A web-based, peer-supported self-management intervention to reduce distress in relatives of people with psychosis or bipolar disorder:the REACT RCT

BACKGROUND: Relatives caring for people with severe mental health problems find information and emotional support hard to access. Online support for self-management offers a potential solution. OBJECTIVE: The objective was to determine the clinical effectiveness and cost-effectiveness of an online supported self-management tool for relatives: the Relatives' Education And Coping Toolkit (REACT). DESIGN AND SETTING: This was a primarily online (UK), single-blind, randomised controlled trial, comparing REACT plus a resource directory and treatment as usual with the resource directory and treatment as usual only, by measuring user distress and other well-being measures at baseline and at 12 and 24 weeks. PARTICIPANTS: A total of 800 relatives of people with severe mental health problems across the UK took part; relatives who were aged ≥ 16 years, were experiencing high levels of distress, had access to the internet and were actively seeking help were recruited. INTERVENTION: REACT comprised 12 psychoeducation modules, peer support through a group forum, confidential messaging and a comprehensive resource directory of national support. Trained relatives moderated the forum and responded to messages. MAIN OUTCOME MEASURE: The main outcome was the level of participants' distress, as measured by the General Health Questionnaire-28 items. RESULTS: Various online and offline strategies, including social media, directed potential participants to the website. Participants were randomised to one of two arms: REACT plus the resource directory (n = 399) or the resource directory only (n = 401). Retention at 24 weeks was 75% (REACT arm, n = 292; resource directory-only arm, n = 307). The mean scores for the General Health Questionnaire-28 items reduced substantially across both arms over 24 weeks, from 40.2 (standard deviation 14.3) to 30.5 (standard deviation 15.6), with no significant difference between arms (mean difference -1.39, 95% confidence interval -3.60 to 0.83; p = 0.22). At 12 weeks, the General Health Questionnaire-28 items scores were lower in the REACT arm than in the resource directory-only arm (-2.08, 95% confidence interval -4.14 to -0.03; p = 0.027), but this finding is likely to be of limited clinical significance. Accounting for missing data, which were associated with higher distress in the REACT arm (0.33, 95% confidence interval -0.27 to 0.93; p = 0.279), in a longitudinal model, there was no significant difference between arms over 24 weeks (-0.56, 95% confidence interval -2.34 to 1.22; p = 0.51). REACT cost £142.95 per participant to design and deliver (£62.27 for delivery only), compared with £0.84 for the resource directory only. A health economic analysis of NHS, health and Personal Social Services outcomes found that REACT has higher costs (£286.77), slightly better General Health Questionnaire-28 items scores (incremental General Health Questionnaire-28 items score adjusted for baseline, age and gender: -1.152, 95% confidence interval -3.370 to 1.065) and slightly lower quality-adjusted life-year gains than the resource directory only; none of these differences was statistically significant. The median time spent online was 50.8 minutes (interquartile range 12.4-172.1 minutes) for REACT, with no significant association with outcome. Participants reported finding REACT a safe, confidential environment (96%) and reported feeling supported by the forum (89%) and the REACT supporters (86%). No serious adverse events were reported. LIMITATIONS: The sample comprised predominantly white British females, 25% of participants were lost to follow-up and dropout in the REACT arm was not random. CONCLUSIONS: An online self-management support toolkit with a moderated group forum is acceptable to relatives and, compared with face-to-face programmes, offers inexpensive, safe delivery of National Institute for Health and Care Excellence-recommended support to engage relatives as peers in care delivery. However, currently, REACT plus the resource directory is no more effective at reducing relatives' distress than the resource directory only. FUTURE WORK: Further research in improving the effectiveness of online carer support interventions is required. TRIAL REGISTRATION: Current Controlled Trials ISRCTN72019945. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 32. See the NIHR Journals Library website for further project information. Relatives of people with severe mental health problems need better access to information and emotional support. The Relatives’ Education And Coping Toolkit (REACT) is a website designed to do this. It includes lots of information presented in text and video, an online forum for relatives to share knowledge and experience, a messaging system where they can ask questions in confidence and a comprehensive directory of contact details for national organisations offering relevant support. Trained relatives support the forum and messaging. In the UK, we recruited 800 relatives of people with severe mental health problems: all were aged ≥ 16 years, had high levels of distress, had access to the internet and wanted help. We divided them into two equal groups: one group received REACT (including the resource directory), whereas the other group received the resource directory only. To ensure that there were no differences between groups at the start, relatives were allocated to the two groups randomly, so they had an equal chance of being in either group. We followed up with both groups at 12 and 24 weeks, and received data from approximately three-quarters of the participants. This trial found that REACT was acceptable, safe and inexpensive to deliver (£62.27 per relative), compared with face-to-face interventions, and that relatives using it felt well supported. However, once we accounted for missing data (relatives who dropped out of the trial or did not complete the follow-up questionnaires), there were no significant differences between the groups. There was no evidence that REACT increased relatives’ quality of life or saved money for the NHS

Improving the Nutritional Value of Nile Tilapia Fillet by Dietary Selenium Supplementation

Selenium (Se) supplementation in animal feeds for producing feasible foodswas successfully experimented with in different meat-producing animals including fish. In the present study, Nile tilapia were fed Se-fortified diets (0.5, 2.0, or 4.0 mg/kg) ad lib for six weeks. In addition to traditional production traits, the antioxidant parameters glutathione (GSH), glutathione peroxidase (GPx), and malondialdehyde (MDA) in the blood, liver, and muscle of the tilapia, Se accumulation in the fillet, and body composition were determined. The highest Se value in the fillet was obtained with the diet containing 2 mg/kg supplementation, where the actual Se content of 2.47 mg/kg Se induced 128 µg/kg Se in the fillet. Selenium incorporation had a cubic relationship with the dietary Se content

80 - Adjustable Autologous Pubovaginal Sling for Complex Recurrent Stress Incontinence

Introduction: Prior studies have shown that autologous pubovaginal slings are efficacious for the management of stress urinary incontinence with success rates of 66% compared to 49% with Burch colposuspension. However, they are also associated with higher rates of voiding dysfunction, urinary tract infections, and postoperative urge incontinence. Despite this, they still serve an important role in recurrent SUI or instances where mesh is contraindicated.A major issue with fascial slings is that there is no standardized method of how to precisely tension them, specifically in recurrent or severe SUI cases where one is trying to balance effective treatment with preventing voiding dysfunction.A potential solution to this issue is the use of a system that allows for individualized sling tensioning. The adjustable mid-urethral sling used in the video is a unique system that utilizes a permanent subcutaneous implant or “varitensor” that rests above the rectus fascia and can be utilized to tension the sling postoperatively using an external manipulator. Evidence has shown that this device can be highly effective for the treatment of stress urinary incontinence with multiple studies citing cure rates of 70-90%. By combining a fascial sling with this tensioning system, we have provided a unique modification for women with severe or recurrent stress urinary incontinence with risk factors for mesh complications, while balancing the undesirable side effects of voiding dysfunction and de novo urgency. Design: This video describes the case of a 59-year-old female with a history of chronic pain and current tobacco use who presented with severe, recurrent stress urinary incontinence after a prior Burch colposuspension. Her post-void residual volume was 60 ml. Given the challenge between resolving her severe stress incontinence symptoms and limiting the risks of urinary retention and mesh complications, the decision was made to proceed with a pubovaginal autologous sling attached to a suprapubic tensioning device that belongs to an adjustable mesh sling system. This component permits personalized post-operative tensioning. Results: This video provides an educational resource demonstrating key surgical steps for this specific modification to a pubovaginal fascial sling procedure as well as postoperative outcomes in similar patients. In the past year we have performed this combined procedure on 7 patients and have seen promising results, including no cases of recurrent SUI or voiding dysfunction. Conclusion: The use of a personalized tensioning device in combination with an autologous pubovaginal sling may balance efficacy with unwanted side effects.Funding None Clinical Trial No Subjects Non

Improving the Nutritional Value of Nile Tilapia Fillet by Dietary Selenium Supplementation

Selenium (Se) supplementation in animal feeds for producing feasible foodswas successfully experimented with in different meat-producing animals including fish. In the present study, Nile tilapia were fed Se-fortified diets (0.5, 2.0, or 4.0 mg/kg) ad lib for six weeks. In addition to traditional production traits, the antioxidant parameters glutathione (GSH), glutathione peroxidase (GPx), and malondialdehyde (MDA) in the blood, liver, and muscle of the tilapia, Se accumulation in the fillet, and body composition were determined. The highest Se value in the fillet was obtained with the diet containing 2 mg/kg supplementation, where the actual Se content of 2.47 mg/kg Se induced 128 µg/kg Se in the fillet. Selenium incorporation had a cubic relationship with the dietary Se content.</jats:p

Caracterización del control interno de las micro y pequeñas empresas del sector comercio del Perú: Caso empresa “Corporación Ferretera Rudhayfre S.A.C.” – Tingo Maria, 2017

TesisEl presente trabajo de investigación tuvo como objetivo general: Determinar y describir las características del control interno de las micro y pequeñas empresas del sector comercio del Perú: Caso Empresa “Corporación Ferretera Rudhayfre S.A.C.” – Tingo María, 2017. La investigación fue descriptiva – bibliográfica – documental y de caso, para el recojo de información se utilizó la técnica de revisión bibliográfica y la entrevista el instrumento fue fichas bibliográficas y el cuestionario; obteniéndose los siguientes resultados: Respecto a la revisión bibliográfica, se encontró lo siguiente: el control interno es una herramienta de gestión la cual proporciona seguridad razonable en cuanto a la consecución de sus objetivos de la entidad, permitiendo la eficacia y eficiencia de los mismos. Asimismo; minimiza los riesgos, previniendo y detectando malos manejos, fraudes y robos, mejorando la gestión, rentabilidad y competitividad de todas las operaciones. Por otro lado; establecen que el control interno es una parte prioritaria para cualquier tipo de empresa. Respecto a los resultados del caso, se ha podido evidenciar que la empresa no cuenta con un sistema de control interno, lo que genera deficiencias en la gestión de la empresa lo cual impide seguridad razonable de sus operaciones, no cuenta con procedimientos adecuados para el cumplimiento de sus objetivos, carece del manual de organización y funciones, tampoco cuenta con un plan estratégico y plan operativo, en lo que se ha identificado sus riesgos internos y externos aunque no cuenta con procedimientos que puedan darle una solución, no existe un monitoreo continuo por parte de la administración, para verificar si el personal cumple adecuadamente con sus funciones