73–0.86] and 0.74 [95% CI = 0.65–0.81]) or four raters (0.84 [95% CI = 0.78–0.89] and 0.79 [95% CI = 0.71–0.85]). The IRR did not improve when QoE was assessed through a consensus rating.ConclusionOur findings suggest that trained individuals using the GRADE approach improves reliability in comparison to intuitive judgments about the QoE and that two individual raters can reliably assess the QoE using the GRADE system.     

The effects of acute alcohol consumption and eccentric muscle damage on neuromuscular function

Voluntary and electrically stimulated muscular performance was examined to identify the effects of acute alcohol consumption on neuromuscular function in the presence and absence of exercise-induced muscle damage (EIMD). After initial neuromuscular performance measures were made, 12 subjects completed a bout of eccentric exercise (EX) using the quadriceps muscles of 1 leg while the remaining 11 subjects did not exercise (NX). Subjects then consumed either an alcoholic beverage containing 1 g·kg(-1) body weight (ALC) or a nonalcoholic beverage (OJ). On another occasion the contralateral leg of both groups was tested and those in the EX group performed an equivalent bout of eccentric exercise after which the other beverage was consumed. Measurements of neuromuscular function were made pre-exercise and 36 and 60?h post-beverage consumption. Creatine kinase (CK) was measured pre-exercise and at 12, 36, and 60?h. Significantly greater (p?< 0.01) decrements in maximal voluntary isometric contraction were observed with EX ALC at 36 and 60?h compared with EX OJ, and no change was seen in the NX group. Significant decreases in voluntary activation were observed at 36?h (p = 0.003) and 60?h (p = 0.01) with EX ALC only. Elevations in CK were observed at all posteccentric exercise time points (all p?< 0.05) under both EX OJ and ALC. No change in electromyography or low-frequency fatigue was observed under either treatment in either group. These results suggest that decreased neural drive appears to contribute to alcohol's effect on the magnitude of EIMD-related decrements in voluntary force generation.     

Patients' help-seeking behaviours for health problems associated with methadone and buprenorphine treatment

Introduction and Aims . Clients in opioid substitution therapy often have considerable unmet health‐care needs. The current study aimed to explore health problems related to opioid substitution therapy among clients on methadone and buprenorphine treatment. Design and Methods . A self‐complete, cross‐sectional survey conducted among 508 patients receiving methadone and buprenorphine treatment at community pharmacies in New South Wales (NSW), Australia. Results . The most common problems for which participants had ever sought help were dental (29.9%), constipation (25.0%) and headache (24.0%). The most common problems for which participants would currently like help were dental (41.1%), sweating (26.4%) and reduced sexual enjoyment (24.2%). There were no significant differences between those currently on methadone and those currently on buprenorphine for any of the health problems explored, nor differences for gender or treatment duration. Participants on methadone doses 100 mg or above were significantly more likely to want help currently for sedation. Discussion and Conclusions . The considerable unmet health care needs among participants in this study suggest that treatment providers should consider improving the detection and response to common health problems related to opioid substitution therapy.     

Correlation of gp140 expression and NGF-induced neuroblast chemotaxis in the embryonic rat spinal cord

During rat embryogenesis, fibers containing nerve growth factor (NGF) are present near the target destinations of migratory spinal neuroblasts, suggesting that diffusible gradients of NGF provide signals to newly generated neurons in the developing cord. In vitro, pM concentrations of NGF induce neuroblast chemotaxis (directed migration along a chemical gradient), indicating evoked motility is mediated by high-affinity receptors. Binding of ¹²⁵I-labelled NGF to fetal cord cells provides additional evidence that rat spinal neuroblasts express the high-affinity receptors; however, their presence has not been directly demonstrated. In the present study, we used immunocytochemistry to show that the high-affinity NGF receptor protein, gp140^trk (trk) is detectable in embryonic spinal tissue sections and in cord dissociates. Correlation of trk expression with NGF-induced chemotaxis revealed that both the receptor protein expression and functional responses to NGF develop along a ventro-dorsal gradient that parallels the in vivo pattern of neurogenesis and migration. Analysis of the temporal changes in trk immunoreactivity demonstrated that expression of gp140^trk is bimodal, possibly reflecting multiple effects of NGF during development. Chemotaxis to NGF was blocked by nM concentrations of the kinase inhibitor, K252a, suggesting that NGF stimulates motility via high-affinity receptors coupled to kinase activity. Elevated 3′,5′-cyclic adenosine monophosphate (cAMP) also attenuated NGF-induced chemotaxis, presenting preliminary evidence that protein kinase A (PKA) may regulate motility responses to NGF.