Natural recovery from cannabis use in people with psychosis: A qualitative study

- Objective There is rapidly growing evidence of natural recovery from cannabis use in people with psychosis, but little is known about how it occurs. This qualitative study explores what factors influence the decision to cease cannabis use, maintain cessation, and prevent relapse. - Methods Ten people with early psychosis and lifetime cannabis misuse, who had been abstinent for at least a month, were recruited from public adult mental health services. These six men and four women participated in a semi-structured qualitative interview assessing reasons for addressing cannabis use, effective change strategies, lapse contexts, and methods used to regain control. Interpretative phenomenological analysis was used to identify themes in their responses. - Results Participants had a mean age of 23 years (SD = 3.7), started using cannabis at age 13.7 (SD = 1.6), began daily use at 17 (SD = 3.1), and had abstained from cannabis for 7.9 months (SD = 5.4). Awareness of the negative impact of substance use across multiple domains and the presence of social support for cannabis cessation were seen as vital to sustained success, as was utilization of a combination of coping strategies. The ability to address pressure from substance-using peers was commonly mentioned. - Conclusions Maximally effective treatment may need to focus on eliciting a range of benefits of cessation and control strategies and on maximizing both support for change and resistance to peer pressure. Further research might focus on comparing perceived effective strategies between individuals who obtain sustained cessation versus those who relapse.

Reconstructing identity of older people in using day care services in Taiwan: A grounded theory study

Adult day care centers provide a means whereby frail or disabled older people can remain living at home particularly when their family care-givers engage in waged work. In Taiwan, adult day care services appear to meet the cultural needs of both older people and their families for whom filial care is vital. Little research attention has been paid to the use of day care services in Taiwan, the uptake rate of which is low. This grounded theory study explored the ways in which older people and family care-givers construct meanings around the use of day care services in Taiwan. The research methodology drew on the theoretical tenets of symbolic interactionism and methods were informed by the grounded theory. In-depth interviews with 30 participants were undertaken. Reconstructing identity in a shifting world is the core category of the study and reflects a process of reframing whereby older people came to new definitions of social responsibility and independence within the context of the day care center. The implications of the findings is that the older people, rather than seeking to be relieved of social responsibilities, worked very hard to frame and reframe a social role. Rather than letting the institutions undermine or disrupt their identity, the older people worked to actively negotiate and redefine the meaning of self. Thus, although reluctant to come to use the services at the outset, they found a way to manage their lives independently. Social roles and responsibilities as older parents were retained. This study explored the process of meaning construction of day care use and the ways in which this process entailed a reconstruction of the identities of the participants. The evidence from this study underlines the importance of recognizing and acknowledging subjectively conceived identities as work that older people undertake, when in care, to render their lives meaningful.

A journey access tool to facilitate mobility-related access for people with disabilities in low and middle income countries

People with disabilities (PWD) experience difficulties in accessing the transport system (including both infrastructure and services) to meet their needs for health care, employment and other activities. Our research shows that lack of access to the journeys needed for these purposes is a more significant barrier in low and middle income countries than in high income countries, and results in inadequate health care, rehabilitation and access to education and employment. At the same time, the existing transport system in low and middle income countries presents much higher road crash risks than in high income countries. By combining the principles and methods of Road Safety Audit and disability access, and adapting these Western approaches to a low/middle income country context, we have worked with Handicap International Cambodia to develop a Journey Access Tool (JAT) for use by disabled peoples’ organisations (DPOs), people with a disability and other key stakeholders. A key element of the approach is that it involves the participation of PWD on the journeys that they need to take, and it identifies infrastructure and service improvements that should be prioritised in order to facilitate access to these journeys. The JAT has been piloted in Cambodia with a range of PWD. This presentation will outline the design of the JAT and the results of the pilot studies. The information gained thus far strongly suggests that the JAT is a valuable and cost-effective approach that can be used by DPOs and professionals to identify barriers to access and prioritise the steps needed to address them.

Long-term effects of fenofibrate on lipoproteins and surrogate markers of macrovascular and microvascular disease in people with type 2 diabetes

Background and aims. Diabetic dyslipidemia is a highly atherogenic triad of increased triglycerides, decreased HDL cholesterol, and small dense LDL. Fibrates have a beneficial effect on diabetic dyslipidemia, and they have reduced cardiovascular events in randomized trials. Fenofibrate has reduced albuminuria and markers of low-grade inflammation and endothelial dysfunction. The present studies were undertaken to characterize the alterations of VLDL and LDL subclasses and to investigate the binding of LDL to arterial wall in type 2 diabetes. Further purpose was to elucidate the effects of fenofibrate on several lipoprotein subclasses, augmentation index (AIx), carotid intima-media thickness (IMT), and renal function. Subjects. 239 type 2 diabetic subjects were recruited among participants of the FIELD (Fenofibrate Intervention and Event Lowering in Diabetes) study at the Helsinki centre. The patients were randomized to fenofibrate (200mg/d) or placebo for 5 years. Additionally, a healthy control group (N = 93) was recruited. Results. VLDL1 triglycerides increased in similar proportion to total triglycerides in type 2 diabetic patients and control subjects. Despite the increase in total apoCIII levels, VLDL apoCIII was decreased in diabetic patients. Enrichment of LDL with apoCIII induced a small increase in binding of LDL to arterial wall proteoglycan. Intrinsic characteristics of diabetic LDL, rather than levels of apoCIII, were responsible for increased proteoglycan binding of diabetic LDL with high apoCIII. Fenofibrate reduced triglycerides, increased LDL size, and shifted HDL subclasses towards smaller particles with no change in levels of HDL cholesterol. High levels of homocysteine were associated with lower increase of HDL cholesterol and apoA-I during fenofibrate treatment. Long-term fenofibrate treatment did not improve IMT, AIx, inflammation, or endothelial function. Fenofibrate decreased creatinine clearance and estimated glomerular filtration rate. No effect on albuminuria was seen with fenofibrate. Instead, Cystatin C was increased during fenofibrate treatment. Conclusions. 1) Elevation of VLDL 1 triglycerides was the major determinant of plasma triglyceride concentration in control subjects and type 2 diabetic patients. 2) LDL with high apoCIII showed multiple atherogenic properties, that were only partially mediated by apoCIII per se in type 2 diabetes 3) Fenofibrate demonstrated no effect on surrogate markers of atherosclerosis. 4) Fenofibrate had no effect on albuminuria and the observed decrease in markers of renal function could complicate the clinical surveillance of the patients. 5) Fenofibrate can be used to treat severe hypertriglyceridemia or in combination therapy with statins, but not to increase HDL levels.

Investigation of a suicide ideation risk profile in people with co-occurring depression and substance use disorder

Disengagement from services is common before suicide, hence identifying factors at treatment presentation that predict future suicidality is important. This article explores risk profiles for suicidal ideation among treatment seekers with depression and substance misuse. Participants completed assessments at baseline and 6 months. Baseline demographics, psychiatric history, and current symptoms were entered into a decision tree to predict suicidal ideation at follow-up. Sixty-three percent of participants at baseline and 43.5% at follow-up reported suicidal ideation. Baseline ideation most salient when psychiatric illness began before adulthood, increasing the rate of follow-up ideation by 16%. Among those without baseline ideation, dysfunctional attitudes were the most important risk factor, increasing rates of suicidal ideation by 35%. These findings provide evidence of factors beyond initial diagnoses that increase the likelihood of suicidal ideation and are worthy of clinical attention. In particular, providing suicide prevention resources to those with high dysfunctional attitudes may be beneficial.

HealthMap: A cluster randomised trial of interactive health plans and self-management support to prevent coronary heart disease in people with HIV

Background The leading causes of morbidity and mortality for people in high-income countries living with HIV are now non-AIDS malignancies, cardiovascular disease and other non-communicable diseases associated with ageing. This protocol describes the trial of HealthMap, a model of care for people with HIV (PWHIV) that includes use of an interactive shared health record and self-management support. The aims of the HealthMap trial are to evaluate engagement of PWHIV and healthcare providers with the model, and its effectiveness for reducing coronary heart disease risk, enhancing self-management, and improving mental health and quality of life of PWHIV. Methods/Design The study is a two-arm cluster randomised trial involving HIV clinical sites in several states in Australia. Doctors will be randomised to the HealthMap model (immediate arm) or to proceed with usual care (deferred arm). People with HIV whose doctors are randomised to the immediate arm receive 1) new opportunities to discuss their health status and goals with their HIV doctor using a HealthMap shared health record; 2) access to their own health record from home; 3) access to health coaching delivered by telephone and online; and 4) access to a peer moderated online group chat programme. Data will be collected from participating PWHIV (n = 710) at baseline, 6 months, and 12 months and from participating doctors (n = 60) at baseline and 12 months. The control arm will be offered the HealthMap intervention at the end of the trial. The primary study outcomes, measured at 12 months, are 1) 10-year risk of non-fatal acute myocardial infarction or coronary heart disease death as estimated by a Framingham Heart Study risk equation; and 2) Positive and Active Engagement in Life Scale from the Health Education Impact Questionnaire (heiQ). Discussion The study will determine the viability and utility of a novel technology-supported model of care for maintaining the health and wellbeing of people with HIV. If shown to be effective, the HealthMap model may provide a generalisable, scalable and sustainable system for supporting the care needs of people with HIV, addressing issues of equity of access. Trial registration Universal Trial Number (UTN) U111111506489; ClinicalTrial.gov Id NCT02178930 submitted 29 June 2014

“Well this is it. Just get on with it”: Pain willingness and activity engagement in people with chronic pain

Pain is recognised as a problem of significant concern worldwide and in the latest Global Burden of Disease Study, low back pain was identified as the biggest contributor worldwide to Years Lived with Disability. There is evidence to suggest that people who accept their chronic pain have a higher quality of life, lower levels of disability and distress, and function better emotionally, socially and physically. Findings on the specific pathways linking pain acceptance to quality of life outcomes are less clear. the two widely accepted pain acceptance factors, pain willingness and activity engagement, have not been well explored in qualitative studies on acceptance of chronic pain. To address this deficit in the literature, the current study has two related aims: 1) to explore pain willingness and activity engagement in the lives of people with chronic pain, and ; 2) to find out what people believe helps them to successfully get on with life in spite of chronic pain.

Management of persistent pain in the older people

Persistent pain is a commonly experienced symptom. It affects 25% of community-dwelling older adults and up to 80% of nursing home residents, and can have a major impact on quality of life and functional capacity. Unfortunately pain in older patients is often undertreated and misunderstood. Assessment of pain type and severity is important. Most older people, even with moderately impaired cognition, are able to self-report pain. Validated assessment tools using non-verbal pain cues are available for people with more advanced cognitive impairment. Management of pain in older people can be challenging. Physiological changes may impact on pain perception and the pharmacodynamics and pharmacokinetics of medications. Older people are often more sensitive to the adverse effects of analgesic medications and are at risk of drug–drug interactions due to the presence of co-morbidities and polypharmacy. In general, analgesic medications should be commenced at low doses, titrated based on effect and tolerability, and regularly reviewed. Contemporary pain management often utilises multiple analgesics in lower doses to optimise efficacy and avoid dose-related toxicity. A bio-psycho-social approach to the management of persistent pain, utilising a multidisciplinary team and including non-drug strategies, may produce the best results. The goal of pain management is not always to eliminate pain, since this may not be attainable, but rather to enhance function and improve quality of life. This article discusses persistent non-cancer pain in older people, its assessment and management, and the risks and benefits of pharmacological treatment in this population.

Power and Distribution Network Structure in the People's Republic of China - The Case of an Inland City in Transition

The aim of the current study is to examine the influence of the channel external environment on power, and the effect of power on the distribution network structure within the People’s Republic of China. Throughout the study a dual research process was applied. The theory was constructed by elaborating the main theoretical premises of the study, the channel power theories, the political economy framework and the distribution network structure, but these marketing channel concepts were expanded with other perspectives from other disciplines. The main method applied was a survey conducted among 164 Chinese retailers, complemented by interviews, photographs, observations and census data from the field. This multi-method approach enabled not only to validate and triangulate the quantitative results, but to uncover serendipitous findings as well. The theoretical contribution of the current study to the theory of marketing channels power is the different view it takes on power. First, earlier power studies have taken the producer perspective, whereas the current study also includes a distributor perspective to the discussion. Second, many power studies have dealt with strongly dependent relationships, whereas the current study examines loosely dependent relationships. Power is dependent on unequal distribution of resources rather than based on high dependency. The benefit of this view is in realising that power resources and power strategies are separate concepts. The empirical material of the current study confirmed that at least some resources were significantly related to power strategies. The study showed that the dimension resources composed of technology, know-how and knowledge, managerial freedom and reputation was significantly related to non-coercive power. Third, the notion of different outcomes of power is a contribution of this study to the channels power theory even though not confirmed by the empirical results. Fourth, it was proposed that channel external environment other than the resources would also contribute to the channel power. These propositions were partially supported thus providing only partial contribution to the channel power theory. Finally, power was equally distributed among the different types of actors. The findings from the qualitative data suggest that different types of retailers can be classified according to the meaning the actors put into their business. Some are more business oriented, for others retailing is the only way to earn a living. The findings also suggest that in some actors both retailing and wholesaling functions emerge, and this has implications for the marketing channels structure.

The management of large mammals in relation to male strategies and conflict with people

Many large mammals such as elephant, rhino and tiger often come into conflict with people by destroying agricultural crops and even killing people, thus providing a deterrent to conservation efforts. The males of these polygynous species have a greater variance in reproductive success than females, leading to selection pressures favouring a ‘high risk-high gain’ strategy for promoting reproductive success. This brings them into greater conflict with people. For instance, adult male elephants are far more prone than a member of a female-led family herd to raid agricultural crops and to kill people. In polygynous species, the removal of a certain proportion of ‘surplus’ adult males is not likely to affect the fertility and growth rate of the population. Hence, this could be a management tool which would effectively reduce animal-human conflict, and at the same time maintain the viability of the population. Selective removal of males would result in a skewed sex ratio. This would reduce the ‘effective population size’ (as opposed to the total population or census number), increase the rate of genetic drift and, in small populations, lead to inbreeding depression. Plans for managing destructive mammals through the culling of males will have to ensure that the appropriate minimum size in the populations is being maintained.

Una gramática descriptiva del chabacano de Ternate

This dissertation is a descriptive grammar of Ternate Chabacano, a Spanish-lexifier Creole spoken by 3.000 people in the town of Ternate, Philippines. The dissertation offers an analysis of the phonological, morphological, and syntactic system of the language. It includes an overview of the historical background, the current situation of the speech community and a collection of annotated texts. Ternate Chabacano shares many characteristics with its main adstrate language Tagalog as well as the dialectal varieties of Spanish. At present, English also exerts an influence, nevertheless mainly affecting its lexicon. The description offered is based on fieldwork conducted in Ternate. Spoken language collected through thematic interviews forms the main type of the material analysed. Information regarding the informants and text types is included in the examples. Ternate Chabacano has a five-vowel system and 17 consonant phonemes. The morphology of the language is largely isolating. Clitics are used extensively for expressing adverbial relations. The verbal system is based on the preverbal markers that express the category of tense, modality and aspect, among which aspect is the main dimension. Complex predicates and verbal chains are used in order to further distinguish aspect and modality, as well as changes of voice and valency. Intransitive verbs express motion, states, and reflexive actions, even though the majority of verbs can occur in both intransitive and transitive clauses. Ternate Chabacano is a nominative-accusative type language but the typological configuration of the Philippine languages influences the marking of its constituents. A case in point is constituted by the nominal determination system. The basic constituent order in a clause is VSO. Equative and attibutive clauses are formed by juxtaposition while the locative clauses feature a copula. Indefinite terms are expressed through existential constructions. The negation of existential clauses differs from standard negation but both are intensified in the same way. In spoken discourse, tag-questions are common. Pragmatic elements and social formulas reflect largely the corresponding Tagalog expressions. Coordination and subordination occur typically without overt markers but a variety of markers exists for expressing different relations, especially those made explicit by adverbial clauses. Verbal chains form a continuum from serial verbs to complementation and ultimately to coordination.