A realist evaluation of a multi-component program with disengaged students.

Periods spent in the absence of education, employment, or training (NEET) are associated with adverse psychological wellbeing, social marginalisation, and premature mortality. Implementing effective programs to re-engage young people who are classified, or are at risk of becoming NEET, is of importance to these individuals, family, and society. We conducted a realist evaluation to understand how, and under which circumstances a multi-component program may impact the engagement, behavioural, and psychosocial outcomes of disengaged students at risk of becoming NEET. During the early project phase, a narrative review of the literature and key stakeholder discussions were conducted to develop our initial program theories regarding how the program was expected to achieve its outcomes. Participant observations, video footage, and forty-two interviews were then conducted with teachers and students to form context-mechanism-outcome configurations and to refine these theories. Overall, refined program theories relating to positions of authority, the power of collective experience, exploration of possible life directions, constructivist pedagogies and active learning, and the endorsement of an ethic of caring and strengths-based orientation were developed. Collectively, our findings provide a detailed understanding of the architecture of programs that may benefit disengaged students and help inform the design of future programs aimed at reducing disaffection.

Wellbeing in high-performance swimming: A grounded theory study.

The demands of elite sport have the potential to negatively impact on athletes' wellbeing (e.g., Arnold & Fletcher, 2012; Rice et al., 2016). Despite this, not all elite athletes experience detrimental effects, rather some individuals thrive in an elite sports environment. The reasons why some athletes experience positive wellbeing while others struggle remains unclear although, in part, due to methodological limitations of previous research. To overcome these limitations, the purpose of the current study was to examine how change in high-performance swimmers' wellbeing occurs. Grounded theory methodology was used to enable examination of processes of change. Semi-structured interviews with 22 current and five retired swimmers, eight coaches, and seven support staff were used to generate data alongside observations and field notes. The resultant theory illustrated how a dominant performance narrative influenced the development and maintenance of an exclusive swimmer identity that was tied to performance. Specifically, transitions were highlighted as critical points where wellbeing was likely to be affected, due to the increased potential for change and uncertainty to impact on performance and subsequently identity. However, the use of proactive coping strategies, such as anticipating and planning, as well as accessing and utilising appropriate support were shown to help minimise the impact on wellbeing.

Evaluating the Effect of Kaftrio on Perspectives of Health and Wellbeing in Individuals with Cystic Fibrosis.

BACKGROUND: Modulator therapy represents a significant step forward in CF care and is expected to have a significant impact on the health and mortality of many individuals with CF. Studies have predominantly explored the physiological effects of modulator therapy on clinical outcomes, with little consideration of the individual lived experience of modulator therapy among adults with Cystic Fibrosis. METHODS: To explore this, semi-structured interviews were conducted with 12 individuals currently taking Kaftrio, which were subsequently thematically analysed. RESULTS: Three overarching themes were identified: (i) positive perception of Kaftrio, (ii) negative perception of Kaftrio, and (iii) the relationships with the clinical team. The experience of modulator therapy should be recognised as being unique to the individual, with perceptions of illness, self-identity, and outcomes strongly dictating the lived experience. CONCLUSIONS: There is a consensus that, while for many, the quality of life is evidently increased through the use of Kaftrio, this is not without its own challenges. This highlights the need for both individuals with CF and their clinical teams to learn to navigate this new disease landscape.

Quality Improvement Methodology Optimizes Infliximab Levels in Pediatric Patients with Inflammatory Bowel Disease.

Achieving and maintaining target serum trough infliximab levels improves outcomes in children and young adults with inflammatory bowel disease. Our goal was to improve adherence to an infliximab therapy guideline. The primary aim was to increase the percentage of patients with infliximab levels ≥5 µg/mL and results checked in the last 12 months from 73% to ≥80% from July 2017 to January 2018. METHODS: We participated in Intermediate Improvement Science Series, a course at Cincinnati Children's Hospital Medical Center designed to catalyze change using quality improvement methodology. We implemented interventions through plan-do-study-act cycles. Our outcome measure was balanced by 2 process measures to determine what actions impacted improvement. These measures included the percentage of infusion plans revised in response to a drug level <5 µg/mL and the proportion of plans for which a follow-up drug level was ordered. RESULTS: We increased the percentage of infusion plans revised before the next infusion from 63% to 87% and the percentage of plans that had an appropriate drug level recheck from 61% to 83% from July 2017 to January 2018. We increased the percentage of patients with an infliximab level >5 µg/mL, and results checked in the last 12 months, from 73% to 80%. CONCLUSIONS: Quality improvement methodology was effective in improving provider adherence to infliximab therapeutic drug monitoring guidelines. Improvement in adherence to guidelines directly improved the percentage of patients achieving target infliximab levels at any time during infliximab therapy.

Time-efficient and computer-guided sprint interval exercise training for improving health in the workplace: a randomised mixed-methods feasibility study in office-based employees.

BACKGROUND: The efficacy of high-intensity interval training (HIT) as a time-efficient exercise strategy for beneficially modifying risk factors for cardiovascular disease has repeatedly been demonstrated in controlled laboratory settings. However, the effectiveness of HIT in an unsupervised workplace setting has not been investigated. The objective of this study was to use mixed methods to investigate the feasibility, acceptability and effectiveness of a short-duration, high-intensity exercise intervention (REHIT) when applied unsupervised in a workplace setting. METHODS: Twenty-five office-workers (mean ± SD age: 47 ± 9 y, BMI: 27.5 ± 4.4 kg·m- 2, V̇O2max: 28 ± 7 mL·kg- 1·min- 1) completed a 6-week REHIT intervention unsupervised in their workplace (n = 13, 6 men), or acted as a no-intervention control (n = 12, 6 men). The intervention consisted of 2 sessions/week of low-intensity (~ 25 W) cycling interspersed with 2 'all-out' sprints, increasing in duration from 10 to 20 s per sprint over the 6 weeks (total time-commitment: 8:40 min per session). V̇O2max was assessed pre- and post-training, whilst questionnaire-based measures of exercise enjoyment, self-efficacy, and acceptability were completed post-training. Eight participants also completed post-intervention semi-structured interviews. RESULTS: V̇O2max significantly improved in the exercise group (2.25 ± 0.75 L·min- 1 vs. 2.42 ± 0.82 L·min- 1; + 7.4%) compared to the control group (2.22 ± 0.72 L·min- 1 vs. 2.17 ± 0.74 L·min- 1; - 2.3%; time*intervention interaction effect: p < 0.01). Participants considered the REHIT intervention acceptable and enjoyable (PACES: 89 ± 17 out of 119) and were confident in their ability to continue to perform REHIT (7.8 ± 1.2 out of 9). Qualitative data revealed that REHIT offered a time-efficient opportunity to exercise, that was perceived as achievable, and which encouraged highly valued post-exercise outcomes (e.g. progress towards health/fitness benefits). CONCLUSIONS: REHIT could be implemented as a feasible, effective and acceptable exercise intervention in a workplace setting, with a total time-commitment of < 20 min/week. Consideration of certain psycho-social factors and behaviour-change techniques may ensure adherence to the REHIT programme in the long term. TRIAL REGISTRATION: The study was registered on ClinicalTrials.gov on 07/05/2019 (registration: NCT03941145).

Mental health first aid for the UK Armed Forces.

Education programmes in mental health literacy can address stigma and misunderstanding of mental health. This study investigated self-rated differences in knowledge, attitudes and confidence around mental health issues following participation in a bespoke Mental Health First Aid (MHFA) training course for the Armed Forces. The mixed methods approach comprised quantitative surveys and qualitative interviews. A survey, administered immediately post-training (n = 602) and again at 10-months post-attendance (n = 120), asked participants to rate their knowledge, attitudes and confidence around mental health issues pre- and post-training. Quantitative findings revealed a significant increase in knowledge, positive attitudes and confidence from the post-training survey which was sustained at 10-months follow-up.Semi-structured telephone interviews (n = 13) were conducted at follow-up, 6-months post-attendance. Qualitative findings revealed that participation facilitated an 'ambassador' type role for participants. This study is the first to have investigated the effect of MHFA in an Armed Forces community. Findings show participants perceived the training to increase knowledge regarding mental health and to enhance confidence and aptitude for identifying and supporting people with mental health problems. Results suggest that such an intervention can provide support for personnel, veterans and their families, regarding mental health in Armed Forces communities.

Facilitators and Barriers for Implementing an Internet Clinic for the Treatment of Pressure Injuries.

Background: Pressure injuries (PIs) represent a frequent, often preventable, secondary complication of spinal cord injury (SCI) with serious consequences to health, societal participation, and quality of life. Specialized knowledge and service delivery related to treatment and prevention are typically located within major health centers.Introduction: For persons with SCI living at home, it can be challenging to access specialized PI care. A telehealth approach could help mitigate this challenge. This multisite pilot investigation assessed the feasibility of integrating information technologies within the management of PIs.Materials and Methods: Each study site formed a specialized interdisciplinary care team that identified components of their standard clinical care pathway and examined how they could be integrated with study technologies. A monitoring system was utilized to enable patients and caregivers to exchange clinical information with the care team.Results: Clinician and patient focus groups were completed to identify facilitators and barriers for long-term implementation. Findings demonstrate that this method of service delivery is feasible but requires further development.Discussion: This model of care requires refinement to address technological, regulatory, and clinician acceptance barriers; however, increased access to these services has the potential for improving PI healing or prevention rates in comparison with those not able to access specialized services.Conclusions: This project demonstrates that PI treatment services can be delivered effectively through the internet. Future trials can investigate efficacy and cost-effectiveness of this model of care to inform sustained implementation.

Midwives understanding of physical activity guidelines during pregnancy.

OBJECTIVE: to examine the current level of understanding held by midwives regarding the NICE physical activity guidelines in the UK, and to investigate the physical activity guidance given to women during pregnancy. DESIGN: an 11 question online survey comprising of a mixture of closed and open ended questions. SETTING: data reflects participants sampled across the United Kingdom. PARTICIPANTS: fifty-nine midwives completed the online survey MEASUREMENTS AND FINDINGS: an electronic survey was used to explore the midwives understanding of physical activity guidelines during pregnancy, and the advice they offered to women in their care. Qualitative content analysis was used to gain a more in-depth understanding of midwife knowledge. Two per cent of midwives correctly identified the physical activity guidelines, with 44% giving partially correct responses, 25% giving incorrect responses and 29% unsure of what the guidelines are. Despite the low level of correct responses, 59% of respondents reported they were confident or very confident in answering questions regarding physical activity. Only 4% of respondents reported having access to continual professional development (CPD) in the area of PA guidance. KEY CONCLUSIONS: there appears to be a misplaced confidence amongst midwives in their knowledge of the NICE PA guidelines for pregnancy. IMPLICATIONS FOR PRACTICE: as physical inactivity can be detrimental for the health of both mother and baby, there is a clear need for better dissemination of the current and future NICE physical activity guidelines in primary health care settings. The current study determined a substantial lack of CPD in the area of PA guidance, which may be a contributing factor to the lack of knowledge of the guidelines. As such, increasing CPD may in turn improve the accuracy of the advice given to pregnant women and consequently benefit the health of both mother and baby.

Improving health maintenance supervision in a paediatric IBD clinic.

BACKGROUND: Previsit planning (PVP) has been an integral part of clinical care for paediatric patients with inflammatory bowel disease (IBD) at Cincinnati Children's Hospital Medical Center since 2007. Over the past years, we have adopted several programmes to improve health maintenance supervision for our paediatric patients with IBD but did not have a sustainable way to provide health maintenance updates for every patient at every encounter that was concise and complete in the setting of an increasing patient population and fewer support staff to complete the work. METHODS: Using quality improvement methods, we completed several Plan-Do-Study-Act (PDSA) cycles aimed at improving our centre's ability to provide complete health maintenance 'bundle' recommendations from 0% to 90% of patients over a period of 11 months. RESULTS: First steps included consensus gathering and summarising evidence into guidelines suitable for the group. PDSAs centred on consensus building from standardised guidelines, using empty checklists for simulated and real patients, and use of autofilled checklists. After several PDSA cycles, we have improved our ability to provide complete health maintenance PVP from 0% to nearly 100% with very little variation. CONCLUSION: Using the health maintenance PVP process, we can now sustainably provide health maintenance guidance for all outpatient clinic visits. We have begun to scale up this work and anticipate over the coming months that we will be able to expand the health maintenance PVP to provide complete PVP for over 90% of patients for any scheduled encounter including biologic infusion visits. We anticipate that using this reliable process we can improve remission rates and reduce preventable infections for these at-risk patients.

Autism-Like Behavior and Epigenetic Changes Associated with Autism as Consequences of In Utero Exposure to Environmental Pollutants in a Mouse Model.

We tested the hypothesis that in utero exposure to heavy metals increases autism-like behavioral phenotypes in adult animals and induces epigenetic changes in genes that have roles in the etiology of autism. Mouse dams were treated with cadmium, lead, arsenate, manganese, and mercury via drinking water from gestational days (E) 1-10. Valproic acid (VPA) injected intraperitoneally once on (E) 8.5 served as a positive control. Young male offspring were tested for behavioral deficits using four standardized behavioral assays. In this study, in utero exposure to heavy metals resulted in multiple behavioral abnormalities that persisted into adulthood. VPA and manganese induced changes in perseverative/impulsive behavior and social dominance behavior, arsenic caused changes only in perseverative/impulsive behavior, and lead induced abnormalities in social interaction in comparison to the control animals. Brain samples from Mn, Pb, and VPA treated and control animals were evaluated for changes in CpG island methylation in promoter regions and associated changes in gene expression. The Chd7 gene, essential for neural crest cell migration and patterning, was found to be hypomethylated in each experimental animal tested compared to water-treated controls. Furthermore, distinct patterns of CpG island methylation yielded novel candidate genes for further investigation.

An exploration of pre-performance routines, self-efficacy, anxiety and performance in semi-professional soccer.

Whilst much research has suggested a positive link between pre-performance routines (PPRs) and performance, the specific mechanisms of the process have yet to be understood fully. It has been suggested that the PPR may influence performance through lowering the athlete's anxiety, and/or increasing their self-efficacy, but to date this has not specifically been explored in detail. As a result the aim of the current study was to explore the impact of specific individualised PPRs on performance, anxiety and self-efficacy in semi-professional soccer players. Participants were 20 male semi-professional soccer players (M = 19.45, SD = 2.81) recruited from clubs in England. Adopting a repeated measure design, players were tested on performance, anxiety, and self-efficacy pre- and post a 7-day intervention period in which the participants learnt a new PPR. The data were analysed using factorial mixed measures analysis of variance (ANOVAs), with the results revealing a significant difference in somatic anxiety for the experimental group and a decrease in performance for the control group. The study provides further support for the suggestion that the PPR can enhance performance by reducing experiences of anxiety prior to performance.

Evaluation of the California Safer Consumer Products Regulation and the impact on consumers and product manufacturers.

Chemistry enables more than 95% of products in the marketplace. Over the past 20 years, various entities began to generate inventories of chemicals ("chemical watch lists") potentially associated with human or environmental health risks. Some lists included thousands of chemicals, while others listed only a few chemistries with limited properties or toxicological endpoints (e.g., neurotoxicants). Enacted on October 1, 2013, the California Safer Consumer Products Regulation (SCP) utilized data from chemical inventory lists to create one master list. This paper aims to discuss the background and requirements of this regulation. Additionally, we wanted to understand the universe of Candidate Chemicals identified by the Regulation. Data from all 23 chemical lists identified in the SCP Regulation were entered into a database. The most prevalent chemicals among the ∼2900 chemicals are identified, including the most prevalent chemical, lead, appearing on 65% of lists, followed by DEHP (52%), perchloroethylene (48%), and benzene (48%). Our results indicated that the most prevalent Candidate Chemicals were either persistent, bioaccumulative, carcinogenic, or reprotoxic. This regulation will have wide-ranging impact in California and throughout the global supply chain, which is highlighted through selected examples and case studies.

Repetitive mass practice or focused precise practice for retraining walking after incomplete spinal cord injury? A pilot randomized clinical trial.

BACKGROUND: Retraining walking following spinal cord injury using visually guided tasks may be especially efficacious because it engages the motor cortex, whose input may facilitate improvements in functional walking. OBJECTIVES: To contrast 2 methods of retraining, one emphasizing precise, visually guided walking over obstacles and on targets (Precision Training), the other emphasizing mass practice of walking on a treadmill (Endurance Training). METHODS: A randomized, single-blind, crossover design was used. Twenty-two participants, ≥7 months postinjury, were randomly allocated to start with Precision or Endurance Training. Each phase of training was 5 times per week for 2 months, followed by a 2-month rest. MEASURES: of walking speed, distance, skill, confidence, and depression were obtained before training, then monthly thereafter. RESULTS: Both forms of training led to significant improvements in walking, with Endurance Training inducing bigger improvements in walking distance than Precision Training, especially for high-functioning walkers who had initial walking speeds >0.5 m/s. The largest improvements in walking speed and distance occurred in the first month of Endurance Training, with minimal changes in the second month of training. In contrast, improvements in walking skill occurred over both months during both types of training. Retention of over ground walking speed, distance, and skill was excellent for both types of training. CONCLUSIONS: Intensive walking training in the chronic phase after spinal cord injury is effective in improving over ground walking. Visually guided tasks for training individuals with chronic spinal cord injury were not superior to mass practice on a treadmill.

A review of educational programs to reduce UTIs among individuals with SCI.

PURPOSE: To evaluate the effectiveness of educational programs in reducing urinary tract infections (UTIs) in individuals with spinal cord injuries (SCI). METHODS: A search of all relevant literature published up to and including July 2012 was conducted using multiple databases. Methodological quality was rated using the PEDro tool for randomized control trials (RCTs) and the Downs and Black tool for non-RCTs; levels of evidence were assigned using a modified Sackett scale. FINDINGS: Four articles were selected for review. As a result of an education program, a level 2 prospective control trial reported a reduction in number of UTIs (p = .02), but a level 2 RCT did not. A pre-post study found a reduction in number of UTIs while a case-control study did not; however, these studies did not compute statistics. CONCLUSIONS: There is limited positive evidence that education programs reduce the incidence of UTIs. CLINICAL RELEVANCE: Optimal urinary health of individuals with SCI may be optimized via education programs that provide information and enhance skills.

Best practices for the treatment and prevention of urinary tract infection in the spinal cord injured population: The Alberta context.

The purpose of this review of clinical guidelines and best practices literature is to suggest prevention options and a treatment approach for intermittent catheter users that will minimize urinary tract infections (UTI). Recommendations are based both on evidence in the literature and an understanding of what is currently attainable within the Alberta context. This is done through collaboration between both major tertiary care centres (Edmonton and Calgary) and between various professionals who regularly encounter these patients, including nurses, physiatrists and urologists.

Meta-analysis of botulinum toxin A detrusor injections in the treatment of neurogenic detrusor overactivity after spinal cord injury.

OBJECTIVE: To examine the effectiveness of botulinum toxin type A (BTX-A) on neurogenic detrusor overactivity (NDO) in individuals with spinal cord injury (SCI). DATA SOURCES: MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for all relevant articles published from 1980 to June 2012. STUDY SELECTION: Trials examining the use of BTX-A injections into the detrusor wall in the treatment of NDO after SCI were included if (1) ≥ 50% of study sample comprised subjects post-SCI; (2) outcomes of interest were assessed before and after treatment with a single injection of BTX-A; and (3) the sample size was ≥ 3. DATA EXTRACTION: A standardized mean difference ± SE (95% confidence interval) was calculated for at least 1 of the following outcomes in every study: postvoid residual urine volume, reflex detrusor volume, bladder capacity, bladder compliance, catheterization frequency, and maximum flow rate. Results from all studies were then pooled using a random-effects model. Treatment effect sizes were interpreted as small, >0.2; moderate, >0.5; or large, >0.8. DATA SYNTHESIS: Fourteen studies representing data from 734 subjects were included. After BTX-A injection, large treatment effects were observed in postvoid residual urine volume, reflex detrusor volume, bladder capacity, bladder compliance, and catheterization frequency (P<.01). Rate of incontinence episodes was reduced from 23% to 1.31% after BTX-A treatment. No significant decrease in max flow rate was observed (P=.403). CONCLUSIONS: Results of the meta-analysis indicate BTX-A is effective in treating NDO after SCI. The use of BTX-A was associated with a decrease in incontinence episodes, catheter use, and bladder pressures.

Arsenic urinary speciation in Mthfr deficient mice injected with sodium arsenate.

In most mammalian species, arsenic biotransformation occurs primarily by biomethylation and reduction reactions, with dimethylarsinic acid being the predominant metabolite excreted in the urine. Methylenetetrahydrofolate reductase (Mthfr) plays a key role in folate metabolism by channeling one-carbon units between nucleotide synthesis and methylation reactions. In the study on transgenic Mtfhr knockout mice we investigated: (1) whether Mthfr is an important determinant in arsenic biotransformation by performing urinary arsenic speciation, and (2) whether dietary folate deficiency alters arsenic biotransformation in these mice. The Mthfr mice fed folate replete or folate deficient diet were injected with sodium arsenate 1mg/kg, and placed in metabolic cages for a urine collection. The urine was analyzed for arsenic species. Additionally, folate and homocysteine plasma level was analyzed in Mthfr mice. When fed a folate control diet, the Mthfr(-/-) mice excreted significantly less of the total arsenic in urine than did the Mthfr(+/+) and Mthfr(+/-) mice. The Mthfr(-/-) had significantly lower levels of pentavalent arsenic in their urine than did the Mthfr(+/+)mice. The wild type mice excreted significantly less pentavalent arsenic when they were fed folate deficient diet comparing to control diet. The current data suggest that both the Mthfr status and food folate level modulate in a significant manner excretion of arsenic in mice, following intraperitoneal administration of sodium arsenate.

Initial characterization of mice null for Lphn3, a gene implicated in ADHD and addiction.

The LPHN3 gene has been associated with both attention deficit-hyperactivity disorder (ADHD) and addiction, suggesting that it may play a role in the etiology of these disorders. Unfortunately, almost nothing is known about the normal functions of this gene, which has hampered understanding of its potential pathogenic role. To begin to characterize such normal functions, we utilized a gene-trap embryonic stem cell line to generate mice mutant for the Lphn3 gene. We evaluated differential gene expression in whole mouse brain between mutant and wild type male littermates at postnatal day 0 using TaqMan gene expression assays. Most notably, we found changes in dopamine and serotonin receptors and transporters (Dat1, Drd4, 5Htt, 5Ht2a), changes in neurotransmitter metabolism genes (Th, Gad1), as well as changes in neural developmental genes (Nurr, Ncam). When mice were examined at 4-6 weeks of age, null mutants showed increased levels of dopamine and serotonin in the dorsal striatum. Finally, null mutant mice had a hyperactive phenotype in the open field test, independent of sex, and were more sensitive to the locomotor stimulant effects of cocaine. Considered together, these results suggest that Lphn3 plays a role in development and/or regulation of monoamine signaling. Given the central role for monoamines in ADHD and addiction, it seems likely that the influence of LPHN3 genotype on these disorders is mediated through alterations in monoamine signaling.

A meta-analysis of botulinum toxin sphincteric injections in the treatment of incomplete voiding after spinal cord injury.

OBJECTIVE: To conduct a systematic review and meta-analysis to examine the effect of injecting botulinum toxin A (BTX-A) into the detrusor sphincter on improving bladder emptying in individuals with spinal cord injury (SCI). DATA SOURCES: MEDLINE, CINAHL, EMBASE, and PsycINFO databases were searched for all relevant articles published from 1980 to September 2011. DATA SELECTION: All trials examining the use of BTX-A injections into the detrusor sphincter for the treatment for incomplete bladder emptying after SCI were included if at least 50% of the study sample comprised subjects with SCI, and if the SCI sample size was 3 or greater. DATA EXTRACTION: A standardized mean difference (SMD) ± SE and 95% confidence interval (CI) were calculated for each outcome of interest, and the results were pooled using a fixed or random effects model, as appropriate. Outcomes assessed included postvoid residual urine volume (PRV), detrusor pressure (PDet), and urethral pressure (UP). Effect sizes were interpreted as small, 0.2; moderate, 0.5; and large, 0.8. DATA SYNTHESIS: A relatively limited number of studies (2 randomized controlled trials, 6 uncontrolled trials) were identified. The 8 studies included results from 129 subjects. There was a statistically significant decrease in PRV at 1 month (SMD=1.119±.140; 95% CI, .844-1.394; P<.001), with a pooled mean PRV decrease from 251.8 to 153.0 mL. There was a moderate statistical effect on PDet (SMD=.570±.217; 95% CI, .145-.995; P=.009); pooled PDet decreased from 88.7 to 20.5 cmH(2)O. A large statistical effect size on UP (SMD=.896±.291; 95% CI, .327-1.466; P=.002) and an improvement from 119.7 to 102.3 cmH(2)O were seen. The systematic review also indicated a 50% reduction in urinary tract infections based on 3 studies. Discontinuation or reduction in catheter usage was reported in 4 studies after BTX-A. CONCLUSIONS: Results of the meta-analysis indicate that BTX-A is effective in reducing PRV and demonstrating a statistically significant reduction in PDet and UP 1 month postinjection. However, the clinical utility of BTX-A is yet to be determined.

Teratogenic effects of antiepileptic drugs.

Many antiepileptic drugs (AEDs) have therapeutic applications that extend beyond epilepsy to include neuropathic pain, migraine headaches and psychiatric disorders. The risk of some AEDs has been clearly established, but for newer drugs, small sample sizes and polytherapy exposures preclude a conclusive determination of their teratogenic potential. Most women with epilepsy will require AED therapy throughout their entire pregnancy to control seizures; the vast majority of pregnancies in women with epilepsy have positive outcomes. A conservative estimate suggests that AED monotherapy doubles, and polytherapy triples, the risk for major congenital malformations. Furthermore, while evidence is still accruing, recent investigations suggest that exposure to select AEDs results in altered cognitive function later in development. There is no evidence to suggest that additional folic acid supplementation ameliorates the increased risk of congenital malformations conferred by in utero AED exposure.