Illness perceptions and coping in physical health conditions: A meta-analysis

Objective: There is a considerable body of research linking elements of Leventhal’s Common Sense Model (CSM) to emotional well-being/distress outcomes among people with physical illness. The present study aims to consolidate this literature and examine the evidence for the role of coping strategies within this literature.
Methods: A systematic review was conducted where the outcomes of interest were: depression, anxiety and quality of life. A total of 1050 articles were identified and 31 articles were considered eligible to be included in the review.
Results: Across a range of illnesses, perceptions of consequences of the illness and emotional representations were consistently the illness perceptions with the strongest relationship with the outcomes. Coping variables tend to be stronger predictors of outcomes than the illness perception variables. The evidence for the mediating effect of coping was inconsistent.
Conclusions: Illness perceptions and coping have an important role to play in the explanation of distress outcomes across a range of physical health conditions. However, some clarity about the theoretical position of coping in relation to illness perceptions, and further longitudinal work is needed if we are to apply this information to the design of interventions for the improvement of psychological health among people with physical health conditions.

The changing epidemiology of Ebstein's anomaly and its relationship with maternal mental health conditions: a European registry-based study

OBJECTIVES: The aim of this study was to describe the epidemiology of Ebstein's anomaly in Europe and its association with maternal health and medication exposure during pregnancy.

DESIGN: We carried out a descriptive epidemiological analysis of population-based data.

SETTING: We included data from 15 European Surveillance of Congenital Anomalies Congenital Anomaly Registries in 12 European countries, with a population of 5.6 million births during 1982-2011. Participants Cases included live births, fetal deaths from 20 weeks gestation, and terminations of pregnancy for fetal anomaly. Main outcome measures We estimated total prevalence per 10,000 births. Odds ratios for exposure to maternal illnesses/medications in the first trimester of pregnancy were calculated by comparing Ebstein's anomaly cases with cardiac and non-cardiac malformed controls, excluding cases with genetic syndromes and adjusting for time period and country.

RESULTS: In total, 264 Ebstein's anomaly cases were recorded; 81% were live births, 2% of which were diagnosed after the 1st year of life; 54% of cases with Ebstein's anomaly or a co-existing congenital anomaly were prenatally diagnosed. Total prevalence rose over time from 0.29 (95% confidence interval (CI) 0.20-0.41) to 0.48 (95% CI 0.40-0.57) (p<0.01). In all, nine cases were exposed to maternal mental health conditions/medications (adjusted odds ratio (adjOR) 2.64, 95% CI 1.33-5.21) compared with cardiac controls. Cases were more likely to be exposed to maternal β-thalassemia (adjOR 10.5, 95% CI 3.13-35.3, n=3) and haemorrhage in early pregnancy (adjOR 1.77, 95% CI 0.93-3.38, n=11) compared with cardiac controls.

CONCLUSIONS: The increasing prevalence of Ebstein's anomaly may be related to better and earlier diagnosis. Our data suggest that Ebstein's anomaly is associated with maternal mental health problems generally rather than lithium or benzodiazepines specifically; therefore, changing or stopping medications may not be preventative. We found new associations requiring confirmation.

Cost-effectiveness of ART restorations in elderly adults: a randomized clinical trial

BACKGROUND: As the world population ages, the requirement for cost-effective methods of treating chronic disease conditions increases. In terms of oral health, there is a rapidly increasing number of dentate elderly with a high burden of maintenance. Population surveys indicate that older individuals are keeping their teeth for longer and are a higher caries risk group. Atraumatic Restorative Treatment (ART) could be suitable for patients in nursing homes or house-bound elderly, but very little research has been done on its use in adults.

OBJECTIVES: To compare the cost-effectiveness of ART and a conventional technique (CT) for restoring carious lesions as part of a preventive and restorative programme for older adults.

METHODS: In this randomized clinical trial, 82 patients with carious lesions were randomly allocated to receive either ART or conventional restorations. Treatment costs were measured based on treatment time, materials and labour. For the ART group, the cost of care provided by a dentist was also compared to the cost of having a hygienist to provide treatment. Effectiveness was measured using percentage of restorations that survived after a year.

RESULTS: Eighty-two patients received 260 restorations, that is, 128 ART and 132 conventional restorations. 91.1% of the restorations were on one surface only. After a year, 252 restorations were assessed in 80 patients. The average cost for ART and conventional restorations was €16.86 and €28.71 respectively; the restoration survival percentages were 91.1% and 97.7%, respectively. This resulted in a cost-effectiveness ratio of 0.18 (ART) and 0.29 (CT). When the cost of a hygienist to provide ART was inserted in the analysis, the resulting ratio was 0.14.

CONCLUSIONS: Atraumatic restorative treatment was found to be a more cost-effective alternative to treat older adults after 1 year, compared to conventional restorations, especially in out of surgery facilities and using alternative workforce such as hygienists. Atraumatic restorative treatment can be a useful tool to provide dental care for frail and fearful individuals who might not access dental treatment routinely.

Generation of an epigenetic signature by chronic hypoxia in prostate cells

Increasing levels of tissue hypoxia have been reported as a natural feature of the aging prostate gland and may be a risk factor for the development of prostate cancer. In this study, we have used PwR-1E benign prostate epithelial cells and an equivalently aged hypoxia-adapted PwR-1E sub-line to identify phenotypic and epigenetic consequences of chronic hypoxia in prostate cells. We have identified a significantly altered cellular phenotype in response to chronic hypoxia as characterized by increased receptor-mediated apoptotic resistance, the induction of cellular senescence, increased invasion and the increased secretion of IL-1 beta, IL6, IL8 and TNFalpha cytokines. In association with these phenotypic changes and the absence of HIF-1 alpha protein expression, we have demonstrated significant increases in global levels of DNA methylation and H3K9 histone acetylation in these cells, concomitant with the increased expression of DNA methyltransferase DMNT3b and gene-specific changes in DNA methylation at key imprinting loci. In conclusion, we have demonstrated a genome-wide adjustment of DNA methylation and histone acetylation under chronic hypoxic conditions in the prostate. These epigenetic signatures may represent an additional mechanism to promote and maintain a hypoxic-adapted cellular phenotype with a potential role in tumour development.

Dysregulation in retinal para-inflammation and age-related retinal degeneration in CCL2 or CCR2 deficient mice

We have shown previously that a para-inflammatory response exists at the retinal/choroidal interface in the aging eye; and this response plays an important role in maintaining retinal homeostasis under chronic stress conditions. We hypothesized that dysregulation of the para-inflammatory response may result in an overt pro-inflammatory response inducing retinal degeneration. In this study, we examined this hypothesis in mice deficient in chemokine CCL2 or its cognate receptor CCR2. CCL2- or CCR2-deficient mice developed retinal degenerative changes with age, characterized as retinal pigment epithelial (RPE) cell and photoreceptor cell death. Retinal cell death was associated with significantly more subretinal microglial accumulation and increased complement activation. In addition, monocytes from CCL2- or CCR2-deficient mice had reduced capacity for phagocytosis and chemotaxis, expressed less IL-10 but more iNOS, IL-12 and TNF-a when compared to monocytes from WT mice. Complement activation at the site of RPE cell death resulted in C3b/C3d but not C5b-9 deposition, indicating only partial activation of the complement pathway. Our results suggest that altered monocyte functions may convert the protective para-inflammatory response into an overtly harmful inflammation at the retina/choroidal interface in CCL2- or CCR2-deficient mice, leading to RPE and photoreceptor degeneration. These data support a concept whereby a protective para-inflammatory response relies upon a normally functioning innate immune system. If the innate immune system is deficient chronic stress may tip the balance towards an overt inflammatory response causing cell/tissue damage.

Evidence-Based Clinical Pathways To Manage Urinary Tract Infections in Long-Term Care Facilities:A Qualitative Case Study Describing Administrator and Nursing Staff Views

Objectives: This article examines the views of nursing staff and administrators in long-term care facilities (LTCFs) regarding a clinical pathway for managing urinary tract infections (UTIs) in LTCF residents. Design: A qualitative (case study) design was used. Setting: Data were collected from 8 LTCFs in southern Ontario and 2 in Iowa enrolled in a larger randomized controlled trial of clinical pathway for managing UTIs in LTCF residents, conducted between September 2001 and March 2003. The clinical pathway, designed to more effectively identify, diagnose, and treat UTIs, and reduce inappropriate antibiotics use for asymptomatic UTIs, introduced 2 decision tools to determine when to order a urine culture and initiate antibiotic treatment for suspected UTIs. Participants: We conducted 19 individual interviews with administrators and 10 focus groups with 52 nurses. Findings: Nurses generally thought that the pathways were well developed and easy to use, and administrators believed they were an important educational resource. Barriers to their use varied by group-initial lack of buy-in from nurses (medical directors), additional work (directors of nursing), and the need to change the protocol to exclude certain residents based on prior health conditions and/or pressure from physicians or families (nurses). Conclusions: Both administrators and staff, once familiar with a new clinical protocol to improve UTI management in LTCFs, generally supported its use. © 2007 American Medical Directors Association.

Using extended contact to improve physiological responses and behavior toward people with schizophrenia

Extended contact has been shown to improve explicit and implicit attitudes toward a number of outgroups, but not yet toward people with mental health conditions. Using people with schizophrenia as the target group, this experiment is the first to demonstrate that extended contact can reduce explicit prejudice, buffer stress responses to future interactions, improve non-verbal behavior, and improve the quality of interactions in a manner detectable by the target group member. Participants watched a video of a brief, positive interaction between two strangers, one of whom they were led to believe had schizophrenia. Control participants watched the same video without being told that the person had schizophrenia. They then participated in a social interaction with a confederate whom they were led to believe had the disorder. Participants' cardiovascular and electrodermal activity were monitored immediately before the interaction. The interaction was also secretly recorded to allow independent judges to assess the participants' non-verbal behaviors. The confederate also rated the positivity of each interaction. Participants in the extended contact condition reported more positive attitudes toward people with schizophrenia, displayed more positive non-verbal behaviors, and had a more positive interaction with the confederate. Moreover, just prior to the interaction, participants in the extended contact condition displayed smaller anticipatory stress responses, as reflected in smaller changes in interbeat interval and non-specific skin conductance responses during this phase. Together, these findings support the use of the extended contact as an intervention that could lead to genuine changes in attitudes toward and treatment of people with severe mental health disorders.

Legislating about Unhealthy Food: A Millian Approach

Tackling food-related health conditions is becoming one of the most pressing issues in the policy agendas of western liberal democratic governments. In this article, I intend to illustrate what the liberal philosopher John Stuart Mill would have said about legislation on unhealthy food and I focus especially on the arguments advanced by Mill in his classic essay On Liberty ([1859] 2006). Mill is normally considered as the archetype of liberal anti-paternalism and his ideas are often invoked by those who oppose state paternalism, including those who reject legislation that restricts the consumption of unhealthy food. Furthermore, his views have been applied to related policy areas such as alcohol minimum pricing (Saunders 2013) and genetically modified food (Holtug 2001). My analysis proceeds as follows. First, I show that Mill’s account warrants some restrictions on food advertising and justifies various forms of food labelling. Second, I assess whether and to what extent Mill’s ‘harm principle’ justifies social and legal non-paternalistic penalties against unhealthy eaters who are guilty of other-regarding harm. Finally, I show that Mill’s account warrants taxing unhealthy foods, thus restricting the freedom of both responsible and irresponsible eaters and de facto justifying what I call ‘secondary paternalism’.

A quality-scalable and energy-efficient approach for spectral analysis of heart rate variability

Today there is a growing interest in the integration of health monitoring applications in portable devices necessitating the development of methods that improve the energy efficiency of such systems. In this paper, we present a systematic approach that enables energy-quality trade-offs in spectral analysis systems for bio-signals, which are useful in monitoring various health conditions as those associated with the heart-rate. To enable such trade-offs, the processed signals are expressed initially in a basis in which significant components that carry most of the relevant information can be easily distinguished from the parts that influence the output to a lesser extent. Such a classification allows the pruning of operations associated with the less significant signal components leading to power savings with minor quality loss since only less useful parts are pruned under the given requirements. To exploit the attributes of the modified spectral analysis system, thresholding rules are determined and adopted at design- and run-time, allowing the static or dynamic pruning of less-useful operations based on the accuracy and energy requirements. The proposed algorithm is implemented on a typical sensor node simulator and results show up-to 82% energy savings when static pruning is combined with voltage and frequency scaling, compared to the conventional algorithm in which such trade-offs were not available. In addition, experiments with numerous cardiac samples of various patients show that such energy savings come with a 4.9% average accuracy loss, which does not affect the system detection capability of sinus-arrhythmia which was used as a test case. 

Collating the knowledge base for core outcome set development: developing and appraising the search strategy for a systematic review

Background: The COMET (Core Outcome Measures in Effectiveness Trials) Initiative is developing a publicly accessible online resource to collate the knowledge base for core outcome set development (COS) and the applied work from different health conditions. Ensuring that the database is as comprehensive as possible and keeping it up to date are key to its value for users. This requires the development and application of an optimal, multi-faceted search strategy to identify relevant material. This paper describes the challenges of designing and implementing such a search, outlining the development of the search strategy for studies of COS development, and, in turn, the process for establishing a database of COS.

Methods: We investigated the performance characteristics of this strategy including sensitivity, precision and numbers needed to read. We compared the contribution of databases towards identifying included studies to identify the best combination of methods to retrieve all included studies.

Results: Recall of the search strategies ranged from 4% to 87%, and precision from 0.77% to 1.13%. MEDLINE performed best in terms of recall, retrieving 216 (87%) of the 250 included records, followed by Scopus (44%). The Cochrane Methodology Register found just 4% of the included records. MEDLINE was also the database with the highest precision. The number needed to read varied between 89 (MEDLINE) and 130 (SCOPUS).

Conclusions: We found that two databases and hand searching were required to locate all of the studies in this review. MEDLINE alone retrieved 87% of the included studies, but actually 97% of the included studies were indexed on MEDLINE. The Cochrane Methodology Register did not contribute any records that were not found in the other databases, and will not be included in our future searches to identify studies developing COS. SCOPUS had the lowest precision rate (0.77) and highest number needed to read (130). In future COMET searches for COS a balance needs to be struck between the work involved in screening large numbers of records, the frequency of the searching and the likelihood that eligible studies will be identified by means other than the database searches.

Concussion and Brain Injury in Contact Sport: Legal Implications

A concussed participant leaving the field of play is one of the most worrying sights in sport. It is also one that might have serious legal implications for sports governing bodies. Over the past number of years, a major class action suit has rumbled through the US courts as taken against that country's biggest professional sport, the National Football League. The NFL is at present attempting to settle the lawsuit from more than 4,500 retired players who claim that the NFL knew for decades about the chronic health risks associated with cumulative concussions in American football but failed to warn players or take preventative steps. Testimony from retired NFL players has revealed stories of chronic headaches, Alzheimer-like forgetfulness, altered personalities and sometimes a downward spiral into depression, violence and suicide. Medical research is suggesting that professional American football players are three times more likely to die as a result of certain neurodegenerative diseases than the general population. This paper notes that the concerns about concussion are not confined to the NFL and extend to contact sport more widely and notably rugby union. This paper also assesses the reaction of leading sports governing bodies globally to the recorded medical risks and accompanying legal vulnerabilities.

Caregiving reduces mortality risk for most caregivers: a census-based record linkage study

Importance Countries with advanced welfare systems are increasingly relying on the input of informal caregivers and there are growing concerns for their mental and physical wellbeing. However, the evidence about the relationship between caregiving and mortality risk is less clear.

Methods A census-based record linkage study with mortality follow-up of thirty-three months. A total of 1,122,779 individuals including 183,842 caregivers, of whom 28.2% (51,927) were providing fifty or more hours caregiving per week.

Results Over thirty-three months of follow-up a total of 29,335 deaths occurred, with 2,443 of these to caregivers. Mortality risk for caregivers was lower than for non-caregivers (HR= 0.72: 95%CI=0.69, 0.75 in the fully adjusted model), and the lower risk was evident even for those providing fifty or more hours of caregiving per week (adjusted Hazard Ratio=0.77: 95%CI=0.71, 0.83 and 0.76: 95%CI=0.69, 0.83 for men and women respectively). There was no evidence that this relationship varied by either age or marital status. Even amongst people with chronic health problems such as poor mental health, caregivers had lower mortality risk than non-caregivers. Caregiving is associated with reduced mortality risk for most causes - for example, the risk of death from Ischaemic Heart Disease for caregivers providing fifty or more hours was 27% and 31% lower for men and for women respectively compared to non-caregivers (HR=0.73: 95%CI=0.60, 0.88 and HR=0.69: 95%CI=0.51, 0.92).

Conclusions This large population-based study confirms that for the majority of caregivers the beneficial effects of caregiving in terms of short-term mortality risk appear to outweigh any negative effects, even amongst people with significant health problems. These results underscore the need for a reappraisal of how caregiving is perceived.


Keywords: caregiving, carers, mortality, longitudinal follow-up.
marital status. Even amongst people with chronic health problems such as poor mental health, caregivers had lower mortality risk than non-caregivers. Caregiving is associated with reduced mortality risk for most causes - for example, the risk of death from Ischaemic Heart Disease for caregivers providing fifty or more hours was 27% and 31% lower for men and for women respectively compared to non-caregivers (HR=0.73: 95%CI=0.60, 0.88 and HR=0.69: 95%CI=0.51, 0.92).

Conclusions This large population-based study confirms that for the majority of caregivers the beneficial effects of caregiving in terms of short-term mortality risk appear to outweigh any negative effects, even amongst people with significant health problems. These results underscore the need for a reappraisal of how caregiving is perceived.

A study protocol for a pilot randomised trial of a structured education programme for the self-management of type 2 diabetes for adults with intellectual disabilities

BACKGROUND: The need for structured education programmes for type 2 diabetes is a high priority for many governments around the world. One such national education programme in the United Kingdom is the DESMOND Programme, which has been shown to be robust and effective for patients in general. However, these programmes are not generally targeted to people with intellectual disabilities (ID), and robust evidence on their effects for this population is lacking. We have adapted the DESMOND Programme for people with ID and type 2 diabetes to produce an amended programme known as DESMOND-ID. This protocol is for a pilot trial to determine whether a large-scale randomised trial is feasible, to test if DESMOND-ID is more effective than usual care in adults with ID for self-management of their type 2 diabetes, in particular as a means to reduce glycated haemoglobin (Hb1Ac), improve psychological wellbeing and quality of life and promote a healthier lifestyle. This protocol describes the rationale, methods, proposed analysis plan and organisational and administrative details.

METHODS/DESIGN: This trial is a two arm, individually randomised, pilot trial for adults with ID and type 2 diabetes, and their family and/or paid carers. It compares the DESMOND-ID programme with usual care. Approximately 36 adults with mild to moderate ID will be recruited from three countries in the United Kingdom. Family and/or paid carers may also participate in the study. Participants will be randomly assigned to one of two conditions using a secure computerised system with robust allocation concealment. A range of data will be collected from the adults with ID (biomedical, psychosocial and self-management strategies) and from their carers. Focus groups with all the participants will assess the acceptability of the intervention and the trial.

DISCUSSION: The lack of appropriate structured education programmes and educational materials for this population leads to secondary health conditions and may lead to premature deaths. There are significant benefits to be gained globally, if structured education programmes are adapted and shown to be successful for people with ID and other cognitive impairments.

TRIAL REGISTRATION: Registered with International Standard Randomised Controlled Trial (identifier: ISRCTN93185560 ) on 10 November 2014.

Development of a new welfare assessment protocol for practical application in long-term dog shelters

In many European shelters, dogs may spend many years confined. A poor environment and inappropriate management may lead to a low quality of life. The absence of harmonised European regulatory frameworks defining the minimum requirements for shelter facilities makes the definition of welfare standards for kennelled dogs challenging. Here, a new protocol was developed and tested to help identify the main welfare issues for shelter dogs. Twenty-six indicators were identified including management, resource and animal based measures. Accuracy and interobserver reliability were checked between four assessors. The protocol was applied in 29 shelters (n=1308 dogs) in six European countries. Overall prevalence of poor health conditions was below 10%. Test-retest reliability and validity of the protocol were investigated with encouraging results. A logistic regression was carried out to assess the potential of the protocol as a tool to identify welfare hazards in shelter environments. Inappropriate space allowance, for example, was found to be a risk factor potentially affecting the animal's cleanliness, skin condition and body condition. The protocol was designed to be concise and easy to implement. Systematic data collection could help identify welfare problems that are likely to arise in certain shelter designs and thus determine improvement in animal care standards.

Intentions Toward Physical Activity and Resting Behavior in Pregnant Women: Using the Theory of Planned Behavior Framework in a Cross-Sectional Study

BACKGROUND: Pregnant women are recommended to 1) perform daily moderate-intensity physical activity and 2) limit the amount of sedentary time. Many women do not meet these recommendations. Reduced physical activity and increased sedentary behavior may result from women actively intending to rest during pregnancy. The Theory of Planned Behavior (TPB) has been used to assess attitudes (e.g., positive/negative beliefs), subjective norms (e.g., perception of others' views), perceived behavioral control (PBC) (e.g., self-efficacy), and intention toward exercising while pregnant but has not been applied to aspects pertaining to resting during pregnancy.

METHODS: Pregnant women (n = 345) completed a cross-sectional questionnaire that included two TPB Questionnaires where the target behaviors were 1) being physically active and 2) resting. Bootstrapped paired t tests, ANOVA, and linear hierarchal regression analyses were performed to identify predictors of intentions and whether intentions toward the two behaviors varied at different stages of pregnancy.

RESULTS: As women progressed in their pregnancy, their attitude, PBC, and intention toward being physically active all significantly declined. A positive attitude, subjective norms, and intention toward resting all significantly increased with the advancing trimester. Self-reported health conditions predicted lower intention for physical activity but not for resting.

DISCUSSION: The significantly inverse relationship between physical activity and resting across time suggests that women feel they should focus on one behavior at the expense of the other. Finding that women generally do not perceive these behaviors as mutually compatible has implications in strategizing as to how to encourage women to be active during pregnancy.