Search

This short fiction was published in New Writing on 27 March 2014 (online), available at http://dx.doi.org/10.1080/14790726.2014.899370

Background: Access to many controlled medicines is inadequate in a number of European countries. This leads to deficits in the treatment of moderate to severe pain as well as in opioid agonist therapy. Objective: The study objective was to elaborate the reasons for this inadequacy. The work plan of the Access to Opioid Medication in Europe (ATOME) project included two six-country workshops. These workshops comprised a national situational analysis, drafting tailor-made recommendations for improvement and developing action plans for their implementation. Methods: In total, 84 representatives of the national Ministries of Health, national controlled substances authorities, experts representing regulatory and law enforcement authorities, leading health care professionals, and patient representatives from 13 European countries participated in either one of the workshops. The delegates used breakout sessions to identify key common challenges. Content analysis was used for the evaluation of protocols and field notes. Results: A number of challenges to opioid accessibility in the countries was identified in the domains of knowledge and educational, regulatory, legislative, as well as public awareness and training barriers that limit opioid prescription. In addition, short validity of prescriptions and bureaucratic practices resulting in overregulation impeded availablity of some essential medicines. Stigmatization and criminalisation of people who use drugs remained the major impediment to increasing opioid agonist program coverage. Conclusions: The challenges identified during outcomes of the workshops were used as the basis for subsequent dissemination and implementation activities in the ATOME project, and in some countries the workshop proceedings already served as a stepping-stone for the first changes in regulations and legislation.

Exposure to microwave radiation enhances the aggregation of bovine serum albumin in vitro in a time- and temperature-dependent manner. Microwave radiation also promotes amyloid fibril formation by bovine insulin at 60 degrees C. These alterations in protein conformation are not accompanied by measurable temperature changes, consistent with estimates from field modelling of the specific absorbed radiation (15-20 mW kg(-1)). Limited denaturation of cellular proteins could explain our previous observation that modest heat-shock responses are induced by microwave exposure in Caenorhabditis elegans. We also show that heat-shock responses both to heat and microwaves are suppressed after RNA interference ablating heat-shock factor function.

Objective: To determine whether passive as well as active smoking by women or smoking by men is associated with delayed conception, after adjustment for confounding factors. Design: Population study of couples expecting a baby. Logistic regression was performed to identify factors associated with delayed conception. Setting: The Avon Health Authority area, United Kingdom. Patient(s): All couples expected to deliver between April 1991 and December 1992. Intervention(s): Questionnaires administered early in pregnancy. Main Outcome Measure(s): Time taken to conceive, categorized as 3 years. Result(s): After correction for confounding factors, delayed conception was statistically significantly associated with both active smoking by the woman (odds ratio [OR] 1.23 [95% CI 0.98–1.49] for > 6 months and 1.54 [95% CI 1.19–2.01] for >12 months) and her exposure to passive smoking (OR 1.17 [95% CI 1.02–1.37] and 1.14 [95% CI 0.92–1.42]) compared with women with no exposure to tobacco smoke (referent). Heavy smoking by men was independently associated with delayed conception. In active smokers, the effect increased with the number of cigarettes. Conclusion(s): Smoking by men and passive and active smoking by women are associated with delayed conception.

Aim To investigate the variations in sociodemographic characteristics of mothers in relation to the types of milk and supplementary drinks consumed by their infants at 4 and 8 months of age. Study design The carers of a randomly chosen population sample of over 1000 infants from the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC) were asked to record all foods and drinks consumed by the child in a 24-h period at both 4 and 8 months of age. Self-completion postal questionnaires were used to ascertain sociodemographic characteristics of the mothers and their infants. Methods Significant differences in the types of milks and supplementary drinks consumed within sociodemographic groups were identified. Infants were also grouped according to the types of milks they were receiving at each age and further differences in sociodemographic characteristics were investigated. Results Highly significant differences existed among various sociodemographic characteristics with regard to the types of drinks used at both ages. Maternal educational level was the most influential of the sociodemographic variables in explaining the differences in consumption of all types of drinks given at 4 months, in particular for breast milk use. Maternal age was also significantly associated with breast feeding. The use of fruit drinks was significantly associated with the presence of older siblings in the family and the use of herbal drinks with the duration of breast feeding. At 8 months of age maternal educational level was again the most highly associated of the sociodemographic variables, being significantly associated with the use of most of the drinks. The presence of older siblings also had a significant independent effect as did duration of breast feeding. The feeding of cows’ (or animal) milk as a main drink at 8 months, contrary to recommendation, was most likely in the group of mothers with vocational education, those in council accommodation, those with two or more children and those with difficulty affording food. Conclusion We have identified certain characteristics of mothers who were more likely than others not to follow current recommendations on infant feeding. The educational level of mothers appears to be of major significance in the choices made about the types of drinks given to infants. It may be possible to target information about infant feeding to certain groups of mothers thus improving weaning patterns.

Objective To investigate the possible role of the maternal diet, particularly vegetarianism and consumption of phytoestrogens, in the origin of hypospadias, which is reported to be increasing in prevalence. Subjects and methods Detailed information was obtained prospectively from mothers, including previous ob-stetric history, lifestyle and dietary practices, using structured self-completed questionnaires during pregnancy. Previously recognized associations with en-vironmental and parental factors were examined, focusing particularly on the hypothesized hormonal link. Multivariate logistic regression was used to identify independent associations. Results Of 7928 boys born to mothers taking part in the Avon Longitudinal Study of Pregnancy and Childhood, 51 hypospadias cases were identified. There were no significant differences in the proportion of hypospadias cases among mothers who smoked, consumed alcohol or for any aspect of their previous reproductive history (including the number of previous pregnancies, number of miscarriages, use of the contraceptive pill, time to conception and age at menarche). Significant differences were detected for some aspects of the maternal diet, i.e. vegetarianism and iron supplementation in the first half of pregnancy. Mothers who were vegetarian in pregnancy had an adjusted odds ratio (OR) of 4.99 (95% confidence interval, CI, 2.10–11.88) of giving birth to a boy with hypospadias, compared with omnivores who did not supplement their diet with iron. Omnivores who supplemented their diet with iron had an adjusted OR of 2.07 (95% CI, 1.00–4.32). The only other statistically significant association for hypospadias was with influenza in the first 3 months of pregnancy (adjusted OR 3.19, 95% CI 1.50–6.78). Conclusion As vegetarians have a greater exposure to phytoestrogens than do omnivores, these results support the possibility that phytoestrogens have a deleterious effect on the developing male reproductive system.

Multivariate analysis of diet among three-year-old children and associations with socio-demographic characteristics

In Britain the government is currently proposing legislation that will encourage welfare recipients to gain employment. A central tenet of this 'welfare to work' policy is that employment will not only reduce the poverty of welfare recipients, but also improve their health. This research assessed the extent to which the movement from 'welfare to work' is likely to benefit the mental and physical health of lone mothers with preschool children. The sample was 719 lone mothers and a comparison group of 8779 women with partners drawn from the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC). Data collected by self completion questionnaire at 33 months postpartum provided information about average weekly take home family income and the mother's employment status. The health outcomes measured were general well being, both minor and major depression (using the Edinburgh Postnatal Depression Scale), self report of respiratory symptoms (cough/cold, wheeze, influenza) from 18-33 months postpartum and self report of symptoms common in the childbearing years (backache, haemorrhoids) also from 18-33 months postpartum. Lone mothers who were not employed were the poorest group in the sample; 94% of this group (402) had a family income of less than pound sterling 200 per week, compared with 72% (188) of lone mothers who were employed, 25% (905) of partnered women who were not employed and 12% (466) of partnered women who were employed. Lone mothers were significantly more likely than women with partners to report poorer well being (chi2 = 11.7, df = 3, P = 0.01), to have a major depressive disorder (chi2 = 92.6, df = 1, P = 0.0001) and to report wheeze (chi2 = 31.1, df = 1, P = 0.0001), but significantly less likely to report cough/cold (chi2 = 9.9, df = 1, P = 0.0001) or haemorrhoids (chi2 = 16.6, df = 1, P = 0.0001). Lone mothers who were unemployed and living on less than pound sterling 100 per week were significantly more likely to be depressed (chi2 = 3.9, df = 1, P = 0.05) than those who were employed and living on pound sterling 200 or more per week, and significantly less likely to report cough/cold (chi2 = 3.8, df = 1, P = 0.05). Logistic regression analyses showed no significant independent association between employment and better health for lone mothers. Rather, when compared with lone mothers who were not working, those who were employed were more likely to report minor respiratory symptoms such as cough/cold (OR = 1.51, 95% CI = 1.00,2.31). Overall, the results suggested that the movement from 'welfare to work' is unlikely to improve the health of lone mothers.

Objectives: To examine the relation between pertussis vaccination and the prevalence of wheezing illnesses in young children. Design: Prospective cohort study. Setting: Three former health districts comprising Avon Health Authority. Subjects: 9444 of 14 138 children enrolled in the Avon longitudinal study of pregnancy and childhood and for whom data on wheezing symptoms, vaccination status, and 15 environmental and biological variables were available. Main outcome measures: Episodes of wheezing from birth to 6 months, 7-18 months, 19-30 months, and 31-42 months. These time periods were used to derive five categories of wheezing illness: early wheezing (not after 18 months); late onset wheezing (after 18 months); persistent wheezing (at every time period); recurrent wheezing (any combination of two or more episodes for each period); and intermittent wheezing (any combination of single episodes of reported wheezing). These categories were stratified according to parental self reported asthma or allergy. Results: Unadjusted comparisons of the defined wheezing illnesses in vaccinated and non-vaccinated children showed no significant association between pertussis vaccination and any of the wheezing outcomes regardless of stratification for parental asthma or allergy. Wheeze was more common in non-vaccinated children at 18 months, and there was a tendency for late onset wheezing to be associated with non-vaccination in children whose parents did not have asthma, but this was not significant. After adjustment for environmental and biological variables, logistic regression analyses showed no significant increased relative risk for any of the wheezing outcomes in vaccinated children: early wheezing (0.99, 95% confidence interval 0.80 to 1.23), late onset wheezing (0.85, 0.69 to 1.05), persistent wheezing (0.91, 0.47 to 1.79), recurrent wheezing (0.96, 0.72 to 1.26), and intermittent wheezing (1.06, 0.81 to 1.37). Conclusions: No evidence was found that pertussis vaccination increases the risk of wheezing illnesses in young children. Further follow up of this population with objective measurement of allergy and bronchial responsiveness is planned to confirm these observations.

Our project, which concluded in 2015, aimed to improve the quality of life of children with life limiting illnesses in Maharashtra State in India, and nationwide in Malawi. Central to the project design was a multi team approach of engaging with expert model providers of children’s palliative care, global experts in children’s palliative care, national palliative care associations, and crucially, the children themselves. Six new sites were identified as being suitable for the incorporation of children’s palliative care into their existing service. The in-country team then developed and delivered training and mentorship to these new sites, building their capacity for children’s palliative care service delivery. The project also focused on advocacy to change restrictive policy, raise awareness and push for sustainable change. It was important to the project team that there was a strong element of beneficiary engagement with the project, both to strengthen the quality of the service and to provide a direct voice to policy makers. 4294 new children received palliative care in the six additional sites over the project period. Children in each setting joined ‘Empowerment Groups’ where they could share their experiences and discuss the changes to the services that were happening around them. These groups had a strong effect on the project, improving confidence and understanding both among the children and their carers, a feeling of support and shared experience. In one setting, the children’s group met directly with the minister of health and inspired her commitment to supporting palliative care for children. The groups gave direct feedback to service providers, allowing for changes in the approach. The empowerment groups were credited with increasing demand for services as caregivers were keen to share their knowledge in the community and in some cases, conducting active case finding and referral to the new services.

Bangladesh is a low income country. In the urban slums of Bangladesh, poverty makes the impact of life-limiting conditions devastating on family and community members. Communities that are already impoverished and marginalised are caring for each other without support, their ability to earn income taken away and without basic necessities. Palliative care services in the urban slum communities have not yet been developed. There are very few, if any, community palliative care projects focussed on older people in urban slums around the world. Together with our partners, we have started a pilot project to address this issue and demonstrate an effective model of palliative care for older people within an urban slum. We are undertaking a situation and needs analysis of the palliative care needs of older people and their carers and the current care provision by family members, community members and organisations. Over the next few months we will be: Running sensitisation programmes in the slums, to increase understanding and awareness of the need for palliative care. Recruiting eight assistants from the slum community, training them in palliative care. The assistants will be responsible for identifying people in need and for providing basic palliative care in their homes. Linking Palliative Care Nurses with the Community assistants to guide and mentor their activities. Linking up with other community health workers, organisations and groups working in the slums to better meet the holistic needs identified. At the mid-point of the project in November we will discuss how this approach is helping provide palliative care outreach services to at least 100 older people and their families in their homes. We will take a critical view of the initial six months of the project and will share our lessons of what has and hasn’t worked in that time.

Background Children’s Palliative Care Project of Indian Association of Palliative Care in Maharashtra, India, worked to increase government commitment to improve quality of life of children with life limiting conditions. Hospice UK, ICPCN-South Africa and Tata Memorial Centre, Mumbai were providing guidance and mentorship. The project was funded by DFID, UK. It aimed to set up three model sites in three different settings. The health care workers were given structured training. Educational material was developed. Aim To assess the needs of children and measure impact of services To plan strategies in quality care and To advocate the need of Children’s Palliative Care Approach used Focus group discussions, one to one interactions and quality of life questionnaires were used to assess the needs and issues faced by children and their families. The inputs were used to plan future strategies and provide quality care by networking with hospitals, orphanages and organisations. Findings Children and caregivers need proper information about diagnosis and prognosis. Needs vary according to the disease trajectories: Caregivers in rural settings cannot afford to lose their daily wages. So children with CP, MR are neglected. Because of the remote geographical locations children cannot be taken to the rehabilitation facilities regularly. In spite of poverty and lack of facilities, caregivers are reluctant to keep the child away from the family. Conclusion Need assessment helps to plan the care. Conventional concept of ‘Hospice’ may not be culturally acceptable by the caregivers. So different models of hospice care may be necessary for different conditions. Hospice care provides solace to patients and their caregivers and can be provided in terms of respite care, rehabilitation, home care and end of life care. Ideally there has to be a set up where all facilities are provided.

Introduction This project brings together partners from India, South Africa, Malawi and the UK to expand children’s palliative care services in Maharashtra state in India and in Malawi. The project results have prompted commitment to palliative care service development above and beyond the original project scope. It demonstrates how international partnerships can inspire and promote others to take on palliative care to meet the huge need for palliative care around the world. Methods The project uses international donor funds to integrate children’s palliative care into existing services in both urban and rural settings. Each partner brings to the project distinct skills and experience; ranging from project and donor management, paediatric palliative care knowledge, training and mentorship expertise, and advocacy skills. Results The mix of these skills has seen the following key results: The development of children’s palliative care services in 5 new settings. The integration of children’s palliative care into health service curricula. The inclusion of children’s palliative care in draft palliative care policy. The project has also prompted extended impact: The National Rural Health Mission (Jawhar, India) has committed to a wider programme of palliative care service delivery and is already funding training, staff and services. District hospitals in Malawi are showing strong interest in developing palliative care services Project stakeholders are increasingly seeking extra funding and gifts in kind to support and develop children’s palliative care services. Discussion The collaborative implementation of this project has proved to be a catalyst for further development of palliative care than originally anticipated. We would like to share our collaborative approach, together with more detailed results to inspire and encourage others to engage in partnerships to maximise impact and rise to the great challenge of meeting the huge need for palliative care internationally.

Introduction The project aims to support the development of children’s palliative care services across Malawi. The project aims to integrate children’s palliative care into existing service provision in 3 central hospitals. Aims In this piece of work within the project, the project team aim to empower children and their guardians to be involved in, and inform, decisions that are made about the provision of paediatric palliative care, at local and national level. Methods Regular empowerment workshops and focus group meetings are held with project beneficiaries (children and their guardians). An advocacy meeting was between child beneficiaries and the Minister for Health for Malawi. Learning and Results Empowerment meetings have resulted in patients and guardians feeling more informed about the care they receive and more in control. Focus group discussions with beneficiaries have resulted in changing practice at the services themselves. Empowerment meetings have been most successful when participants identify their own key concerns and have the space to explore solutions with others. Experience sharing and testimonies have played a great part in encouraging and learning from each other. The workshop with the project beneficiaries and Minister for Health allowed policy makers to hear first hand the experience of those living with life-limiting illnesses resulted in the minister pledging support to children’s palliative care in Malawi. The project is of interest to others who are working to support development of children’s palliative care. We would like to share our approach and learning with others, and to encourage discussion about participation and empowerment in any palliative care setting.

ObjectiveTo document the type and volume of drinks given to infants and investigate whether giving supplementary drinks leads to reduced milk consumption.DesignCarers were asked to record all drinks consumed by the infants in a 24-hour period at two ages, detailing the types and volume taken.SettingThe Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC).SubjectsA randomly chosen population sample of over 1000 infants at 4 and 8 months of age.ResultsThe different types of milk feed were used to group infants, compare volumes consumed and look at the use of non-milk drinks. The average volume of drinks consumed over 24 hours at 4 months was 861 ml and at 8 months was 662 ml. At 4 months 69.7% consumed infant formula and 43.0% breast milk. The mean volume of milk consumed by those having only formula was 802 ml and for those having only breast milk was estimated at 850 ml. The volumes of milks consumed were slightly lower in the groups who also had supplementary drinks. A quarter of infants were given fruit drinks and 14.6% herbal drinks. Supplementary drinks and solids were more likely to be given to formula-fed than breast-fed infants. At 8 months, formula milk was consumed by 71.4% and breast milk use had decreased (22.9%) but fruit drink use had increased (squash/cordial: 55.8%, fruit juice: 14.9%), with 13.9% of infants having no infant milk at all. More infants were fed formula milk and less were fed cows' milk compared with a nationally representative British study conducted 5 years earlier.ConclusionsMany infants were given supplementary drinks by 4 months; there is some evidence that this led to a small reduction in milk intake. A minority were not being given infant milks at all by 8 months, contrary to British infant feeding recommendations.