Leg-ulcer care in the community,before and after implementation of an evidence-based service

Background

Leg ulcers usually occur in older patients, a growing population for which increasing health care resources are required. Treatment is mainly provided in patients'' homes; however, patients often receive poorly integrated services in multiple settings. We report the results of a prospective study of a community-based care strategy for leg ulcers.

Methods

International practice recommendations and guidelines were adapted to make a new clinical protocol. The new model, for a dedicated service staffed by specially trained registered nurses, established initial and ongoing assessment time frames and provided enhanced linkages to medical specialists. Data were collected for 1 year before and after implementation; outcome measures included 3-month healing rates, quality of life and resource usage.

Results

Three-month healing rates more than doubled between the year before implementation (23% [18/78]) and the year afterward (56% [100/180]). The number of nursing visits per case declined, from a median of 37 to 25 (p = 0.041); the median supply cost per case was reduced from $1923 to $406 (p = 0.005).

Interpretation

Reorganization of care for people with leg ulcers was associated with improved healing and a more efficient use of nursing visits.Although not always recognized as a pressing health care problem, leg ulcers are a common, complex, and costly condition. International studies have shown that their occurrence increases with age.^1,2,3,4,5 Chronic ulcers are an ongoing burden to patients and to the health care system.^6,7,8,9,10 Patients tend to receive poorly integrated services in multiple settings.The Ottawa Community Care Access Centre, an eastern Ontario home-care authority, observed a pattern of yearly increases in the resources required to care for people with chronic wounds. Researchers from Queen''s University, Ottawa University and 3 nursing agencies undertook a comprehensive regional needs assessment to understand the population and the care environment. They documented an estimated prevalence of 1.8 cases of leg ulcer per 1000 population, an incidence comparable to rates reported from other countries.¹¹Profile information revealed a population complex in terms of health problems and care challenges. Most patients were over 65 years in age; nearly three-quarters had 3 or more other conditions. Over two-thirds had experienced leg ulcers for many months. Half of the affected population had a leg-ulcer history spanning 5–10 years; a third, exceeding 10 years. Our 4-week costing study¹² estimated that 192 people receiving care would annually consume $1 million in nursing care services and $260 000 in wound-care supplies.Home care nurses and family physicians had varying levels of confidence in managing patients with leg ulcers.^13,14 In general, they were unaware of the relative effectiveness of compression therapy for venous leg ulcers, i.e., that 1 of 6 patients so treated would heal (95% confidence interval [CI] 4–18).^15,16 Practice audits indicated that assessments were not standardized: ultrasound readings of the ankle brachial pressure index (measured with a hand-held Doppler) to rule out arterial disease were not routine; serial measurements of ulcers were carried out inconsistently; and compression bandaging, the standard of care for venous ulcers, was underutilized and yet also occasionally applied inappropriately to ulcers with arterial involvement.¹⁷The researchers and organizations involved collaborated and fed information back and forth, generating regional data which, when combined with available external evidence, provided information appropriate to the local community. Regional decision-makers agreed to a redesign of the delivery of care to these patients, based on that information. This involved changing to a nurse-led service providing clinical care in accordance with a set of evidence-based guidelines.^18,19,20 The objective of our study was to determine and compare the health outcomes and efficiencies of the former and new services.     

Development and implementation of evidence-based guidelines for IV insulin: A statewide collaborative approach

Purpose: Recent studies have shown that the outcomes of hospitalized patients are greatly enhanced when steps are taken to improve control of their blood glucose levels. The Georgia Hospital Association Research and Education Foundation's Partnership for Health Accountability established a Diabetes Special Interest Group (D-SIG) in February 2003. Goals of the D-SIG were to enlighten health care professionals in Georgia hospitals about the benefits of controlling hyperglycemia in hospitalized patients and to develop processes to assist hospitals in the adoption of an IV insulin dosing algorithm, development of an IV insulin standing order set, and implementation of a hyperglycemia management plan.Methods: The D-SIG created an assessment tool titled “Key Elements of IV Insulin Guidelines” and evaluated numerous published IV insulin administration algorithms and protocols. After an extensive literature review, including international protocols and guidelines, user-friendly guidelines for subcutaneous and IV insulin were developed by a multidisciplinary work group, with members representing hospitals and other stakeholders from throughout the state. The group chose a well-researched method that was available in both computerized and hand-calculated formats and developed a Columnar Insulin Dosing Chart to assist with IV insulin infusions. This insulin-infusion table stems from mathematical formulas published by multiple investigators since the 1980s. The D-SIG guidelines and dosing chart were evaluated for ease of use, effectiveness, and safety in 3 settings: a small, rural critical-access hospital (CAH); an intensive care unit (ICU) in the trauma center of a large Georgia teaching hospital; and a surgical ICU in a midsize metropolitan hospital.Results: After implementation of the guidelines, the incidence of hypoglycemia (blood glucose level <60 mg/dL) was 0.9% in the trauma center ICU and 0.6% in the surgical ICU. All hypoglycemic patients in these 2 settings were asymptomatic, remained hypoglycemic only for a short time, and experienced no complications attributable to hypoglycemia. Using a moderate insulin sensitivity level for dosing initiations resulted in a time to target blood glucose level (80–110 mg/dL) of 6.4 hours, whereas using the most conservative approach required 12.8 hours to attain target range. At the CAH, time to reach the target blood glucose level (90–140 mg/dL) was 5.8 hours, and no episodes of hypoglycemia were reported. Although not part of the pilot initiative, the surgical ICU also reported a 5-fold reduction in surgical infection rates. The success of the dosing chart and standing order set paralleled that of the computerized formula when similar initiation doses were used.Conclusions: The Columnar Insulin Dosing Chart and sample clinical guidelines were piloted at 3 different settings and found to be safe and effective. Furthermore, by including the treatment for hypoglycemia in the guidelines, nurses in all patient care areas were able to manage blood glucose levels below the target range in a safe and timely manner. Use of the dosing chart and guidelines reduced blood glucose levels to the target range with no clinically significant hypoglycemia.     

Evaluation of evidence-based literature and formulation of recommendations for the clinical preventive guidelines for immigrants and refugees in Canada

Background:

This article describes the evidence review and guideline development method developed for the Clinical Preventive Guidelines for Immigrants and Refugees in Canada by the Canadian Collaboration for Immigrant and Refugee Health Guideline Committee.

Methods:

The Appraisal of Guidelines for Research and Evaluation (AGREE) best-practice framework was combined with the recently developed Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to produce evidence-based clinical guidelines for immigrants and refugees in Canada.

Results:

A systematic approach was designed to produce the evidence reviews and apply the GRADE approach, including building on evidence from previous systematic reviews, searching for and comparing evidence between general and specific immigrant populations, and applying the GRADE criteria for making recommendations. This method was used for priority health conditions that had been selected by practitioners caring for immigrants and refugees in Canada.

Interpretation:

This article outlines the 14-step method that was defined to standardize the guideline development process for each priority health condition.Primary care practitioners who care for recently arrived immigrants and refugees have raised concerns over the lack of evidence-based guidelines for clinical prevention, noting that it is not always clear whether current recommendations made for the general population in Canada can be generalized to this population. In 2006, the Canadian Collaboration for Immigrant and Refugee Health (CCIRH) Guideline Committee was formed to address this issue by first identifying the top-priority health conditions for this population. The group of 20 health conditions identified was very diverse ranging from infectious disease to chronic conditions including depression. The challenge was creating a rigorous interdisciplinary process and then to generate pragmatic recommendations. This document outlines the systematic approach designed to produce the evidence reviews.A variety of methods is used for developing clinical guidelines and practice recommendations.¹ We used the recently developed approach of moving away from recommendations classified by letters and numbers to the simplified classification system recommended by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group² and applied this to clinical preventive actions. Our guideline development process followed the Appraisal of Guidelines Research & Evaluation (AGREE) instrument (www.agreetrust.org), which is recognized internationally as providing best-practice criteria for evidence-based guideline development.We developed the recommendations on the basis of a pre-specified process overseen by the CCIRH Guideline Committee. Defining a methods process ensured that each guideline was developed in a systematic, reproducible manner and was based on the best evidence available. This process was based on existing guidelines including the Canadian Medical Association Journal handbook on developing clinical practice guidelines¹ and the ADAPTE framework for adapting existing guidelines.³ Our process emphasized identifying immigrant- and refugee-specific evidence on efficacy and population characteristics from guidelines, systematic reviews and primary studies. When immigrant- and refugee-specific evidence was unavailable, we used specific criteria, adapted from the Cochrane Handbook,⁴ to judge how this evidence applied to our intended target population.Conditions considered most important by practitioners caring for immigrants and refugees in Canada were assigned to groups of content experts to develop evidence reviews with clinical conclusions for recent immigrants and refugees to Canada using a logic model and following a structured 14-step process. The guidelines focus on clinical care gaps¹ during the “health settlement period,” which we define as the first five years of residence in a new country for an immigrant or refugee. This is the time in which health practitioners are likely to have initial contact with this population and the time during which stressors from one’s country of origin and country of settlement are most likely to manifest. Immigrants and refugees are thus grouped together by this organizing period of resettlement; however, the heterogeneity, complexities, and differences between and within these groups were recognized throughout the process.In our process, we emphasized making clinically relevant recommendations and establishing an extension to existing guidelines rather than a replacement or revision.     

Enhanced implementation of low back pain guidelines in general practice: study protocol of a cluster randomised controlled trial

Implementation of evidence-based practice (EBP) is regarded as core competence to improve healthcare quality. In the current study, we investigated the EBP of six groups of professionals: physicians, nurses, pharmacists, physical therapists, technicians, and other allied healthcare personnel. A structured questionnaire survey of regional hospitals throughout Taiwan was conducted by post in 2011. Questionnaires were mailed to all healthcare workers of 11 randomly selected hospitals. Linear and logistic regression models were used to examine predictors for implementing EBP. In total, 6,160 returned questionnaires, including 645 from physicians, 4,206 from nurses, 430 from pharmacists, 179 from physical therapists, 537 from technicians, and 163 from other allied healthcare professionals, were valid for the analysis. Physicians and pharmacists were more aware of EBP than were the other professional groups (p < 0.001). Positive attitudes toward and beliefs in EBP were significantly lower among nurses than in the other groups (p < 0.001). Physicians had more sufficient knowledge and skills of EBP than did the other professionals (p < 0.001); in addition, they implemented EBP for clinical decision-making more often and perceived fewer personal barriers to EBP (p < 0.001). Multivariate logistic regression analyses showed that EBP implementation was associated with the following characteristics of participants: EBP training, having a faculty position, academic degree, one's profession, and perceptions (beliefs, attitudes, knowledge, skills and barriers). This study depicts various levels of EBP implementation among medical, nursing, pharmacological, and allied healthcare personnel. There were significant differences in their implementation of EBP. We observed that certain factors were associated with EBP implementation, including personal backgrounds and perceptions toward EBP. The data suggest that strategies for enhancing EBP implementation should differ for various groups of professionals.     

Implementing international osteoarthritis treatment guidelines in primary health care: study protocol for the SAMBA stepped wedge cluster randomized controlled trial

Background

Previous research indicates that people with osteoarthritis (OA) are not receiving the recommended and optimal treatment. Based on international treatment recommendations for hip and knee OA and previous research, the SAMBA model for integrated OA care in Norwegian primary health care has been developed. The model includes physiotherapist (PT) led patient OA education sessions and an exercise programme lasting 8–12 weeks. This study aims to assess the effectiveness, feasibility, and costs of a tailored strategy to implement the SAMBA model.

Methods/design

A cluster randomized controlled trial with stepped wedge design including an effect, process, and cost evaluation will be conducted in six municipalities (clusters) in Norway. The municipalities will be randomized for time of crossover from current usual care to the implementation of the SAMBA model by a tailored strategy. The tailored strategy includes interactive workshops for general practitioners (GPs) and PTs in primary care covering the SAMBA model for integrated OA care, educational material, educational outreach visits, feedback, and reminder material. Outcomes will be measured at the patient, GP, and PT levels using self-report, semi-structured interviews, and register based data. The primary outcome measure is patient-reported quality of care (OsteoArthritis Quality Indicator questionnaire) at 6-month follow-up. Secondary outcomes include referrals to PT, imaging, and referrals to the orthopaedic surgeon as well as participants’ treatment satisfaction, symptoms, physical activity level, body weight, and self-reported and measured lower limb function. The actual exposure to the tailor made implementation strategy and user experiences will be measured in a process evaluation. In the economic evaluation, the difference in costs of usual OA care and the SAMBA model for integrated OA care will be compared with the difference in health outcomes and reported by the incremental cost-effectiveness ratio (ICER).

Discussion

The results from the present study will add to the current knowledge on tailored strategies, which aims to improve the uptake of evidence-based OA care recommendations and improve the quality of OA care in primary health care. The new knowledge can be used in national and international initiatives designed to improve the quality of OA care.

Trial registration

ClinicalTrials.gov NCT02333656

     

Changes in fatty-acid composition of body fat before and after birth in Tanzania: an international comparative study.

Changes in the fatty-acid composition of human adipose tissue before birth and during infancy and childhood were studied in Tanzania and compared with data for British and Dutch infants in relation to their diet. From the 32nd to the 37th week of gestation in Tanzania the proportion in the body fat of the unsaturated fatty acid linoleic acid tended to rise, suggesting an adequate supply of this essential fatty acid from the mother to the fetus. At term 2.5% of the total fatty acids of the body fat was linoleic acid, which corresponded with values in Dutch newborn infants but was significantly higher than those in British infants. During infancy in Tanzania the composition of the fat showed a dramatic increase in the proportions of the saturated fatty acids lauric acid and myristic acid, which did not occur in Dutch and British infants. The proportion of linoleic acid increased to 8%. These changes were a reflection of the fatty-acid composition of the fat in the human milk that the infants received. During weaning (1-2 years of age) the fatty-acid composition changed only slightly. The specific fatty-acid composition of the fat in Tanzanian breast milk may have a beneficial influence on the extent of intestinal absorption in the newborn child.     

Effectiveness of a regional trauma system in reducing mortality from major trauma: before and after study.

OBJECTIVE: To assess the effect of the development of an experimental trauma centre and regional trauma system on the survival of patients with major trauma. DESIGN: Controlled before and after study examining outcomes between 1990 and 1993, spanning the introduction of the system in 1991-2. SETTING: Trauma centre in North Staffordshire Royal Infirmary and five associated district general hospitals in the North West Midlands regional trauma system, and two control regions in Lancashire and Humberside. SUBJECTS: All trauma patients taken by the ambulance services serving the regions or arriving other than by ambulance with injury severity scores > 15, whether or not they had vital signs on arrival at hospital. MAIN OUTCOME MEASURES: Survival rates standardised for age, severity of injury, and revised trauma score. RESULTS: In 1990, 33% of major trauma patients in the experimental region were taken to the trauma centre, and by 1993 this had risen to only 39%. Crude death rates changed by the same amount in the control regions (46.5% in 1990-1 to 44.4% in 1992-3) as in the experimental region (44.8% to 41.3%). After standardisation, the estimated change in the probability of dying in the experimental region compared with the control regions was -0.8% per year (95% confidence interval -3.6% to 2.2%); for out of hours care, the change was 1.6% per year (-2.3% to 5.6%), and, for multiply injured patients, the change was -1.6% (-6.1% to 2.6%). CONCLUSION: Any reductions in mortality from regionalising major trauma care in shire areas of England would probably be modest compared with reports from the United States.     

Variability in adherence to clinical practice guidelines and recommendations in COPD outpatients: a multi-level,cross-sectional analysis of the EPOCONSUL study

Background

Clinical audits have reported considerable variability in COPD medical care and frequent inconsistencies with recommendations. The objectives of this study were to identify factors associated with a better adherence to clinical practice guidelines and to explore determinants of this variability at the the hospital level.

Methods

EPOCONSUL is a Spanish nationwide clinical audit that evaluates the outpatient management of COPD. Multilevel logistic regression with two levels was performed to assess the relationships between individual and disease-related factors, as well as hospital characteristics.

Results

A total of 4508 clinical records of COPD patients from 59 Spanish hospitals were evaluated. High variability was observed among hospitals in terms of medical care. Some of the patient’s characteristics (airflow obstruction, degree of dyspnea, exacerbation risk, presence of comorbidities), the hospital factors (size and respiratory nurses available) and treatment at a specialized COPD outpatient clinic were identified as factors associated with a better adherence to recommendations, although this only explains a small proportion of the total variance.

Conclusion

To be treated at a specialized COPD outpatient clinic and some intrinsic patient characteristics were factors associated with a better adherence to guideline recommendations, although these variables were only explaining part of the high variability observed among hospitals in terms of COPD medical care.

     

Reconciling research and implementation in micro health insurance experiments in India: study protocol for a randomized controlled trial

Background

Recent attention has focused on strategies to combat the forecast epidemic of type-2 diabetes (T2DM) and its major vascular sequelae. Metabolic syndrome (MetS) comprises a constellation of factors that increase the risk of cardiovascular disease (CVD) and T2DM. Our study aims to develop a structured self-management education programme for people with MetS, which includes management of cardiovascular and diabetes risk factors, and to determine its impact. This paper describes the rationale and design of the TRIMS study, including intervention development, and presents baseline data.

Methods

Subjects recruited from a mixed-ethnic population with MetS were randomised to intervention or control arms. The intervention arm received structured group education based on robust psychological theories and current evidence. The control group received routine care. Follow-up data will be collected at 6 and 12 months. The primary outcome measure will be reversal of metabolic syndrome in the intervention group subjects compared to controls at 12 months follow-up.

Results

82 participants (44% male, 22% South Asian) were recruited between November 2009 and July 2010. Baseline characteristics were similar for both the intervention (n = 42) and control groups (n = 40). Median age was 63 years (IQR 57 - 67), mean waist size 106 cm (SD ± 11), and prescribing of statins and anti-hypertensives was 51% in each case.

Conclusion

Results will provide information on changes in diabetes and CVD risk factors and help to inform primary prevention strategies in people with MetS from varied ethnic backgrounds who are at high risk of developing T2DM and CVD. Information gathered in relation to the programme's acceptability and effectiveness in a multi-ethnic population would ensure that our results are widely applicable.

Trial registration

The study is registered at ClinicalTrials.gov, study identifier: NCT01043770.     

SIMPLE34: an improved and enhanced implementation for VAX and Sun computers of the SIMPLE algorithm for analysis of clustered repetitive motifs in nucleotide sequences

SIMPLE34 is an improved and enhanced version of SIMPLE for Vaxand SunOS systems. It now provides a length-independent measureof the overall level of tri- and tetra nucleotide motif clusteringwithin nucleotide sequences and its significant deviation fromrandom expectation. It now also provides information on tri-and tetranucleotide motifs showing higher levels of clusteringthan would be expected in random sequences. Sequence simplicityof test sequences can be judged with respect to random sequencesgenerated on the basis of base composition, positional basecomposition or doublet frequency. These options can be usedto investigate factors resulting in sequence simplicity.     

Risk of renal stone events in primary hyperparathyroidism before and after parathyroid surgery: controlled retrospective follow up study

AimTo study the risk of renal stone episodes and risk factors for renal stones in primary hyperparathyroidism before and after surgery.DesignRegister based, controlled retrospective follow up study.SettingTertiary hospitals in Denmark.Participants674 consecutive patients with surgically verified primary hyperparathyroidism. Each patient was compared with three age- and sex-matched controls randomly drawn from the background population. Hospital admissions for renal stone disease were compared between patients and controls. Risk factors for renal stones among patients were assessed.ResultsRelative risk of a stone episode was 40 (95% confidence interval 31 to 53) before surgery and 16 (12 to 23) after surgery. Risk was increased 10 years before surgery, and became normal more than 10 years after surgery. Stone-free survival 20 years after surgery was 90.4% in patients and 98.7% in controls (risk difference 8.3%, 4.8% to 11.7%). Patients with preoperative stones had 27 times the risk of postoperative stone incidents than controls. Before surgery, males had more stone episodes than females and younger patients had more stone episodes than older patients. Neither parathyroid pathology, weight of removed tissue, plasma calcium levels, nor skeletal pathology (fractures) influenced the risk of renal stones. After surgery, younger age, preoperative stones and ureteral strictures were significant risk factors for stones.ConclusionsThe risk of renal stones is increased in primary hyperparathyroidism and decreases after surgery. The risk profile is normal 10 years after surgery. Preoperative stone events increase the risk of postoperative stones. Stone formers and non-stone formers had the same risk of skeletal complications.

What is already known on this topic

Patients with primary hyperparathyroidism have an increased risk of renal stone eventsThe extent to which parathyroid surgery reduces the risk of further stones is unclear

What this study adds

The risk of a new stone event was 8.3% higher in patients than in controls after surgeryIn patients with stone disease before operation the risk rate for a postoperative stone event was 27times that in controlsThe risk of a renal stone event was higher than the risk among controls until more than 10 years after surgery     

CRUST: Software for the implementation of Regional Chronology Standardisation: Part 2. Further RCS options and recommendations

A number of processing options associated with the use of a “regional curve” to standardise tree-ring measurements and generate a chronology representing changing tree growth over time are discussed. It is shown that failing to use pith offset estimates can generate a small but systematic chronology error. Where chronologies contain long-timescale signal variance, tree indices created by division of the raw measurements by RCS curve values produce chronologies with a skewed distribution. A simple empirical method of converting tree-indices to have a normal distribution is proposed. The Expressed Population Signal, which is widely used to estimate the statistical confidence of chronologies created using curve-fitting methods of standardisation, is not suitable for use with RCS generated chronologies. An alternative implementation, which takes account of the uncertainty associated with long-timescale as well as short-timescale chronology variance, is proposed. The need to assess the homogeneity of differently-sourced sets of measurement data and their suitability for amalgamation into a single data set for RCS standardisation is discussed. The possible use of multiple growth-rate based RCS curves is considered where a potential gain in chronology confidence must be balanced against the potential loss of long-timescale variance. An approach to the use of the “signal-free” method for generating artificial measurement series with the ‘noise’ characteristics of real data series but with a known chronology signal applied for testing standardisation performance is also described.     

European guidelines for quality assurance in cervical cancer screening: recommendations for collecting samples for conventional and liquid-based cytology.

The current paper presents an annex in the second edition of the European Guidelines for Quality Assurance in Cervical Cancer Screening. It provides guidance on how to make a satisfactory conventional Pap smear or a liquid-based cytology (LBC) sample. Practitioners taking samples for cytology should first explain to the woman the purpose, the procedure and how the result will be communicated. Three sampling methods are considered as acceptable for preparing conventional Pap smears: (i) the cervical broom; (ii) the combination of a spatula and an endocervical brush; and (iii) the extended tip spatula. Smear takers should take care to sample the entire circumference of the transformation zone, to quickly spread the cellular material over a glass slide, and to fix the preparation within a few seconds to avoid drying artefacts. According to local guidelines, one of these three methods may be preferred. Sampling with a cotton tip applicator is inappropriate. Similar procedures should be followed for sampling cells for LBC, but only plastic devices may be used. The collected cells should be quickly transferred into a vial with fixative liquid according to the instructions of the manufacturer of the LBC system. Subsequently, the slide or vial and the completed request form are sent to the laboratory for cytological interpretation.     

Zooplankton biomass in the Oosterschelde (SW Netherlands) before,during and after the construction of a storm-surge barrier

The hydrodynamic consequences of large coastal engineering (barrier-construction) works in the Oosterschelde were: prolonged residence times of the water, increased sinking of particulate material, and higher water transparencies. This strongly influenced the phytoplankton (Bakker et al., 1990; 1994) and phytoplankton biomass increased in the shallow Eastern compartment of the Oosterschelde (Bakker & Vink, 1994) while phytoplankton concentration of the seston rose.Zooplankton biomass, especially of copepods (Temora) and meroplankton (barnacle larvae) increased during the post-barrier period in the eastern compartment. It is hypothesized that this is caused by the improved feeding conditions and the increased retention times in this area.The barrier years 1985 and 1986 were characterized by low current velocities. In the Eastern compartment, this may have favoured the development of the rotifer Synchaeta (Bakker, 1994) and of the important copepod predator Pleurobrachia (Ctenophora).In the Western compartment, zooplankton developments in the post-barrier years were rather similar to those in the pre-barrier period. This led to the disappearance of the previously existing biomass gradients West-East (maxima in West). At present a trend in the opposite direction (maxima in East) is observed.     

Influence network linkages across implementation strategy conditions in a randomized controlled trial of two strategies for scaling up evidence-based practices in public youth-serving systems

Background

Given the importance of influence networks in the implementation of evidence-based practices and interventions, it is unclear whether such networks continue to operate as sources of information and advice when they are segmented and disrupted by randomization to different implementation strategy conditions. The present study examines the linkages across implementation strategy conditions of social influence networks of leaders of youth-serving systems in 12 California counties participating in a randomized controlled trial of community development teams (CDTs) to scale up use of an evidence-based practice.

Methods

Semi-structured interviews were conducted with 38 directors, assistant directors, and program managers of county probation, mental health, and child welfare departments. A web-based survey collected additional quantitative data on information and advice networks of study participants. A mixed-methods approach to data analysis was used to create a sociometric data set (n?=?176) to examine linkages between treatment and standard conditions.

Results

Of those network members who were affiliated with a county (n?=?137), only 6 (4.4%) were directly connected to a member of the opposite implementation strategy condition; 19 (13.9%) were connected by two steps or fewer to a member of the opposite implementation strategy condition; 64 (46.7%) were connected by three or fewer steps to a member of the opposite implementation strategy condition. Most of the indirect steps between individuals who were in different implementation strategy conditions were connections involving a third non-county organizational entity that had an important role in the trial in keeping the implementation strategy conditions separate. When these entities were excluded, the CDT network exhibited fewer components and significantly higher betweenness centralization than did the standard condition network.

Conclusion

Although the integrity of the RCT in this instance was not compromised by study participant influence networks, RCT designs should consider how influence networks may extend beyond boundaries established by the randomization process in implementation studies.

Trial registration

NCT00880126

     

Isolation of a protease from sea urchin eggs before and after fertilization.

Upon fertilization, sea urchin eggs (Stronglyocentrotus pupuratus) release a protease into the surrounding sea water. This protease is in a particulate form which can be solubilized. The soluble form was purified by affinity chromatography on columns of immobilized soybean trypsin inhibitor. The purified enzyme is similar to bovine trypsin both in molecular weight (22500) and in susceptibility to inhibitors such as diisopropyl phosphofluoridate and soybean trypsin inhibitor. In contrast, extracts of unfertilized eggs appear to contain an inactive form of the enzyme which can be activated by dialysis at pH 4.6. The enzyme, as purified from extracts activated in this manner, was similar in its properties to that from fertilized eggs.