Facility characteristics preferred by older men seeking medical male circumcision services in Kenya: qualitative findings from the 'Tasco' study (May 2014-June 2016).

Primary healthcare facilities are central to the implementation of voluntary medical male circumcision (VMMC) as points of access to integrated health services in line with the Kenya AIDS Strategic Framework II (2020/21-2024/25). Knowledge of factors that explain men's uptake of VMMC and sexual health services at these facilities and preferences of where to get the services remain poorly understood. Using qualitative methodologies, we examined factors that determined facility choice for VMMC services and reasons for preferring the facility among men aged 25-39 years who previously underwent VMMC. The current study draws from focus group discussion interviews with circumcised men and their partners conducted as part of a randomized controlled trial to assess impact of two demand creation interventions in western Kenya. This involved 12 focus group discussions (FGD) with 6-10 participants each. Six FGDs were conducted with circumcised men, and 6 with their sex partners. Thematic issues relevant to a predetermined framework were identified. The themes were organized as follows: service availability, accessibility, affordability, appropriateness and, acceptability. Facility location, physical layout, organization of patient flow, infrastructure, and service provider skills were the outstanding factors affecting the choice of VMMC service outlets by men aged 25-39 years. Additionally, preferences were influenced by individual's disposition, attitudes, knowledge of VMMC services and tacit balance between their own recognized health needs versus desire to conform to social-cultural norms. Facility choice and individual preference are intricate issues, simultaneously involving multiple but largely intra-personal and facility-level factors. The intrapersonal dimensions elicited may also reflect differential responses to strategic communications and demand creation messages with promotion and prevention frames.

Predictors of mortality and survival probability distribution among patients on tuberculosis treatment in Vihiga County, Kenya.

Background: Tuberculosis (TB) related mortality remains a serious impediment in ending TB epidemic. Objective: To estimate survival probability and identify predictors, causes and conditions contributing to mortality among TB patients in Vihiga County. Methods: A cohort of 291 patients from 20 purposively selected health facilities were prospectively considered. Data was obtained by validated questionnaires through face-to-face interviews. Survival probabilities were estimated using Kaplan-Meier method while Cox proportional hazard model identified predictors of TB mortality through calculation of hazard ratios at 95% confidence intervals. Mortality audit data was qualitatively categorized to elicit causes and conditions contributing to mortality. Results: 209 (72%) were male, median age was 40 (IQR=32-53) years while TB/HIV coinfection rate was 35%. Overall, 45 (15%) patients died, majority (78% (log rank<0.001)) during intensive phase. The overall mortality rate was 32.2 (95% CI 23.5 - 43.1) deaths per 1000 person months and six months' survival probability was 0.838 (95% CI, 0.796-0.883). Mortality was higher (27%) among HIV positive than HIV negative (9%) TB patients. Independent predictors of mortality included; comorbidities (HR = 2.72, 95% CI,1.36-5.44, p< 0.005), severe illness (HR=5.06, 95% CI,1.59-16.1, p=0.006), HIV infection (HR=2.56, 95% CI,1.28-5.12, p=0.008) and smoking (HR=2.79, 95% CI,1.01-7.75, p=0.049). Independent predictors of mortality among HIV negative patients included; comorbidities (HR = 4.25, 95% CI; 1.15-15.7, p = 0.03) and being clinically diagnosed (HR = 4.8, 95% CI; 1.43-16, P = 0.01) while among HIV positive; they included smoking (HR = 4.05, 95% CI;1.03-16.0, P = 0.04), severe illness (HR = 5.84, 95% CI; 1.08-31.6, P = 0.04), severe malnutrition (HR = 4.56, 95% CI; 1.33-15.6, P = 0.01) and comorbidities (HR = 3.04, 95% CI; 1.03-8.97, p = 0.04). More than a half (52%) of mortality among HIV positive were ascribed to advanced HIV diseases while majority of (72%) of HIV negative patients died to TB related lung disease. Conditions contributing to mortality were largely patient and health system related. Conclusion: Risk of TB mortality is high and is attributable to comorbidities, severe illness, HIV and smoking. Causes and conditions contributing to TB mortality are multifaceted but modifiable. Improving TB/HIV care could reduce mortality in this setting.

Determinants of tuberculosis treatment interruption among patients in Vihiga County, Kenya.

BACKGROUND: Despite robust Tuberculosis (TB) program with effective chemotherapy and high coverage, treatment interruption remains a serious problem. Interrupting TB treatment means that patients remain infectious for longer time and are at risk of developing drug resistance and death. This study was conducted to identify and describe predictors of TB treatment interruption. METHODS: A cohort of 291 notified TB patients from 20 selected health facilities in Vihiga County were enrolled in to the study and followed up until the end of treatment. Patient characteristics that potentially predict treatment interruption were recorded during treatment initiation using structured questionnaires. Patients who interrupted treatment were traced and reasons for stoppage of treatment recorded. Kaplan Meier method was used to estimate probabilities of treatment interruption by patient characteristics and determine time intervals. The Log rank test for the equality of survival distributions analyzed significance of survival differences among categorical variables. For multivariable analysis, Cox proportional hazard model, was fitted to identify predictors of TB treatment interruption through calculation of hazard ratios with 95% Confidence Intervals (CIs). For variable analysis, statistical significance was set at P ≤ 0.05. Reasons for treatment interruption were categorized according to most recurrent behavioral or experiential characteristics. RESULTS: Participants' median age was 40 years (IQR = 32-53) and 72% were male. Of the 291 patients, 11% (n = 32) interrupted treatment. Incidences of treatment interruption significantly occurred during intensive phase of treatment. Independent predictors of treatment interruption included alcohol consumption (HR = 9.2, 95% CI; 2.6-32.5, p < 0.001), being female (HR = 5.01, 95% CI; 1.68-15.0, p = 0.004), having primary or lower education level (HR = 3.09, 95% CI; 1.13-8.49, p < 0.029) and having a treatment supporter (HR = 0.33, 95% CI; 0.14-0.76, p = 0.009). Reasons for interrupting treatment were categorized as: alcoholism, feeling better after treatment initiation, associated TB stigma, long distance to health facility, lack of food, perception of not having TB and pill burden. CONCLUSION: TB treatment interruption was high and largely associated with patients' socio-demographic and behavioral characteristics. These multidimensional factors suggest the need for interventions that not only target individual patients but also environment in which they live and receive healthcare services.

Patient-level cost of home- and facility-based child pneumonia treatment in Suba Sub County, Kenya.

BACKGROUND: Globally, pneumonia accounted for 16% of deaths among children under 5 years of age and was one of the major causes of death overall in 2018. Kenya is ranked among the top 15 countries with regard to pneumonia prevalence and contributed approximately 74% of the world's annual pneumonia cases in 2018. Unfortunately, less than 50% of children with pneumonia receive appropriate antibiotics for treatment. Homa-Bay County implemented pneumonia community case management utilizing community health workers, as recommended by the World Health Organization (WHO), in 2014. However, since implementation of the program, the relative patient-level cost of home-based and facility-based treatment of pneumonia, as well as the main drivers of these costs in Suba Subcounty, remain uncertain. Therefore, the main objective of this study was to compare the patient-level costs of home based treatment of pneumonia by a community health worker with those of health facility-based treatment. METHODS AND FINDINGS: Using a cross-sectional study design, a structured questionnaire was used to collect quantitative data from 208 caregivers on the direct costs (consultation, medicine, transportation) and indirect costs (opportunity cost) of pneumonia treatment. The average household cost for the community managed patients was KSH 122.65 ($1.29) compared with KSh 447.46 ($4.71), a 4-fold difference, for those treated at the health facility. The largest cost drivers for home treatment and health facility treatment were opportunity costs (KSH 88.25 ($ 0.93)) and medicine costs (KSH 126.16 ($ 1.33)), respectively. CONCLUSION: This study demonstrates that the costs incurred for home-based pneumonia management are considerably lower compared to those incurred for facility-based management. Opportunity costs (caregiver time and forgone wages) and the cost of medication were the key cost-drivers in the management of pneumonia at the health facility and at home, respectively. These findings emphasize the need to strengthen and scale community case management to overcome barriers and delays in accessing the correct treatment for pneumonia for sick children under 5 years of age.

Voluntary medical male circumcision scale-up in Nyanza, Kenya: evaluating technical efficiency and productivity of service delivery.

BACKGROUND: Voluntary medical male circumcision (VMMC) service delivery is complex and resource-intensive. In Kenya's context there is still paucity of information on resource use vis-à-vis outputs as programs scale up. Knowledge of technical efficiency, productivity and potential sources of constraints is desirable to improve decision-making. OBJECTIVE: To evaluate technical efficiency and productivity of VMMC service delivery in Nyanza in 2011/2012 using data envelopment analysis. DESIGN: Comparative process evaluation of facilities providing VMMC in Nyanza in 2011/2012 using output orientated data envelopment analysis. RESULTS: Twenty one facilities were evaluated. Only 1 of 7 variables considered (total elapsed operation time) significantly improved from 32.8 minutes (SD 8.8) in 2011 to 30 minutes (SD 6.6) in 2012 (95%CI = 0.0350-5.2488; p = 0.047). Mean scale technical efficiency significantly improved from 91% (SD 19.8) in 2011 to 99% (SD 4.0) in 2012 particularly among outreach compared to fixed service delivery facilities (CI -31.47959-4.698508; p = 0.005). Increase in mean VRS technical efficiency from 84% (SD 25.3) in 2011 and 89% (SD 25.1) in 2012 was not statistically significant. Benchmark facilities were #119 and #125 in 2011 and #103 in 2012. Malmquist Productivity Index (MPI) at fixed facilities declined by 2.5% but gained by 4.9% at outreach ones by 2012. Total factor productivity improved by 83% (p = 0.032) in 2012, largely due to progress in technological efficiency by 79% (p = 0.008). CONCLUSIONS: Significant improvement in scale technical efficiency among outreach facilities in 2012 was attributable to accelerated activities. However, ongoing pure technical inefficiency requires concerted attention. Technological progress was the key driver of service productivity growth in Nyanza. Incorporating service-quality dimensions and using stepwise-multiple criteria in performance evaluation enhances comprehensiveness and validity. These findings highlight site-level resource use and sources of variations in VMMC service productivity, which are important for program planning.

Systematic monitoring of male circumcision scale-up in Nyanza, Kenya: exploratory factor analysis of service quality instrument and performance ranking.

BACKGROUND: Considerable conceptual and operational complexities related to service quality measurements and variability in delivery contexts of scaled-up medical male circumcision, pose real challenges to monitoring implementation of quality and safety. Clarifying latent factors of the quality instruments can enhance contextual applicability and the likelihood that observed service outcomes are appropriately assessed. OBJECTIVE: To explore factors underlying SYMMACS service quality assessment tool (adopted from the WHO VMMC quality toolkit) and; determine service quality performance using composite quality index derived from the latent factors. STUDY DESIGN: Using a comparative process evaluation of Voluntary Medical Male Circumcision Scale-Up in Kenya site level data was collected among health facilities providing VMMC over two years. Systematic Monitoring of the Medical Male Circumcision Scale-Up quality instrument was used to assess availability of guidelines, supplies and equipment, infection control, and continuity of care services. Exploratory factor analysis was performed to clarify quality structure. RESULTS: Fifty four items and 246 responses were analyzed. Based on Eigenvalue >1.00 cut-off, factors 1, 2 & 3 were retained each respectively having eigenvalues of 5.78; 4.29; 2.99. These cumulatively accounted for 29.1% of the total variance (12.9%; 9.5%; 6.7%) with final communality estimates being 13.06. Using a cut-off factor loading value of ≥0.4, fifteen items loading on factor 1, five on factor 2 and one on factor 3 were retained. Factor 1 closely relates to preparedness to deliver safe male circumcisions while factor two depicts skilled task performance and compliance with protocols. Of the 28 facilities, 32% attained between 90th and 95th percentile (excellent); 45% between 50th and 75th percentiles (average) and 14.3% below 25th percentile (poor). CONCLUSION: the service quality assessment instrument may be simplified to have nearly 20 items that relate more closely to service outcomes. Ranking of facilities and circumcision procedure using a composite index based on these items indicates that majority performed above average.

Quality of voluntary medical male circumcision services during scale-up: a comparative process evaluation in Kenya, South Africa, Tanzania and Zimbabwe.

BACKGROUND: The rapid expansion of voluntary medical male circumcision (VMMC) has raised concerns whether health systems can deliver and sustain VMMC according to minimum quality criteria. METHODS AND FINDINGS: A comparative process evaluation was used to examine data from SYMMACS, the Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-Up, among health facilities providing VMMC across two years of program scale-up. Site-level assessments examined the availability of guidelines, supplies and equipment, infection control, and continuity of care services. Direct observation of VMMC surgeries were used to assess care quality. Two sample tests of proportions and t-tests were used to examine differences in the percent of facilities meeting requisite preparedness standards and the mean number of directly-observed surgical tasks performed correctly. Results showed that safe, high quality VMMC can be implemented and sustained at-scale, although substantial variability was observed over time. In some settings, facility preparedness and VMMC service quality improved as the number of VMMC facilities increased. Yet, lapses in high performance and expansion of considerably deficient services were also observed. Surgical tasks had the highest quality scores, with lower performance levels in infection control, pre-operative examinations, and post-operative patient monitoring and counseling. The range of scale-up models used across countries additionally underscored the complexity of delivering high quality VMMC. CONCLUSIONS: Greater efforts are needed to integrate VMMC scale-up and quality improvement processes in sub-Saharan African settings. Monitoring of service quality, not just adverse events reporting, will be essential in realizing the full health impact of VMMC for HIV prevention.

Work experience, job-fulfillment and burnout among VMMC providers in Kenya, South Africa, Tanzania and Zimbabwe.

BACKGROUND: Human resource capacity is vital to the scale-up of voluntary medical male circumcision (VMMC) services. VMMC providers are at risk of "burnout" from performing a single task repeatedly in a high volume work environment that produces long work hours and intense work effort. METHODS AND FINDINGS: The Systematic Monitoring of the Voluntary Medical Male Circumcision Scale-up (SYMMACS) surveyed VMMC providers in Kenya, South Africa, Tanzania, and Zimbabwe in 2011 (n = 357) and 2012 (n = 591). Providers self-reported on their training, work experience, levels of job-fulfillment and work fatigue/burnout. Data analysis included a descriptive analysis of VMMC provider characteristics, and both bivariate and multivariate analyses of factors associated with provider work fatigue/burnout. In 2012, Kenyan providers had worked in VMMC for a median of 31 months compared to South Africa (10 months), Tanzania (15 months), and Zimbabwe (11 months). More than three-quarters (78 - 99%) of providers in all countries in 2012 reported that VMMC is a personally fulfilling job. However, 67% of Kenyan providers reported starting to experience work fatigue/burnout compared to South Africa (33%), Zimbabwe (17%), and Tanzania (15%). Despite the high level of work fatigue/burnout in Kenya, none of the measured factors (i.e., gender, age, full-time versus part-time status, length of service, number of operations performed, or cadre) were significantly associated with work fatigue/burnout in 2011. In 2012, logistic regression found increases in age (p<.05) and number of months working in VMMC (p<.01) were associated with an increased likelihood of experiencing work fatigue/burnout, while higher career total VMMCs decreased the likelihood of experiencing burnout. CONCLUSION: Given cross-country differences, further elucidation of cultural and other contextual factors that may influence provider burnout is required. Continuing to emphasize the contribution that providers make in the fight against HIV/AIDS is important.

Ethical issues evolving from patients' perspectives on compulsory screening for syphilis and voluntary screening for cervical cancer in Kenya.

BACKGROUND: Public health aims to provide universal safety and progressive opportunities to populations to realise their highest level of health through prevention of disease, its progression or transmission. Screening asymptomatic individuals to detect early unapparent conditions is an important public health intervention strategy. It may be designed to be compulsory or voluntary depending on the epidemiological characteristics of the disease. Integrated screening, including for both syphilis and cancer of the cervix, is a core component of the national reproductive health program in Kenya. Screening for syphilis is compulsory while it is voluntary for cervical cancer. Participants' perspectives of either form of screening approach provide the necessary contextual information that clarifies mundane community concerns. METHODS: Focus group discussions with female clients screened for syphilis and cancer of the cervix were conducted to elicit their perspectives of compulsory and voluntary screening. The discussions were audiotaped, transcribed and thematic content analysis performed manually to explore emerging ethics issues. RESULTS: The results indicate that real ethical challenges exist in either of the approaches. Also, participants were more concerned about the benefits of the procedure and whether their dignity is respected than the compulsoriness of screening per se. The implication is for the policy makers to clarify in the guidelines how to manage ethical challenges, while at the operational level, providers need to be judicious to minimize potential harms participants and families when screening for disease in women. CONCLUSIONS: The context for mounting screening as a public health intervention and attendant ethical issues may be more complex than hitherto perceived. Interpreting emerging ethics issues in screening requires more nuanced considerations of individuals' contextual experiences since these may be contradictory to the policy position. In considering mounting screening for Syphilis and cervical cancer as a public heal intervention, the community interests and perspectives should be inculcated into the program. Population lack of information on procedures may influence adversely the demand for screening services by the individuals at risk or the community as a collective agent.

Bacteriology of chronic suppurative otitis media (CSOM) in children in Garissa district, Kenya: a point prevalence study.

OBJECTIVES: To identify by type and sensitivity to drugs the bacteria found in ears of school-going children with chronic otitis media in Garissa district. STUDY DESIGN: This was a descriptive prevalence study of CSOM bacterial flora in eligible ears conducted among a cohort of children attending public and private primary as well as Islamic religious schools, screened for chronic ear discharge in Garissa district, Kenya. Procedure and bacteriological techniques: We used sterile swab-sticks to collect a specimen of the discharge from eligible ears of consenting pupils at the induction stage of the zinc supplementation trial for treatment of chronic suppurative otitis media conducted between January and July 2010. All pupils below 18 years present on day of visit were eligible. Both aerobic and anaerobic bacterial cultures were done to identify clinically and epidemiologically important bacteria. Sensitivity tests were based on disc diffusion methods. Results are presented as frequencies and proportions. RESULTS: Of the pupils seen, 61% were still in pre- or lower primary school. Majority were aged 13 and 14 years. Of the 261 ear swab samples processed, 336 isolates - either in mixed or pure flora - were identified, being almost exclusively aerobes. Proteus spp., Enterococcus, Staphylococcus aureus and Pseudomonas spp. were isolated in 32.7%, 28.6%, 12.8% and 11.3% respectively. Proteus was susceptible to majority of the antibiotics tested for, while Enterococcus was poorly susceptible. CONCLUSIONS: Aerobic bacteria were most prevalent in this study. Several of the bacteria identified are known to require iron for their growth. This may be important for CSOM treatment if biofilm formation is involved in pathogenesis. Majority of the isolates were susceptible to basic antibiotics compared to Enterococcus bacteria. This portends an important consideration for clinical management and therapeutic decision-making. Additionally, given the prevalence of Enterococcus bacteria, which is an indicator of faecal contamination of the environment, there is need to consider relevant public health components in managing childhood CSOM besides the clinical ones alone.

In vivo acid etching effect on bacteria within caries-affected dentin.

Acid etching procedures may disrupt residual bacteria and contribute to the success of incomplete caries removal followed by adhesive restoration. This study evaluated the in vivo effect of acid etching on cariogenic bacterial activity within affected dentin after minimally invasive treatment of caries lesions. Twenty-eight carious permanent teeth received standardized selective caries removal and random acid etch treatment (E) or not (NE) prior to adhesive restoration. Baseline and 3-month dentin biopsies were collected. The number of bacteria and activity of total bacterial cells and Streptococcus mutans were determined by quantitative PCR and RT-PCR. No statistically significant differences were observed in total bacterial number and activity between E and NE treatments (p > 0.3008). For NE, however, the residual S. mutans bacterial cells were reduced (p = 0.0027), while the activity per cell was significantly increased (p = 0.0010) after reentry at 3 months after restoration. This effect was not observed in group E. Although no significant differences were found between groups, this study suggests that acid etching of affected dentin prior to adhesive restoration may directly or indirectly have an inhibitive effect on the activity of residual cariogenic bacteria. Further research is required to investigate this potential effect.

In vivo dentin microhardness beneath a calcium-phosphate cement.

A minimally invasive caries-removal technique preserves potentially repairable, caries-affected dentin. Mineral-releasing cements may promote remineralization of soft residual dentin. This study evaluated the in vivo remineralization capacity of resin-based calcium-phosphate cement (Ca-PO(4)) used for indirect pulp-capping. Permanent carious and sound teeth indicated for extraction were excavated and restored either with or without the Ca-PO(4) base (control), followed by adhesive restoration. Study teeth were extracted after 3 months, followed by sectioning and in vitro microhardness analysis of the cavity floor to 115-microm depth. Caries-affected dentin that received acid conditioning prior to Ca-PO(4) basing showed significantly increased Knoop hardness near the cavity floor. The non-etched group presented results similar to those of the non-treated group. Acid etching prior to cement application increased microhardness of residual dentin near the interface after 3 months in situ.

In vivo dentin remineralization by calcium-phosphate cement.

Minimally invasive caries-removal procedures remove only caries-infected dentin and preserve caries-affected dentin that becomes remineralized. Dental cements containing calcium phosphate promote remineralization. This study evaluated the in vivo remineralization capacity of resin-based calcium-phosphate cement (Ca-P) used for indirect pulp-capping. Carious and sound teeth indicated for extraction were randomly restored with the Ca-P base or without base (control), followed by adhesive restoration. Study teeth were extracted after three months, followed by elemental analysis of the cavity floor. Mineral content of affected or sound dentin at the cavity floor was quantified by electron probe micro-analysis to 100-mum depth. After three months, caries-affected dentin underneath the Ca-P base showed significantly increased calcium and phosphorus content to a depth of 30 mum. Mineral content of treated caries-affected dentin was in the range of healthy dentin, revealing the capacity of Ca-P base to promote remineralization of caries-affected dentin.

Overcoming the barriers experienced in conducting a medication trial in adults with aggressive challenging behaviour and intellectual disabilities.

BACKGROUND: Aggressive challenging behaviour in people with intellectual disability (ID) is frequently treated with antipsychotic drugs, despite a limited evidence base. METHOD: A multi-centre randomised controlled trial was undertaken to investigate the efficacy, adverse effects and costs of two commonly prescribed antipsychotic drugs (risperidone and haloperidol) and placebo. RESULTS: The trial faced significant problems in recruitment. The intent was to recruit 120 patients over 2 years in three centres and to use a validated aggression scale (Modified Overt Aggression Scale) score as the primary outcome. Despite doubling the period of recruitment, only 86 patients were ultimately recruited. CONCLUSIONS: Variation in beliefs over the efficacy of drug treatment, difficulties within multidisciplinary teams and perceived ethical concerns over medication trials in this population all contributed to poor recruitment. Where appropriate to the research question cluster randomised trials represent an ethically and logistically feasible alternative to individually randomised trials.

Neuroleptics in the treatment of aggressive challenging behaviour for people with intellectual disabilities: a randomised controlled trial (NACHBID).

OBJECTIVE(S): To assess the effects and cost-effectiveness of haloperidol, risperidone and placebo on aggressive challenging behaviour in adults with intellectual disability. DESIGN: A double-blind randomised controlled trial of two drugs and placebo administered in flexible dosage, with full, independent assessments of aggressive and aberrant behaviour, global improvement, carer burden, quality of life and adverse drug effects at baseline, 4, 12 and 26 weeks, and comparison of total care costs in the 6 months before and after randomisation. At 12 weeks, patients were given the option of leaving the trial or continuing until 26 weeks. Assessments of observed aggression were also carried out with key workers at weekly intervals throughout the trial. SETTING: Patients were recruited from all those being treated by intellectual disability services in eight sites in England, one in Wales and one in Queensland, Australia. PARTICIPANTS: Patients from all severity levels of intellectual disability; recruitment was extended to include those who may have been treated with neuroleptic drugs in the past. EXCLUSION CRITERIA: treatment with depot neuroleptics/another form of injected neuroleptic medication within the last 3 months; continuous oral neuroleptic medication within the last week; those under a section of the Mental Health Act 1983 or Queensland Mental Health Act 2000. INTERVENTIONS: Randomisation to treatment with haloperidol (a typical neuroleptic drug), risperidone (an atypical neuroleptic drug) or placebo using a permuted blocks procedure. Dosages were: haloperidol 1.25-5.0 mg daily; risperidone 0.5-2.0 mg daily. MAIN OUTCOME MEASURES: Primary: reduction in aggressive episodes between baseline and 4 weeks using Modified Overt Aggression Scale. Secondary: Aberrant Behaviour Checklist; Uplift/Burden Scale; 40-item Quality of Life Questionnaire; Udvalg for Kliniske Undersøgelser scale; Clinical Global Impressions scale. Economic costs recorded using a modified version of Client Service Receipt Inventory for 6 months before and after randomisation. RESULTS: There were considerable difficulties in recruitment because of ethical and consent doubts. Twenty-two clinicians recruited a total of 86 patients. Mean daily dosages were 1.07 mg rising to 1.78 mg for risperidone and 2.54 mg rising to 2.94 mg for haloperidol. Aggression declined dramatically with all three treatments by 4 weeks, with placebo showing the greatest reduction (79%, versus 57% for combined drugs) (p = 0.06). Placebo-treated patients showed no evidence of inferior response in comparison to patients receiving neuroleptic drugs. An additional study found that clinicians who had not participated in clinical trials before were less likely to recruit. Mean total cost of accommodation, services, informal care and treatment over the 6 months of the trial was 16,336 pounds for placebo, 17,626 pounds for haloperidol and 18,954 pounds for risperidone. CONCLUSIONS: There were no significant important benefits conferred by treatment with risperidone or haloperidol, and treatment with these drugs was not cost-effective. While neuroleptic drugs may be of value in the treatment of aggressive behaviour in some patients with intellectual disability, the underlying pathology needs to be evaluated before these are given. The specific diagnostic indications for such treatment require further investigation. Prescription of low doses of neuroleptic drugs in intellectual disability on the grounds of greater responsiveness and greater liability to adverse effects also needs to be re-examined.

Measuring depressive symptoms in the naturalistic primary-care setting.

BACKGROUND: The majority of individuals with major depressive disorder are diagnosed and treated in the primary-care setting. A quantifiable critical objective in the management of depression is to achieve and sustain full symptomatic remission. The HAMD-7 is a depression metric validated in both tertiary and primary-care settings. METHODS: Herein, we further characterise the psychometric properties of the HAMD-7 in depressed patients treated in primary-care settings. Several cut-scores were evaluated for maximum agreement; diagnostic efficacy statistics with the original HAMD-7 items were also evaluated. We compared performance of the HAMD-7 in primary care to a previously characterised tertiary sample. RESULTS: The depressive symptoms most frequently endorsed (>or=70%) and most sensitive to change during antidepressant treatment in depressed primary-care patients were depressed mood, guilt, work and activities, psychic and somatic anxiety and fatigue. LIMITATIONS: This is a post hoc analysis of a primary-care database; assumptions regarding the definition of symptomatic remission in depression affect interpretation. CONCLUSION: Measurement-based care with the HAMD-7 quantifies the severity of commonly reported depressive items and their responsivity to treatment. The HAMD-7, inclusive of the suicide item, is capable of tracking symptom progress, with a validated remission cut-score.

Probing the origins and control of shrinkage stress in dental resin-composites: I. Shrinkage stress characterization technique.

The accurate and reliable characterization of the polymerization shrinkage stress is becoming increasingly important, as the shrinkage stress still is a major drawback of current dimethacrylate-based dental materials and restricts its range of applications. The purpose of this research is to develop a novel shrinkage stress measurement device to elucidate the shrinkage stress evolution of dental restorative composites while allowing for controlled sample deformation during the polymerization. Furthermore, the device is designed to mimic the clinically relevant cusp-to-cusp displacement by systematically adjusting the instrument compliance, the bonded surface area/unbonded area by sample geometry, and the total bonded area by sample diameter. The stress measurement device based on the cantilever beam deflection theory has been successfully developed and characterized using a commercial dental composite. It was shown that this device is a highly effective, practical and reliable shrinkage stress measurement tool, which enables its facile applications to the investigation of shrinkage stress kinetics of both commercial and experimental composites, as well as for probing various aspects that dictate shrinkage stress development.

Impact of patient suicide on psychiatrists and psychiatric trainees.

OBJECTIVE: The authors investigated the impact of patient suicides on trainees and psychiatrists and their utilization of supports. METHODS: Graduates in practice and trainees of the residency program of the University of Toronto from 1980-1995 (N=495) were surveyed, retrospectively, with 239/495 responding (48%). Demographic and educational information, exposure to suicide, impact of the suicide(s), use of support systems, acute stress disorder and posttraumatic stress disorder symptoms, and impact of events and social relationship scores were collected. RESULTS: One-half of the respondents (120/239) experienced at least one suicide of a patient, 62% of them (74/120) during postgraduate training. Biologically oriented psychiatrists in practice were more at risk for patient suicide. An important minority (one-quarter) among those who experienced patient suicide had substantially higher (morbid) scores than the overall group. They also scored higher on an acute stress disorder and a posttraumatic stress disorder symptom checklist. The impact was more severe when the patient suicide occurred during training than after graduation and was inversely correlated with clinicians' perceived social integration into their relational professional network. CONCLUSIONS: The experience of patient suicide is common during training and in clinical practice. The majority of trainees and clinicians are able to cope normally with the trauma, but in an important minority the emotional impact approaches morbid levels. Training programs should prepare students for this occupational hazard and implement systematic protocols to support those trainees who are especially vulnerable to their patient's suicide and reduce their social isolation from their peer group. Formal and informal professional networks should heighten awareness of the impact of patient suicide on practicing colleagues and take adequate measures to support them.

Determination of double bond conversion in dental resins by near infrared spectroscopy.

OBJECTIVES: This study determined the validity and practicality of near infrared (NIR) spectroscopic techniques for measurement of conversion in dental resins. METHODS: Conversion measurements by NIR and mid-IR were compared using two techniques: (1) The conversion of 3mm thick photopolymerized Bis-GMA/TEGDMA resin specimens was determined by transmission NIR. Specimens were then ground and reanalyzed in KBr pellet form by mid-IR. (2) As further verification, thin resin films were photocured and analyzed by mid-IR. Multiple thin films were then compressed into a thick pellet for examination by NIR. RESULTS: Conversion values obtained by NIR and mid-IR techniques did not differ significantly. A correction for changing specimen thickness due to polymerization shrinkage was applied to NIR conversion measurements since an internal standard reference peak was not employed. Sensitivity of the NIR technique was superior to those based on the mid-IR. SIGNIFICANCE: The nondestructive analysis of conversion in dental resins by NIR offers advantages of convenience, practical specimen dimensions and precision compared with standard mid-IR analytical procedures. Because glass is virtually transparent in the NIR spectrum, this technique has excellent potential for use with filled dental resins as well.