Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial

Objective: To test the effectiveness of a complex intervention designed, within a theoretical framework, to improve outcomes for patients with coronary heart disease. Design: Cluster randomised controlled multicentre trial. Setting: General practices in Northern Ireland and the Republic of Ireland, regions with different healthcare systems. Participants: 903 patients with established coronary heart disease registered with one of 48 practices. Intervention: Tailored care plans for practices (practice based training in prescribing and behaviour change, administrative support, quarterly newsletter), and tailored care plans for patients (motivational interviewing, goal identification, and target setting for lifestyle change) with reviews every four months at the practices. Control practices provided usual care. Main outcome measures: The proportion of patients at 18 month follow-up above target levels for blood pressure and total cholesterol concentration, and those admitted to hospital, and changes in physical and mental health status (SF-12). Results: At baseline the numbers (proportions) of patients above the recommended limits were: systolic blood pressure greater than 140 mm Hg (305/899; 33.9%, 95% confidence interval 30.8% to 33.9%), diastolic blood pressure greater than 90 mm Hg (111/901; 12.3%, 10.2% to 14.5%), and total cholesterol concentration greater than 5 mmol/l (188/860; 20.8%, 19.1% to 24.6%). At the 18 month follow-up there were no significant differences between intervention and control groups in the numbers (proportions) of patients above the recommended limits: systolic blood pressure, intervention 98/360 (27.2%) v control, 133/405 (32.8%), odds ratio 1.51 (95% confidence interval 0.99 to 2.30; P=0.06); diastolic blood pressure, intervention 32/360 (8.9%) v control, 40/405 (9.9%), 1.40 (0.75 to 2.64; P=0.29); and total cholesterol concentration, intervention 52/342 (15.2%) v control, 64/391 (16.4%), 1.13 (0.63 to 2.03; P=0.65). The number of patients admitted to hospital over the 18 month study period significantly decreased in the intervention group compared with the control group: 107/415 (25.8%) v 148/435 (34.0%), 1.56 (1.53 to 2.60; P=0.03). Conclusions: Admissions to hospital were significantly reduced after an intensive 18 month intervention to improve outcomes for patients with coronary heart disease, but no other clinical benefits were shown, possibly because of a ceiling effect related to improved management of the disease. Trial registration: Current Controlled Trials ISRCTN24081411.

Promoting Health Behaviour Change in the Cardiac Patient

The importance of giving patients advice in relation to positive health behaviour change geared towards maximizing physical health must not be overlooked and is an important role of the cardiac nurse in contemporary health care. However, over-reliance on offering advice can often be counter-productive and less likely to achieve effective change. Patients are more likely to make positive health behaviour changes when they self-generate their own solutions to the health issues and problems that they face. In this article, the authors encourage cardiac nurses to embrace a less directive and more facilitative approach to patient health behaviour change in light of the mounting evidence that exists to the effectiveness of motivational interviewing techniques.

Parent-offspring conflict and motivational control of brooding in an amphipod (Crustacea)

Models of parent - offspring conflict concerning levels of caregiving centre on conflict resolution by offspring control, compromise or offspring 'honest signalling' that parents use to maximize their own fitness. Recent empirical studies on motivational control of parental feeding of offspring are interpreted as supporting the latter model. Here, we examine parental care in an amphipod, Crangonyx pseudogracilis, which directs care to embryos in a brood pouch. Embryo removal and transplantation elucidated causal factors that determine levels of caregiving. In the short-term, females with all embryos removed reduced care activities, but partial embryo removal did not affect caregiving, evidence of 'unshared' parental care. In the long-term, females with all embryos removed ceased care. Thus, females have a maternal state that is maintained by stimuli from offspring. Transplantation of early/late stage embryos among females originally carrying early/late stage embryos revealed that stimuli from embryos indicate their age-dependent needs, but only modify caregiving within the constraints of a changing endogenous maternal state. Thus, we demonstrate that mothers and offspring share motivational control of care. However, we highlight the inappropriate use of motivational data in reaching conclusions about the resolution of parent - offspring conflict.

Honest and dishonest displays, motivational state and subsequent decisions in hermit crab shell fights

Animal fights are typically preceded by displays and there is debate whether these are always honest. We investigated the prefight period in hermit crabs, Pagurus bernhardus, during which up to four types of display plus other activities that might provide information are performed. We determined how each display influences or predicts various fight decisions, and related these displays to the motivational state of the attacker, as determined by a startle response, and of the motivational state of the defender, as determined by the duration for which it resisted eviction from its shell. Two displays appeared to have consistent but different effects. Cheliped presentation, where the claws were held in a stationary position, often by both crabs but for longer by the larger, seemed to be honest, and allowed for mutual size assessment. This display enhanced the motivation and the success of the larger crab. In contrast, cheliped extension, involving the rapid thrust of the open chelae towards the opponent, did not seem to allow for mutual size assessment and may contain an element of bluff. It was performed more by the smaller crab and enhanced its success. The complexity of displays in this species appears to allow for both honesty and manipulation.

Motivational change during shell fights in the hermit crab Pagurus bernhardus

During agonistic interactions the motivation of each contestant is expected to vary because of increased information and changes in fighting ability. In shell fights between hermit crabs over gastropod shells, attackers rap their shell in a series of bouts against that of the defender whereas defenders remain withdrawn into their shells until the encounter is resolved; either the defender is evicted from its shell or the attacker 'gives up' and the defender retains its shell. We assessed the motivational state of attackers for performing rapping by measuring the duration of startle responses elicited by a novel stimulus. We staged fights between pairs of crabs in six different groups defined by the potential gain in shell quality available to attackers (high or low) and by the point at which the novel stimulus was applied (prior to rapping, after one bout or after four bouts). Startle response duration decreased during the first four bouts of fighting and showed a U-shaped relationship with the relative difference in size between the crabs. There was, no difference in startle response duration between high- and low-gain groups. Individuals showing short startle responses were likely to be victorious and we conclude that the relationship between the relative size difference of the opponents and. startle duration reflects that between size difference and the cost of gaining an eviction. (C) 2001 The Association for the Study of Animal Behaviour.

Interviewing children with acquired brain injury (ABI).

Research into the lives of children with acquired brain injury (ABI) often neglects to incorporate children as participants, preferring to obtain the opinions of the adult carer (e.g. McKinlay et al., 2002). There has been a concerted attempt to move away from this position by those working in children’s research with current etiquette highlighting the inclusion of children and the use of a child-friendly methodology (Chappell, 2000). Children with disabilities can represent a challenge to the qualitative researcher due to the combination of maintaining the child’s attention and the demands placed on them by their disability. The focus of this article is to discuss possible impediments to interviewing children with acquired brain injury (ABI) and provide an insight into how the qualitative researcher may address these.

Motivational trade-offs and potential pain experience in hermit crabs

One criterion of pain experience is that the emotional response to pain may be traded-off against other motivational requirements. This was tested in hermit crabs, housed in either preferred or unpreferred species of shells, by subjecting their abdomens to electric shocks of gradually increasing intensity. The first observable response was not affected by shell species but those in preferred shells evacuated at a higher shock level than those in poor quality shells. Thus, they seem to trade-off the requirement to retain a high quality shell with that of avoidance of the noxious stimulus. Some crabs returned to their shells and those that got back into the preferred species did so with less probing of the aperture before getting in and subsequently thrust their abdomen in and out less often in further investigation, thus confirming their shell species preference. Not all crabs returned to the vicinity of the shell and some attempted to climb the wall of the experimental chamber. Others engaged in shell rapping as if in a fight and grooming of the abdomen was noted. These findings are consistent with the idea of a pain experience rather than a nociceptive reflex. (C) 2009 Elsevier B.V. All rights reserved.