Practice Links [Issue 48, June 2012]

Practice Links is a free e-publication for practitioners working in Irish social services, voluntary and nongovernmental sectors. Practice Links was created to enable practitioners to keep up-to-date with new publications, electronic resources and conference opportunities. Issue 48 contains information regarding spiritual and religious interventions for adults in the terminal stage of disease as well as research examining the effects focused deterrence strategies have on crime.

The utility of survey and administrative data to generate information for research and outcomes-based oral health services development

The aim of this research, which focused on the Irish adult population, was to generate information for policymakers by applying statistical analyses and current technologies to oral health administrative and survey databases. Objectives included identifying socio-demographic influences on oral health and utilisation of dental services, comparing epidemiologically-estimated dental treatment need with treatment provided, and investigating the potential of a dental administrative database to provide information on utilisation of services and the volume and types of treatment provided over time. Information was extracted from the claims databases for the Dental Treatment Benefit Scheme (DTBS) for employed adults and the Dental Treatment Services Scheme (DTSS) for less-well-off adults, the National Surveys of Adult Oral Health, and the 2007 Survey of Lifestyle Attitudes and Nutrition in Ireland. Factors associated with utilisation and retention of natural teeth were analysed using count data models and logistic regression. The chi-square test and the student’s t-test were used to compare epidemiologically-estimated need in a representative sample of adults with treatment provided. Differences were found in dental care utilisation and tooth retention by Socio-Economic Status. An analysis of the five-year utilisation behaviour of a 2003 cohort of DTBS dental attendees revealed that age and being female were positively associated with visiting annually and number of treatments. Number of adults using the DTBS increased, and mean number of treatments per patient decreased, between 1997 and 2008. As a percentage of overall treatments, restorations, dentures, and extractions decreased, while prophylaxis increased. Differences were found between epidemiologically-estimated treatment need and treatment provided for those using the DTBS and DTSS. This research confirms the utility of survey and administrative data to generate knowledge for policymakers. Public administrative databases have not been designed for research purposes, but they have the potential to provide a wealth of knowledge on treatments provided and utilisation patterns.

An investigation into mechanisms of visceral pain in rodents

Visceral pain is a debilitating symptom of irritable bowel syndrome (IBS), a disorder affecting up to 30% of adults. A better understanding of the mechanisms underlying visceral hypersensitivity may facilitate development of more targeted therapies, improving the quality of life of these individuals. The studies performed in this thesis were designed to investigate important factors of visceral pain, including early-life manipulations, genetic predisposition and sex hormones. Maternal separation (MS) consistently reproduces visceral hypersensitivity and altered anxiety-like behaviours in rats, symptoms associated with IBS. It has been found that 5-HT2B receptor antagonism blocks visceral pain but no difference in relative 5-HT2B receptor mRNA expression was found in hippocampus, amygdala and colon. The neuronal activation patterns of prefrontal cortex and amygdala of MS rats were then investigated. MS animals are characterised by differential activation of the prefrontal cortex (anterior cingulate cortex (ACC), infralibic cortex, prelimbic cortex) as well as the central nucleus of the amygdala (CeA). Genetic factors also contribute to pain syndromes such as IBS. We utilised the Wistar Kyoto (WKY) rat, a stress-sensitive strain, as an animal model of brain-gut axis dysfunction. WKY rats have a lower expression of the glutamate transporter EAAT2 and mGlu4 receptor in the ACC. Another early-life factor that can increase susceptibility to functional gastrointestinal symptoms later life is disruption of the gut microbiota, thus early-life antibiotic treatment was used to assess this effect. Antibiotic treatment induced visceral hypersensitivity in adulthood and may be related to observed reductions in spinal cord alpha-2A adrenoreceptor (adra2A) mRNA. Lastly, we investigated sex differences in visceral sensitivity. EAAT1 & 2 mRNA levels are lower in females, potentially increasing glutamatergic concentration at the symaptic level. Moreover, NR1 and NR2B subunits mRNA of NMDA receptor were increased in caudal ACC of females. These findings may account for sex differences in visceral sensitivity.

The architecture of influence: Paul Rudolph's Art and Architecture Building at Yale

Focussing on Paul Rudolph’s Art & Architecture Building at Yale, this thesis demonstrates how the building synthesises the architect’s attitude to architectural education, urbanism and materiality. It tracks the evolution of the building from its origins – which bear a relationship to Rudolph’s pedagogical ideas – to later moments when its occupants and others reacted to it in a series of ways that could never have been foreseen. The A&A became the epicentre of the university’s counter culture movement before it was ravaged by a fire of undetermined origins. Arguably, it represents the last of its kind in American architecture, a turning point at the threshold of postmodernism. Using an archive that was only made available to researchers in 2009, this is the first study to draw extensively on the research files of the late architectural writer and educator, C. Ray Smith. Smith’s 1981 manuscript about the A&A entitled “The Biography of a Building,” was never published. The associated research files and transcripts of discussions with some thirty interviewees, including Rudolph, provide a previously unavailable wealth of information. Following Smith’s methodology, meetings were recorded with those involved in the A&A including, where possible, some of Smith’s original interviewees. When placed within other significant contexts – the physicality of the building itself as well as the literature which surrounds it – these previously untold accounts provide new perspectives and details, which deepen the understanding of the building and its place within architectural discourse. Issues revealed include the importance of the influence of Louis Kahn’s Yale Art Gallery and Yale’s Collegiate Gothic Campus on the building’s design. Following a tumultuous first fifty years, the A&A remains an integral part of the architectural education of Yale students and, furthermore, constitutes an important didactic tool for all students of architecture.

Training in and assessment of the procedural skills required to perform peripheral nerve blockade

The training and ongoing education of medical practitioners has undergone major changes in an incremental fashion over the past 15 years. These changes have been driven by patient safety, educational, economic and legislative/regulatory factors. In the near future, training in procedural skills will undergo a paradigm shift to proficiency based progression with associated requirements for competence-based programmes, valid, reliable assessment tools and simulation technology. Before training begins, the learning outcomes require clear definition; any form of assessment applied should include measurement of these outcomes. Currently training in a procedural skill often takes place on an ad hoc basis. The number of attempts necessary to attain a defined degree of proficiency varies from procedure to procedure. Convincing evidence exists that simulation training helps trainees to acquire skills more efficiently rather than relying on opportunities in their clinical practice. Simulation provides a safe, stress free environment for trainees for skill acquisition, generalization and transfer via deliberate practice. The work described in this thesis contributes to a greater understanding of how medical procedures can be performed more safely and effectively through education. The effect of feedback, provided to novices in a standardized setting on a bench model, based on knowledge of performance was associated with an increase in the speed of skill acquisition and a decrease in error rate during initial learning. The timing of feedback was also associated with effective learning of skill. A marked attrition of skills (independent of the type of feedback provided) was demonstrable 24 hrs after they have first been learned. Using the principles of feedback as described above, when studying the effect of an intense training program on novices of varied years of experience in anaesthesia (i.e. the present training programmes / courses of an intense training day for one or more procedures). There was a marked attrition of skill at 24 hours with a significant correlation with increasing years of experience; there also appeared to be an inverse relationship between years of experience in anaesthesia and performance. The greater the number of years of practice experience, the longer it required a learner to acquire a new skill. The findings of the studies described in this thesis may have important implications for the trainers, trainees and training bodies in the design and implementation of training courses and the formats of delivery of changing curricula. Both curricula and training modalities will need to take account of characteristics of individual learners and the dynamic nature of procedural healthcare.

Perceived acceptability of home-based couples voluntary HIV counseling and testing in Northern Tanzania.

It is estimated that 5.6% of the Tanzanian population ages 15-49 are infected with HIV, but only 30% of adults have ever had an HIV test. Couples' testing has proven to increase testing coverage and introduce HIV prevention, but barriers include access to testing services and unequal gender dynamics in relationships. Innovative approaches are needed to address barriers to couple's testing and increase uptake of HIV testing. Using qualitative data collection methods, a formative study was conducted to assess the acceptability of a home-based couples counseling and testing (HBCCT) approach. Eligible study participants included married men and women, HIV-infected individuals, health care and home-based care providers, voluntary counseling and testing counselors, and community leaders. A total of 91 individuals participated in focus group discussions (FGDs) and in-depth interviews conducted between September 2009 and January 2010 in rural settings in Northern Tanzania. An HBCCT intervention appears to be broadly acceptable among participants. Benefits of HBCCT were identified in terms of access, confidentiality, and strengthening the relationship. Fears of negative consequences from knowing one's HIV status, including stigma, blame, physical abuse, or divorce, remain a concern and a potential barrier to the successful provision of the intervention. Lessons for implementation highlighted the importance of appointments for home visits, building relationships of confidence and trust between counselors and clients, and assessing and responding to a couple's readiness to undergo HIV testing. HBCCT should addresses HIV stigma, emphasize confidentiality, and improve communication skills for disclosure and decision-making among couples.

Correlates of HIV testing among abused women in South Africa.

Gender-based violence increases a woman's risk for HIV but little is known about her decision to get tested. We interviewed 97 women seeking abuse-related services from a nongovernmental organization (NGO) in Johannesburg, South Africa. Forty-six women (47%) had been tested for HIV. Caring for children (odds ratio [OR] = 0.27, 95% confidence interval [CI] = [0.07, 1.00]) and conversing with partner about HIV (OR = 0.13, 95% CI = [0.02, 0.85]) decreased odds of testing. Stronger risk-reduction intentions (OR = 1.27, 95% CI = [1.01, 1.60]) and seeking help from police (OR = 5.51, 95% CI = [1.18, 25.76]) increased odds of testing. Providing safe access to integrated services and testing may increase testing in this population. Infection with HIV is highly prevalent in South Africa where an estimated 16.2% of adults between the ages of 15 and 49 have the virus. The necessary first step to stemming the spread of HIV and receiving life-saving treatment is learning one's HIV serostatus through testing. Many factors may contribute to someone's risk of HIV infection and many barriers may prevent testing. One factor that does both is gender-based violence.

Explanatory Model for the Use of Traditional Medicines in Kilimanjaro, Tanzania

Introduction: Traditional medicines are one of the most important means of achieving total health care coverage globally, and their importance in Tanzania extends beyond the impoverished rural areas. Their use remains high even in urban settings among the educated middle and upper classes. They are a critical component healthcare in Tanzania, but they also can have harmful side effects. Therefore we sought to understand the decision-making and reasoning processes by building an explanatory model for the use of traditional medicines in Tanzania.

Methods: We conducted a mixed-methods study between December 2013 and June 2014 in the Kilimanjaro Region of Tanzania. Using purposive sampling methods, we conducted focus group discussions (FGDs) and in-depth interviews of key informants, and the qualitative data were analyzed using an inductive Framework Method. A structured survey was created, piloted, and then administered it to a random sample of adults. We reported upon the reliability and validity of the structured survey, and we used triangulation from multiple sources to synthesize the qualitative and quantitative data.

Results: A total of five FGDs composed of 59 participants and 27 in-depth interviews were conducted in total. 16 of the in-depth interviews were with self-described traditional practitioners or herbal vendors. We identified five major thematic categories that relate to the decision to use traditional medicines in Kilimanjaro: healthcare delivery, disease understanding, credibility of the traditional practices, health status, and strong cultural beliefs.

A total of 473 participants (24.1% male) completed the structured survey. The most common reasons for taking traditional medicines were that they are more affordable (14%, 12.0-16.0), failure of hospital medicines (13%, 11.1-15.0), they work better (12%, 10.7-14.4), they are easier

to obtain (11%, 9.48-13.1), they are found naturally or free (8%, 6.56-9.68), hospital medicines have too many chemical (8%, 6.33-9.40), and they have fewer side effects (8%, 6.25-9.30). The most common uses of traditional medicines were for symptomatic conditions (42%), chronic diseases (14%), reproductive problems (11%), and malaria and febrile illnesses (10%). Participants currently taking hospital medicines for chronic conditions were nearly twice as likely to report traditional medicines usage in the past year (RR 1.97, p=0.05).

Conclusions: We built broad explanatory model for the use of traditional medicines in Kilimanjaro. The use of traditional medicines is not limited to rural or low socioeconomic populations and concurrent use of traditional medicines and biomedicine is high with frequent ethnomedical doctor shopping. Our model provides a working framework for understanding the complex interactions between biomedicine and traditional medicine. Future disease management and treatment programs will benefit from this understanding, and it can lead to synergistic policies with more effective implementation.

Cumulative exposure to traumatic events in older adults.

OBJECTIVES: The present study examined the impact of cumulative trauma exposure on current posttraumatic stress disorder (PTSD) symptom severity in a nonclinical sample of adults in their 60s. The predictive utility of cumulative trauma exposure was compared to other known predictors of PTSD, including trauma severity, personality traits, social support, and event centrality. METHOD: Community-dwelling adults (n = 2515) from the crest of the Baby Boom generation completed the Traumatic Life Events Questionnaire, the PTSD Checklist, the NEO Personality Inventory, the Centrality of Event Scale, and rated their current social support. RESULTS: Cumulative trauma exposure predicted greater PTSD symptom severity in hierarchical regression analyses consistent with a dose-response model. Neuroticism and event centrality also emerged as robust predictors of PTSD symptom severity. In contrast, the severity of individuals' single most distressing life event, as measured by self-report ratings of the A1 PTSD diagnostic criterion, did not add explanatory variance to the model. Analyses concerning event categories revealed that cumulative exposure to childhood violence and adulthood physical assaults were most strongly associated with PTSD symptom severity in older adulthood. Moreover, cumulative self-oriented events accounted for a larger percentage of variance in symptom severity compared to events directed at others. CONCLUSION: Our findings suggest that the cumulative impact of exposure to traumatic events throughout the life course contributes significantly to posttraumatic stress in older adulthood above and beyond other known predictors of PTSD.

Systematic review and metasummary of attitudes toward research in emergency medical conditions

Emergency departments are challenging research settings, where truly informed consent can be difficult to obtain. A deeper understanding of emergency medical patients' opinions about research is needed. We conducted a systematic review and meta-summary of quantitative and qualitative studies on which values, attitudes, or beliefs of emergent medical research participants influence research participation. We included studies of adults that investigated opinions toward emergency medicine research participation. We excluded studies focused on the association between demographics or consent document features and participation and those focused on non-emergency research. In August 2011, we searched the following databases: MEDLINE, EMBASE, Google Scholar, Scirus, PsycINFO, AgeLine and Global Health. Titles, abstracts and then full manuscripts were independently evaluated by two reviewers. Disagreements were resolved by consensus and adjudicated by a third author. Studies were evaluated for bias using standardised scores. We report themes associated with participation or refusal. Our initial search produced over 1800 articles. A total of 44 articles were extracted for full-manuscript analysis, and 14 were retained based on our eligibility criteria. Among factors favouring participation, altruism and personal health benefit had the highest frequency. Mistrust of researchers, feeling like a 'guinea pig' and risk were leading factors favouring refusal. Many studies noted limitations of informed consent processes in emergent conditions. We conclude that highlighting the benefits to the participant and society, mitigating risk and increasing public trust may increase research participation in emergency medical research. New methods for conducting informed consent in such studies are needed.

Genetic structure of whiting (Merlangius merlangus) in the north east Atlantic and adjacent waters

Accurate identification of stock boundaries is essential for efficient fisheries management, hence the present study focused on the genetic structure of whiting. To this aim, 488 individuals collected from the southern Bay of Biscay to the southern Norwegian coast were genotyped using seven microsatellites. A low level of genetic structuring was detected in Atlantic waters since only the Bay of Biscay differentiated from more northern samples. The lack of genetic structure along the western margin of the British Isles is consistent with a high level of passive transport of pelagic eggs and larvae due to the combined influence of the North Atlantic Current and the Shelf Edge Current. High levels of dispersal could also occur between the western British Isles and the North Sea through both the branching of the North Atlantic Current into the northern North Sea and from the residual current flowing from the English Channel to the Southern Bight. In contrast, a significant genetic structure was identified within the North Sea, and this may be associated with the complex oceanography of this basin and retention systems reducing larval dispersal. In addition, considering also genetic, phenotypic and tag-recapture data collected on whiting, a learned homing behaviour of adults toward spawning areas may be hypothesised.

Exceptional abundance of the snake pipefish (Entelurus aequoreus) in the north-eastern Atlantic Ocean

Pipefish (Syngnathidae) have occurred with unprecedented frequency in Continuous Plankton Recorder (CPR) samples to the west of the British Isles from 2003 to 2005. Identification by mtDNA sequencing established that they were snake pipefish, Entelurus aequoreus. The geographical range of the records were from the outer continental shelf of the Celtic Sea and north-west of Ireland to the mid-Atlantic Ridge between 40° and 57°N, with the greatest abundance near the shelf edge and adjacent oceanic waters south of Ireland and west of Brittany. There were records in every month from February to November but most were in late spring and summer. A proposed mechanism for the increase in abundance of the species is that recent climate change has had beneficial impacts on the reproduction of adults and the survival of larvae and juveniles.

Analysis about the society of 'Pa Negre' (Agustí Villaronga, 2010)

This article has developed with the intention of analyzing how the stereotypes, prejudices and lies can influence the education of the children. Formation, that usually comes from family and teachers, who sometimes move for extremist ideologies. There exist multiple fictions in which we observe these social archetypes, but it is the case of the movie Pa negre (Agustí Villaronga, 2010), where the principal personage evolves psychologically, because of that its eyes observe and the ideas that the people transmit him on its family, in the rural environments, where the tradition of the rumors coexists.

Correlates of reproductive success in a population of nine-banded armadillos: a preliminary report.

We used microsatellite DNA markers to identify the putative parents of 69 litters of nine-banded armadillos (Dasypus novemcinctus) over 4 years. Male and female parents did not differ in any measure of body size in comparisons with nonparents. However, males observed paired with a female were significantly larger than unpaired males, although paired females were the same size as unpaired females. Females categorized as possibly lactating were significantly larger than females that were either definitely lactating or definitely not lactating. There was no evidence of assortative mating: body-size measurements of mothers were not significantly correlated with those of fathers. Nine-banded armadillos give birth to litters of genetically identical quadruplets. Mothers (but not fathers) of female litters were significantly larger than mothers of male litters, and maternal (but not paternal) body size was positively correlated with the number of surviving young within years, but not cumulatively. There were no differences in dates of birth between male and female litters, nor were there any significant relationships between birth date and maternal body size. Body size of either parent was not correlated with the body sizes of their offspring. Cumulative and yearly reproductive success did not differ between reproductively successful males and females. Average reproductive success (which included apparently unsuccessful individuals) also did not differ between males and females. The majority of adults in the population apparently failed to produce any surviving offspring, and even those that did usually did so in only 1 of the 4 years. This low reproductive success is unexpected, given the rapid and successful range extension of this species throughout the southeastern United States in this century.

Revolution and the ritual year: religious conflict and innovation in Cristero Mexico

This article analyses Catholic responses to persecution of the Church by the Mexican state during Mexico's cristero rebellion (1926–9) and seeks to make a new contribution to the revolt's religious history. Faced with the Calles regime's anticlericalism, the article argues, Mexico's episcopate developed an alternative cultic model premised on a revitalised lay religion. The article then focuses on changes and continuities in lay – clerical relations, and on the new religious powers of the faithful, now empowered to celebrate ‘white’ masses and certain sacraments by themselves. The article concludes that persecution created new spaces for lay religious participation, showing the 1910–40 Revolution to be a period of religious, as well as social, upheaval.