Setting the stage : from prodrome to treatment resistance in bipolar disorder

Bipolar disorder is common, and both difficult to detect and diagnose. Treatment is contingent on clinical needs, which differ according to phase and stage of the illness. A staging model could allow examination of the longitudinal course of the illness and the temporal impact of interventions and events. It could allow for a structured examination of the illness, which could set the stage for algorithms that are tailored to the individuals needs. A staging model could further provide as structure for assessment, gauging treatment and outcomes. The model incorporates prodromal stages and emphasizes early detection and algorithm appropriate intervention where possible. At the other end of the spectrum, the model attempts to operationalize treatment resistance. The utility of the model will need to be validated by empirical research.

The cost-effectiveness of universal newborn screening for bilateral permanent congenital hearing impairment : systematic review

Objective - Universal newborn hearing screening for bilateral permanent congenital hearing impairment is standard practice in many developed economies, but until there is clear evidence of cost-effectiveness, it remains a controversial use of limited health care resources. We conducted a formal systematic review of studies of newborn hearing screening that considered both costs and outcomes to produce a summary of the available evidence and to determine whether there was a need for further research.

Methods - A search was conducted of medical and nursing databases and gray literature websites by the use of multiple keywords. The titles and abstracts of studies were examined for preliminary inclusion if reference was made to newborn hearing screening, and to both costs and outcomes. Studies of potential relevance were independently assessed by 2 health economists for final inclusion in the review. Studies that met inclusion criteria were appraised by the use of existing guidelines for observational studies, economic evaluations and decision analytic models, and reported in a narrative literature review.

Results - There were 22 distinct observational or modeled evaluations of which only 2 clearly compared universal newborn hearing screening to risk factor screening for bilateral permanent congenital hearing impairment. Of these, the single evaluation that examined long-term costs and outcomes found that universal newborn hearing screening could be cost-saving if early intervention led to a substantial reduction in future treatment costs and productivity losses.

Conclusions - There are only a small number of economic evaluations that have examined the long-term cost-effectiveness of universal newborn hearing screening. This is partly attributable to ongoing uncertainty about the benefits gained from the early detection and treatment of bilateral permanent congenital hearing impairment. There is a clear need for further research on long-term costs and outcomes to establish the cost-effectiveness of universal newborn hearing screening in relation to other approaches to screening, and to establish whether it is a good long term investment.

Conservation cornerstones : capitalising on the endeavours of long-term monitoring projects

Ecological monitoring is widely used to measure change through time in ecosystems. The current extinction crisis has resulted in a wealth of monitoring programs focussed on tracking the status of threatened species, and the perceived importance of monitoring has seen it become the cornerstone of many biodiversity conservation programs. However, many monitoring programs fail to produce useful outcomes due to inherent flaws. Here we use a monitoring program from south-eastern Australia as a case study to illustrate the potential of such endeavours. The threatened carnivorous marsupial, the brush-tailed phascogale (Phascogale tapoatafa), has been monitored at various locations between 2000 and 2010. We present strong evidence for a decline in relative abundance during this period, and also describe relationships with environmental variables. These results provide insights likely to be valuable in guiding future management of the species. In the absence of the monitoring program, informed management would not be possible. While early detection of population declines is important, knowledge of the processes driving such declines is required for effective intervention. We argue that monitoring programs will be most effective as a tool for enhanced conservation management if they test specific hypotheses relating to changes in population trajectories. Greater emphasis should be placed on rigorous statistical analysis of monitoring datasets in order to capitalise on the resources devoted to monitoring activities. Many datasets are likely to exist for which careful analysis of results would have benefits for determining management directions.

Decision support and the effectiveness of web-based delivery and information tailoring for bowel cancer screening : an exploratory study

Background: Colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and the second in females throughout the developed world. Population screening using fecal occult blood tests (FOBTs) facilitates early detection and greater chance of survival, but participation rates are low. We developed a Web-based decision tool to provide information tailored to an individual’s decision stage for CRC screening and attitude toward screening utilizing the Preventive Health Model (PHM) and Precaution Adoption Process Model (PAPM) as theoretical frameworks for screening behavior. We describe the practical steps employed in the tool’s design and the subsequent conduct of an exploratory study.
Objective: To design a decision tool for CRC screening and conduct an exploratory study among average-risk men and women to (1) test the impact of message type (tailored vs non-tailored) and message delivery modality (Web-based vs paper-based) on attitudes toward screening and screening uptake, and (2) investigate the acceptability of the decision tool and relevance of materials.
Methods: Participants (n = 100), recruited from a population sample of men and women aged 50-76 residing in urban Adelaide, Australia, were randomly assigned to a control group or one of 4 interventions: (1) Web-based and tailored information, (2) paper-based and tailored information, (3) Web-based and non-tailored (generic) information, or (4) paper-based and non-tailored information. Participation was augmented by snowball recruitment (n = 19). Questionnaires based on PHM variables were administered pre- and post-intervention. Participants were given the opportunity to request an FOBT. Following the intervention, participants discussed the acceptability of the tool.
Results: Full data were available for 87.4% (104/119) of participants. Post-intervention, perceived susceptibility scores for individuals receiving tailored information increased from mean 10.6 (SD 2.1) to mean 11.8 (SD 2.2). Scores on self-efficacy increased in the tailored group from mean 11.7 (SD 2.0) to mean 12.6 (SD 1.8). There were significant time x modality x message effects for social influence and salience and coherence, reflecting an increase in these scores for tailored Web-based participants only; social influence scores increased from mean 11.7 (SD 2.6) to mean 14.9 (SD 2.3), and salience and coherence scores increased from mean 16.0 (SD 2.2) to mean 17.7 (SD 2.1). There was no greater influence of modality or message type on movement toward a decision to screen or screening uptake, indicating that neither tailored messages nor a Web modality had superior effect. Overall, participants regarded tailored messages positively, but thought that the Web tool lacked “media richness.”
Conclusions: This exploratory study confirms that tailoring on PHM predictors of CRC screening has the potential to positively address attitudes toward screening. However, tailoring on these variables did not result in significantly increased screening uptake. Future research should consider other possible psychosocial influences. Mode of delivery did not affect outcomes, but as a delivery medium, the Web has economic and logistical advantages over paper.

Mother-daughter communication about mammography in an Australian sample

Breast cancer is a significant health problem for aging women. Despite constant efforts to promote mammography in Australia to facilitate early detection, screening rates through the national mammography screening service remain at just 57%. Based on a theoretical rationale informed by Family Communication Patterns theory, the current study used semi-structured interviews with Australian mother-daughter dyads (N = 8) to examine their health communication, with a view to exploring the potential for daughters to deliver mammography promotion messages to their mothers. Consistent with results of previous studies conducted in different cultural contexts, the Australian mothers and daughters in this sample frequently communicated about health topics. Daughters were a source of information and influence for their mother's health decision making. The delivery of mammography promotion messages to the mother by the daughter may be most successful for dyads that value bidirectional conversation. Aspects of the Australian culture may facilitate the success of this strategy.

Using the theory of planned behaviour and implementation intentions to predict and facilitate upward family communication about mammography

Regular mammography facilitates early detection of breast cancer, and thus increases the chances of survival from this disease. Daughter-initiated (i.e. upward) communication about mammography within mother–daughter dyads may promote mammography to women of screening age. The current study examined this communication behaviour within the context of the Theory of Planned Behaviour (TPB), and aimed to bridge the intention-behaviour gap by trialling an implementation intention (II) intervention that aimed to facilitate upward family communication about mammography. Young women aged 18–39 (N = 116) were assigned to either a control or experimental condition, and the latter group formed IIs about initiating a conversation with an older female family member about mammography. Overall, those who formed IIs were more likely to engage in the target communication behaviour, however the intervention was most effective for those who reported low levels of intention at baseline. Perceived behavioural control emerged as the most important variable in predicting the target behaviour. The altruistic nature of this behaviour, and the fact that it is not wholly under volitional control, may have contributed to this finding. Future studies that systematically explore the relative roles of intention and perceived behavioural control in behaviours of this nature are warranted.

The natural history of self-harm from adolescence to young adulthood : a population-based cohort study

Background Knowledge about the natural history of self-harm is scarce, especially during the transition from adolescence to young adulthood, a period characterised by a sharp rise in self-inflicted deaths. From a repeated measures cohort of a representative sample, we describe the course of self-harm from middle adolescence to young adulthood.

Methods A stratified, random sample of 1943 adolescents was recruited from 44 schools across the state of Victoria, Australia, between August, 1992, and January, 2008. We obtained data pertaining to self-harm from questionnaires and telephone interviews at seven waves of follow-up, commencing at mean age 15·9 years (SD 0·49) and ending at mean age 29·0 years (SD 0·59). Summary adolescent measures (waves three to six) were obtained for cannabis use, cigarette smoking, high-risk alcohol use, depression and anxiety, antisocial behaviour and parental separation or divorce.

Findings 1802 participants responded in the adolescent phase, with 149 (8%) reporting self-harm, More girls (95/947 [10%]) than boys (54/855 [6%]) reported self-harm (risk ratio 1·6, 95% CI 1·2–2·2). We recorded a substantial reduction in the frequency of self-harm during late adolescence. 122 of 1652 (7%) participants who reported self-harm during adolescence reported no further self-harm in young adulthood, with a stronger continuity in girls (13/888) than boys (1/764). During adolescence, incident self-harm was independently associated with symptoms of depression and anxiety (HR 3·7, 95% CI 2·4–5·9), antisocial behaviour (1·9, 1·1–3·4), high-risk alcohol use (2·1, 1·2–3·7), cannabis use (2·4, 1·4–4·4), and cigarette smoking (1·8, 1·0–3·1). Adolescent symptoms of depression and anxiety were clearly associated with incident self-harm in young adulthood (5·9, 2·2–16).

Interpretation Most self-harming behaviour in adolescents resolves spontaneously. The early detection and treatment of common mental disorders during adolescence might constitute an important and hitherto unrecognised component of suicide prevention in young adults.

Funding National Health and Medical Research Council, Australia, and operational infrastructure support programme, Government of Victoria, Australia.

Does screening high school students for psychological distress, deliberate self-harm, or suicidal ideation cause distress--and is it acceptable? An Australian-based study

Programs designed to detect students at risk of depression and suicidality have shown success (Shaffer et al., 2004). The current study sought to examine whether or not such a program was acceptable to participants and whether or not it caused distress. Participants were boys aged 14 to 16. Participants were assessed using an on-line questionnaire; acceptability was measured via postal questionnaire. Of 272 participants, 31 (11.4%) were considered at-risk; 13 required ongoing support, 8 of whom had not previously sought help. Overall screening did not appear to cause significant undue distress, although some differences were evident between at-risk and not at-risk students. All participants found the program acceptable. When conducted carefully, early detection programs can be an effective and acceptable method of identifying at-risk adolescents.

Review of guidelines for children's vision screenings

The aim of children's vision screenings is to detect visual problems that are common in this age category through valid and reliable tests. Nevertheless, the cost effectiveness of paediatric vision screenings, the nature of the tests included in the screening batteries and the ideal screening age has been the cause of much debate in Australia and worldwide. Therefore, the purpose of this review is to report on the current practice of children's vision screenings in Australia and other countries, as well as to evaluate the evidence for and against the provision of such screenings. This was undertaken through a detailed investigation of peer-reviewed publications on this topic. The current review demonstrates that there is no agreed vision screening protocol for children in Australia. This appears to be a result of the lack of strong evidence supporting the benefit of such screenings. While amblyopia, strabismus and, to a lesser extent refractive error, are targeted by many screening programs during pre-school and at school entry, there is less agreement regarding the value of screening for other visual conditions, such as binocular vision disorders, ocular health problems and refractive errors that are less likely to reduce distance visual acuity. In addition, in Australia, little agreement exists in the frequency and coverage of screening programs between states and territories and the screening programs that are offered are ad hoc and poorly documented. Australian children stand to benefit from improved cohesion and communication between jurisdictions and health professionals to enable an equitable provision of validated vision screening services that have the best chance of early detection and intervention for a range of paediatric visual problems.

The influence of cover on nesting Red-capped Plovers: a trade-off between thermoregulation and predation risk?

 Some ground-nesting birds adopt a mixed strategy of nesting in the open, or under cover (e.g. vegetation). This may represent a trade-off between thermally favourable nest sites (covered) and those that enable the early detection and avoidance of predators (open). This study examined whether such a trade-off exists for Redcapped Plover Charadrius ruficapillus, whose eggs are preyed upon principally by Little Raven Corvus mellori. For real and artificial nests, nest temperatures under cover (real, 25.9 ± 0.1°C; false, 16.2 ± 0.5°C) were cooler than those in the open (real, 26.8 ± 0.1°C; false, 17.4 ± 0.9°C). Covered nests had more visual obstructions than open nests (covered, 65.5% ± 11.4%; open, 7.4% ± 2.8%) and a standardised measure of incubator escape distance, initiated by experimental human approaches, indicated incubators fled open nests at longer distances than for covered nests. Nests under cover showed a slightly (non-significant) higher probability of surviving one day (Daily Survival Rate [DSR] = 0.978) than those in the open (DSR = 0.950). For false nests containing model eggs, covered nests exhibited better survival to 10 days compared with open nests (20.4% vs. 4.7%). Thus, covered nests are associated with enhanced thermal environments and egg survival, but predators can approach the incubator more closely. Overall, the proposed trade-off between thermal and predation risks associated with nest sites appears to exist and explains the ongoing occurrence of nests in open and covered locations.

The German SCREEN project - design and evaluation of the communication strategy

Background: Skin cancer is the most common cancer in light-skinned populations worldwide. Primary and secondary preventive activities such as skin cancer screening are intended to reduce skin cancer burden. In 2003, a population-based skin cancer screening project [SCREEN (Skin Cancer Research to Provide Evidence for Effectiveness of Screening in Northern Germany)] was conducted in Northern Germany with more than 360 000 people screened. SCREEN was supported by a communication intervention that was aimed at informing the population about skin cancer, its risk factors and the screening intervention as well as preparing the health professionals for the project. Within SCREEN both physicians and practice nurses were educated in counselling. The aim of the present article is to describe and evaluate the communication strategy accompanying SCREEN. Methods: Two computer-assisted telephone interview surveys were performed in April/May 2003 and May 2004. Participants had to be members of the statutory health insurance and be aged ≥20 years. They were asked about knowledge of skin cancer, perception of physicians' performance and skin cancer screening in general. Data are mainly presented in a descriptive manner. For statistical analyses, Mann-Whitney U test and Pearson's chi-square test were used. Results: Knowledge about sunburn in childhood and high ultraviolet exposure as skin cancer risk factors increased during SCREEN. Simultaneously, the awareness for early detection of skin cancer increased significantly from 41.3 to 74.0% (P < 0.001). A total of 21.5% of the interviewees participated in the skin cancer screening project, similar to the population-based participation rate reached. Conclusion: A comprehensive communication strategy accompanying a screening intervention improves the knowledge of potential screenees and may additionally increase the participation rate.

Minimising post-operative risk using a Post-Anaesthetic Care Tool (PACT): protocol for a prospective observational study and cost-effectiveness analysis

Introduction: While the risk of adverse events following surgery has been identified, the impact of nursing care on early detection of these events is not well established. A systematic review of the evidence and an expert consensus study in post-anaesthetic care identified essential criteria for nursing assessment of patient readiness for discharge from the Post-Anaesthetic Care Unit. These criteria were included in a new nursing assessment tool, the Post-Anaesthetic Care Tool (PACT), and incorporated into the post-anaesthetic documentation at a large health service. The aim of this study is to test the clinical reliability of the PACT and evaluate whether use of PACT will i) enhance the recognition and response to patients at risk of deterioration in PACU; ii) improve documentation for handover from PACU nurse to ward nurse; iii) result in improved patient outcomes; and iv) reduce health care costs.

Methods and analysis: A prospective, non-randomised, pre- and post-implementation design comparing: (i) patients (n=750) who have surgery prior to the implementation of the PACT and (ii) patients (n=750) who have surgery after PACT. The study will examine the use of the tool through the observation of patient care and nursing handover. Patient outcomes and cost effectiveness will be determined from health service data and medical record audit. Descriptive statistics will be used to describe the sample and compare the two patient groups (pre- and post-intervention). Differences in patient outcomes between the two groups will be compared using the Cochran-Mantel-Haenszel test and regression analyses and reported as odds ratios with the corresponding 95% confidence intervals.

Conclusion: This study will test the clinical reliability and cost-effectiveness of the PACT. It is hypothesised that the PACT will enable nurses to recognise and respond to patients at risk of deterioration, improve handover to ward nurses, improve patient outcomes, and reduce health care costs.

An alternative clustering scheme in WSN

Despite significant advancements in wireless sensor networks (WSNs), energy conservation in the networks remains one of the most important research challenges. One approach commonly used to prolong the network lifetime is through aggregating data at the cluster heads (CHs). However, there is possibility that the CHs may fail and function incorrectly due to a number of reasons such as power instability. During the failure, the CHs are unable to collect and transfer data correctly. This affects the performance of the WSN. Early detection of failure of CHs will reduce the data loss and provide possible minimal recovery efforts. This paper proposes a self-configurable clustering mechanism to detect the disordered CHs and replace them with other nodes. Simulation results verify the effectiveness of the proposed approach.