FACT effectiveness in primary care; a single visit RCT for depressive symptoms.

BACKGROUND: Patients with depressive symptoms are common in primary care. Brief, simple therapies are needed. AIM: Is a focussed acceptance and commitment therapy (FACT) intervention more effective than the control group for patients with depressive symptoms in primary care at one week follow up?Design and setting: A randomised, blinded controlled trial at a single primary care clinic in Auckland, New Zealand. METHODS: Patients presenting to their primary care practice for any reason were recruited from the clinic waiting room. Eligible patients who scored ≥2 on the PHQ-2 indicating potential depressive symptoms were randomised using a remote computer to intervention or control groups. Both groups received a psychosocial assessment using the "work-love-play" questionnaire. The intervention group received additional FACT-based behavioural activation activities. The primary outcome was the mean PHQ-8 score at one week. RESULTS: 57 participants entered the trial and 52 had complete outcome data after one week. Baseline PHQ-8 scores were similar for intervention (11.0) and control (11.7). After one week, the mean PHQ-8 score was significantly lower in the intervention group (7.4 vs 10.1 for control; p<0.039 one sided and 0.078 two sided). The number needed to treat to achieve a PHQ-8 score ≤6 was 4.0 on intention to treat analysis (p = 0.043 two sided). There were no significant differences observed on the secondary outcomes. CONCLUSION: This is the first effectiveness study to examine FACT in any population. The results suggest that it is effective compared with control, at one week, for patients with depressive symptoms in primary care.

Controlled before-after intervention study of suburb-wide street changes to increase walking and cycling: Te Ara Mua-Future Streets study design.

BACKGROUND: Achieving a shift from car use to walking, cycling and public transport in cities is a crucial part of healthier, more environmentally sustainable human habitats. Creating supportive active travel environments is an important precursor to this shift. The longevity of urban infrastructure necessitates retrofitting existing suburban neighbourhoods. Previous studies of the effects of street changes have generally relied on natural experiments, have included few outcomes, and have seldom attempted to understand the equity impacts of such interventions. METHODS: In this paper we describe the design of Te Ara Mua - Future Streets, a mixed-methods, controlled before-after intervention study to assess the effect of retrofitting street changes at the suburb scale on multiple health, social and environmental outcomes. The study has a particular focus on identifying factors that improve walking and cycling to local destinations in low-income neighbourhoods and on reducing social and health inequities experienced by Maori (Indigenous New Zealanders) and Pacific people. Qualitative system dynamics modelling was used to develop a causal theory for the relationships between active travel, and walking and cycling infrastructure. On this basis we selected outcomes of interest. Together with the transport funder, we triangulated best evidence from the literature, transport policy makers, urban design professionals and community knowledge to develop interventions that were contextually and culturally appropriate. Using a combination of direct observation and random sample face to face surveys, we are measuring outcomes in these domains of wellbeing: road-user behaviour, changes to travel mode for short trips, physical activity, air quality, road traffic injuries, greenhouse gas emissions, and perceptions of neighbourhood social connection, safety, and walking and cycling infrastructure . DISCUSSION: While building on previous natural experiments, Te Ara Mua - Future Streets is unique in testing an intervention designed by the research team, community and transport investors together; including a wide range of objective outcome measures; and having an equity focus. When undertaking integrated intervention studies of this kind, a careful balance is needed between epidemiological imperatives, the constraints of transport funding and implementation and community priorities, while retaining the ability to contribute new evidence for healthy, equitable transport policy. The study was retrospectively registered as a clinical trial on 21 June 2018 in the ISCRTN registry: ISRCTN89845334 http://www.isrctn.com/ISRCTN89845334.

Mechanical properties and innervation of the smooth muscle layers of the urethra of greyhounds.

OBJECTIVE: To investigate the properties of the smooth muscle layers in the urethral wall of male and female greyhounds, and to consider their roles in continence and micturition. MATERIALS AND METHODS: The distribution and innervation of the smooth muscle layers of the prostate capsule and membranous urethra of male greyhounds were assessed. Strips of smooth muscle from these regions were used to determine the neuropharmacological properties by assessing the excitatory and inhibitory responses to nerve stimulation, and the effects of blocking agents. These were compared with strips from the proximal urethra and from the female urethra. RESULTS: The smooth muscle of the membranous urethra comprised 9% of the wall and received its innervation exclusively in branches from the pelvic plexus. The cholinergic innervation in the male produced 80% of the total contractile response in the longitudinal membranous urethra, 50% in the prostate capsule and 13% in the circular muscle of the proximal urethra. In the female all areas had poor contractile responses. Inhibitory fibres produced relaxation in all parts of male and female urethrae with the major effect caused by nitric oxide. Adrenergic nerves contributed to both residual excitation (alpha receptors) and inhibition (beta receptors). CONCLUSIONS: The longitudinal smooth muscle of the male membranous urethra probably shortens the urethra during micturition, through the activity of cholinergic nerves, whereas the circular smooth muscle of the proximal urethra, under adrenergic control, may be contracted during continence and ejaculation. In the female, the smooth muscle plays a minor role.

The innervation and properties of the urethral striated muscle.

The striated muscle forms an outer sleeve around the urethra and occupies about 80% of the wall. In humans more than 60% of the muscle consists of slow, fatigue resistant type I fibres whereas in male greyhounds only about 6% are type I. Most of the remainder (70% of fibres) are type IIa which are classified as fast but can contract for several hours with little decline in amplitude. Stimulation of pudendal but not pelvic nerves produces contraction of the striated muscle and a rapid increase in urethral pressure. Pelvic nerve branches enter the striated muscle sleeve but pass through it to supply the inner layer of smooth muscle. The striated muscles are well suited to maintain contraction necessary for continence.

Continence and some properties of the urethral striated muscle of male greyhounds.

OBJECTIVE: To determine the properties of the striated muscle of the greyhound (dog) urethra and to consider its role in maintaining continence. Materials and methods The thickness of the muscle layers and the muscle types were determined by examining sections stained with haematoxylin and eosin or Masson's trichrome. These factors were correlated with the mechanical and electrical responses of muscle strips to nerve stimulation, and compared with muscle from other breeds of dog and other parts of the animal. RESULTS: The striated muscle formed approximately 70% of the membranous urethra and was predominantly (68%) type IIa muscle (i.e. fast but fatigue-resistant). The mean resting membrane potential was -74 mV; nerve stimulation produced an action potential with a mean amplitude of 97 mV and contraction lasting about 200 ms. All responses were abolished by D-tubocurarine. The contractions were well maintained with continuous or intermittent stimulation. The properties were intermediate between those of the anconeus (slow) and the extensor carpi radialis (fast) muscles. CONCLUSIONS: The distribution, fibre type and contractile characteristics would enable the striated urethral muscle to maintain tension for continence at rest and provide additional continence during sprints.

Innervation of the striated muscle of the membranous urethra of the male dog.

PURPOSE: To identify the functional innervation of the striated muscle layer of the post-prostatic urethra of male dogs. MATERIALS AND METHODS: Detailed anatomic dissection of the pelvic and pudendal nerves was carried out. The pressure and contractile responses to stimulation of these nerves were recorded in vivo and in vitro. RESULTS: Small branches of the pelvic nerve entered the membranous urethra but passed through the striated muscle to the inner smooth muscle layer. Stimulation of the nerve with 1 msec pulses at 10 Hz produced a slow contraction of the urethra which was unaffected by d-tubocurarine. Pudendal nerve branches entered the striated layer from the caudal end. Stimulation produced a rapid, visible contraction that was abolished by d-tubocurarine. Field stimulation of isolated strips of striated muscle resulted only in rapid, d-tubocurarine sensitive contractions. CONCLUSIONS: The striated muscle of the membranous urethra is innervated exclusively by the pudendal nerve.

The 'urogenital diaphragm', external urethral sphincter and radical prostatectomy.

BACKGROUND: The present study was performed to determine whether a 'urogenital diaphram' exists, to examine the true nature of the striated external urethral sphincter and to evaluate whether the standard technique for radical prostatectomy damages the external sphincter. METHODS: Fifty radical prostatectomies were performed using optical magnification and the dorsal bunching technique, and the external sphincter was carefully examined. Ten human cadavers and one 5-year-old baboon were dissected with longitudinal (sagittal) and transverse sections being taken through the prostate apex, membranous and bulbar urethrae. During the standard technique for dorsal vein control during radical prostatectomy, the tissue incorporated within the ligature was examined for striated muscle. RESULTS: No 'urogenital diaphragm' could be demonstrated in any human or baboon tissue. The striated external urethral sphincter is a cylinder of muscle surrounding the membranous urethra, extending from the perineal membrane to the prostate and continuing over the prostate as part of the anterior fibromuscular stroma. Striated muscle was present in the ligated material from the dorsal venous complex. CONCLUSIONS: The 'urogenital diaphragm' is a myth. The standard technique of radical prostatectomy significantly damages the external sphincter.