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1.  Exploring the Nature of Therapeutic Massage Bodywork Practice 
Research on therapeutic massage bodywork (TMB) continues to expand, but few studies consider how research or knowledge translation may be affected by the lack of uniformly standardized competencies for most TMB therapies, by practitioner variability from training in different forms of TMB, or from the effects of experience on practice.
This study explores and describes how TMB practitioners practice, for the purpose of improving TMB training, practice, and research.
Participants & Setting
19 TMB practitioners trained in multiple TMB therapies, in Alberta, Canada.
Research Design
Qualitative descriptive sub-analysis of interviews from a comprehensive project on the training and practice of TMB, focused on the delivery of TMB therapies in practice.
Two broad themes emerged from the data: (1) every treatment is individualized, and (2) each practitioner’s practice of TMB therapies evolves. Individualization involves adapting treatment to the needs of the patient in the moment, based on deliberate and unconscious responses to verbal and nonverbal cues. Individualization starts with initial assessment and continues throughout the treatment encounter. Expertise is depicted as more nuanced and skilful individualization and treatment, evolved through experience, ongoing training, and spontaneous technique exploration. Practitioners consider such individualization and development of experience desirable. Furthermore, ongoing training and experience result in therapy application unique to each practitioner. Most practitioners believed they could not apply a TMB therapy without influence from other TMB therapies they had learned.
There are ramifications for research design, knowledge translation, and education. Few practitioners are likely able to administer treatments in the same way, and most would not like to practice without being able to individualize treatment. TMB clinical studies need to employ research methods that accommodate the complexity of clinical practice. TMB education should facilitate the maturation of practice skills and self-reflection, including the mindful integration of multiple TMB therapies.
PMCID: PMC3577637  PMID: 23481609
complementary therapies/methods; massage; musculoskeletal manipulations; clinical competence; decision-making; qualitative research; clinical practice
2.  Adaptation of the CARE Guidelines for Therapeutic Massage and Bodywork Publications: Efforts To Improve the Impact of Case Reports 
Case reports provide the foundation of practice-based evidence for therapeutic massage and bodywork (TMB), as well as many other health-related fields. To improve the consistency of information contained in case reports, the CARE (CAse REport) Group developed and published a set of guidelines for the medical community to facilitate systematic data collection ( Because of the differences between the practice of medicine and TMB, modifying some sections of the CARE guidelines is necessary to make them compatible with TMB case reports. Accordingly, the objectives of this article are to present the CARE guidelines, apply each section of the guidelines to TMB practice and reporting with suggested adaptations, and highlight concerns, new ideas, and other resources for potential authors of TMB case reports.
The primary sections of the CARE guidelines adapted for TMB case reports are diagnostic assessment, follow-up and outcomes, and therapeutic intervention. Specifically, because diagnosis falls outside of the scope of most TMB practitioners, suggestions are made as to how diagnoses made by other health care providers should be included in the context of a TMB case report. Additionally, two new aspects of the case presentation section are recommended: a) assessment measures, which outline and describe the outcome measures on which the case report will focus, and b) a description of the TMB provider (i.e., scope of practice, practice environment, experience level, training, credentialing, and/or expertise) as part of the intervention description.
This article culminates with practical resources for TMB practitioners writing case reports, including a TMB Case Report Template—a single document that TMB practitioners can use to guide his or her process of writing a case report. Once the template is adopted by authors of TMB case reports, future efforts can explore the impact on the quality and quantity of case reports and how they impact TMB practice, research, education and, ultimately, the clients.
PMCID: PMC4145002  PMID: 25184013
case study; massage therapy; manual therapy; evidenced-based practice
3.  Negotiating Consent: Exploring Ethical Issues when Therapeutic Massage Bodywork Practitioners Are Trained in Multiple Therapies 
Obtaining informed consent from competent patients is essential to the ethical delivery of health care, including therapeutic massage and bodywork (TMB). The informed consent process used by TMB practitioners has not been previously studied. Little information is available about the practice of informed consent in a treatment-focused environment that may involve multiple decision points, use of multiple TMB therapies, or both.
As part of a larger study on the process of providing TMB therapy, 19 practitioners were asked about obtaining informed consent during practice. Qualitative description was used to analyze discussions of the consent process generally, and about its application when practitioners use multiple TMB therapies.
Two main consent approaches emerged, one based on a general consent early in the treatment process, and a second ongoing consent process undertaken throughout the course of treatment. Both processes are constrained by how engaged a patient wants to be, and the amount of information and time needed to develop a truly informed consent.
An understanding-based consent process that accommodates an acknowledged information differential between the patient and practitioner, and that is guided by clearly delineated goals within a trust-based relationship, may be the most effective consent process under the conditions of real practice conditions.
PMCID: PMC4240696  PMID: 25452820
complementary therapies/methods; massage; musculoskeletal manipulations; consent; decision-making; qualitative research; clinical practice
4.  A Descriptive Study of the Practice Patterns of Massage New Zealand Massage Therapists 
Massage therapy has grown in popularity, yet little is known globally or in New Zealand about massage therapists and their practices.
Purpose and Setting:
The aims of this study were to describe the practice patterns of trained Massage New Zealand massage therapists in New Zealand private practice, with regard to therapist characteristics; practice modes and settings, and therapy characteristics; referral patterns; and massage therapy as an occupation.
Research Design and Participants:
A survey questionnaire was mailed to 66 trained massage therapist members of Massage New Zealand who were recruiting massage clients for a concurrent study of massage therapy culture.
Most massage therapists were women (83%), NZ European (76%), and holders of a massage diploma qualification (89%). Massage therapy was both a full- (58%) and part-time (42%) occupation, with the practice of massage therapy being the only source of employment for 70% of therapists. Nearly all therapists (94%) practiced massage for more than 40 weeks in the year, providing a median of 16 – 20 hours of direct client care per week. Most massage therapists worked in a “solo practice” (58%) and used a wide and active referral network. Almost all therapists treated musculoskeletal symptoms: the most common client issues or conditions treated were back pain/problem (99%), neck/shoulder pain/problem (99%), headache or migraine (99%), relaxation and stress reduction (96%), and regular recovery or maintenance massage (89%). The most frequent client fee per treatment was NZ$60 per hour in a clinic and NZ$1 per minute at a sports event or in the workplace. Therapeutic massage, relaxation massage, sports massage, and trigger-point therapy were the most common styles of massage therapy offered. Nearly all massage therapists (99%) undertook client assessment; 95% typically provided self-care recommendations; and 32% combined other complementary and alternative medicine therapies with their massage consultations.
This study provides new information about the practice of massage therapy by trained massage therapists. It will help to inform the massage industry and other health care providers, potential funders, and policymakers about the provision of massage therapy in the NZ health care system.
PMCID: PMC3088528  PMID: 21589692
Complementary and alternative therapies; massage therapy; New Zealand; integrative care; practice patterns
5.  Intervention development for integration of conventional tobacco cessation interventions into routine CAM practice 
Practitioners of complementary and alternative medicine (CAM) therapies are an important and growing presence in health care systems worldwide. A central question is whether evidence-based behavior change interventions routinely employed in conventional health care could also be integrated into CAM practice to address public health priorities. Essential for successful integration are intervention approaches deemed acceptable and consistent with practice patterns and treatment approaches of different types of CAM practitioners – that is, they have context validity. Intervention development to ensure context validity was integral to Project CAM Reach (CAMR), a project examining the public health potential of tobacco cessation training for chiropractors, acupuncturists and massage therapists (CAM practitioners). This paper describes formative research conducted to achieve this goal.
Intervention development, undertaken in three CAM disciplines (chiropractic, acupuncture, massage therapy), consisted of six iterative steps: 1) exploratory key informant interviews; 2) local CAM practitioner community survey; 3) existing tobacco cessation curriculum demonstration with CAM practitioners; 4) adapting/tailoring of existing curriculum; 5) external review of adaptations; 6) delivery of tailored curriculum to CAM practitioners with follow-up curriculum evaluation.
CAM practitioners identified barriers and facilitators to addressing tobacco use with patients/clients and saw the relevance and acceptability of the intervention content. The intervention development process was attentive to their real world intervention concerns. Extensive intervention tailoring to the context of each CAM discipline was found unnecessary. Participants and advisors from all CAM disciplines embraced training content, deeming it to have broad relevance and application across the three CAM disciplines. All findings informed the final intervention.
The participatory and iterative formative research process yielded an intervention with context validity in real-world CAM practices as it: 1) is patient/client-centered, emphasizing the practitioner’s role in a healing relationship; 2) is responsive to the different contexts of CAM practitioners’ work and patient/client relationships; 3) integrates relevant best practices from US Public Health Service Clinical Practice Guidelines on treating tobacco dependence; and 4) is suited to the range of healing philosophies, scopes of practice and practice patterns found in participating CAM practitioners. The full CAMR study to evaluate the impact of the CAMR intervention on CAM practitioners’ clinical behavior is underway.
PMCID: PMC4391469  PMID: 25887742
Context validity; Intervention protocol; Curriculum development; Training; Interprofessional education; Tobacco cessation; Chiropractic; Acupuncture; Massage therapist; Community based participatory research
6.  Advancing the Therapeutic Massage Research Agenda(s) 
Therapeutic massage and bodywork (TMB) is now an established field of research with dedicated funding, researchers, and many venues and channels for dissemination of TMB research. Research agendas are a way for a profession to focus the development and funding of research on facets of TMB practice and education that are most needed at a given point of time to best move forward the practice and professionalization of TMB. Of the two TMB research agendas, one is currently being updated, the other is newly developed. Because of the impact on the development of the profession, gaps in research agendas also need to be carefully considered. Three areas that could use further consideration or support within the current agendas include education, methods and methodologies, and underlying assumptions. TMB researchers need to engage with and support the current agendas, and participate in their evolution.
PMCID: PMC3757228  PMID: 24000302
7.  The Greater Value of the CONSORT Statement Guidelines: Guideposts for Designing and Reporting all TMB Research 
The IJTMB recommends the use of the CONSORT Statement (Consolidated Standards of Reporting Trials) guidelines for the reporting of randomized, controlled clinical trials (RCTs). A careful review of the guidelines shows important applications of these guidelines to all types of research reporting and design, not just RCTs. There is an Extension to these guidelines specific to nonpharmacologic interventions, including manually applied therapies and complementary medicine, and thus therapeutic massage and bodywork (TMB). Components of the Extension are thus relevant to publication in the IJTMB and should be considered part of standard reporting. As well, while the goals of the CONSORT Statement guidelines are to improve reporting of RCTs, the issues raised in the guidelines and explanatory document are relevant to all forms of TMB research and should be considered in all TMB research manuscripts. Finally, while not their purpose, the guidelines could also be used as an informal checklist when developing robust TMB research.
PMCID: PMC3528186  PMID: 23431357
8.  Attitudes and Practices of Massage Therapists as Related to Conventional Medicine 
Research into opinions about complementary and alternative medicine (CAM) has focused on conventional medical practitioners with little exploration of CAM practitioners’ views.
To survey attitudes and practices of massage therapists toward conventional medicine.
Research Design
An anonymous online survey consisting of Likert-type scales, fill-in answers, and multiple-choice questions was used.
Members of the Associated Bodywork & Massage Professionals (ABMP), the largest massage therapy association in the US with over 77,000 members.
Main Outcome Measures
Participants were asked about their years of practice and training, choice of health care practitioners, sources for information about CAM and Western/allopathic medicine, client referral patterns, optimal treatment approaches for various medical conditions, and overall impressions of CAM and Western/ allopathic medicine.
Analysis of n = 3,148 responses indicated that while 66.9% of respondents had a neutral or worse impression of Western/allopathic medicine, 64.3% use a conventional medicine practitioner as their primary health care provider, 61.9% have referred clients to a conventional medicine practitioner in the past six months, and 90.5% seek out information on Western/allopathic medicine. The mode response of the best treatment approach to various medical problems was a mix of Western/allopathic medicine and CAM.
This study suggests that despite the ambivalence of many massage therapists towards conventional medicine, many use it, encourage clients to do so, and see involvement of both as crucial to health.
PMCID: PMC3312644  PMID: 22553480
complementary; alternative medicine; attitudes; massage
9.  TSH-Mediated TNFα Production in Human Fibrocytes Is Inhibited by Teprotumumab, an IGF-1R Antagonist 
PLoS ONE  2015;10(6):e0130322.
Fibrocytes (FC) are bone marrow-derived progenitor cells that are more abundant and infiltrate the thyroid and orbit in Graves orbitopathy (GO). FCs express high levels of thyrotropin receptor (TSHR) and insulin-like growth factor-1 receptor (IGF-1R). These receptors are physically and functionally associated, but their role in GO pathogenesis is not fully delineated. Treatment of FCs with thyroid stimulating hormone (TSH) or M22 (activating antibody to TSHR) induces the production of numerous cytokines, including tumor necrosis factor α (TNFα). Teprotumumab (TMB) is a human monoclonal IGF-1R blocking antibody currently in clinical trial for GO and inhibits TSHR-mediated actions in FCs.
To characterize the molecular mechanisms underlying TSH-induced TNFα production by FCs, and the role of IGF-1R blockade by TMB.
FCs from healthy and GD patients were treated with combinations of TSH, M22, MG132 and AKTi (inhibitors of NF-κB and Akt, respectively), and TMB. TNFα protein production was measured by Luminex and flow cytometry. Messenger RNA expression was quantified by real time PCR.
Treatment with TSH/M22 induced TNFα protein and mRNA production by FCs, both of which were reduced when FCs were pretreated with MG132 and AKTi (p<0.0001). TMB decreased TSH-induced TNFα protein production in circulating FCs from mean fluorescent index (MFI) value of 2.92 to 1.91, and mRNA expression in cultured FCs from 141- to 52-fold expression (p<0.0001). TMB also decreased M22-induced TNFα protein production from MFI of 1.67 to 1.12, and mRNA expression from 6- to 3-fold expression (p<0.0001).
TSH/M22 stimulates FC production of TNFα mRNA and protein. This process involves the transcription factor NF-κB and its regulator Akt. Blocking IGF-1R attenuates TSH/M22-induced TNFα production. This further delineates the interaction of TSHR and IGF1-R signaling pathways. By modulating the proinflammatory properties of FCs such as TNFα production, TMB may be a promising therapeutic agent for GO.
PMCID: PMC4472723  PMID: 26087256
10.  Diffuse Axonal Injury at Ultra-High Field MRI 
PLoS ONE  2015;10(3):e0122329.
Diffuse axonal injury (DAI) is a specific type of traumatic brain injury caused by shearing forces leading to widespread tearing of axons and small vessels. Traumatic microbleeds (TMBs) are regarded as a radiological marker for DAI. This study aims to compare DAI-associated TMBs at 3 Tesla (T) and 7 T susceptibility weighted imaging (SWI) to evaluate possible diagnostic benefits of ultra-high field (UHF) MRI.
Material and Methods
10 study participants (4 male, 6 female, age range 20-74 years) with known DAI were included. All MR exams were performed with a 3 T MR system (Magnetom Skyra) and a 7 T MR research system (Magnetom 7 T, Siemens AG, Healthcare Sector, Erlangen, Germany) each in combination with a 32-channel-receive coil. The average time interval between trauma and imaging was 22 months. Location and count of TMBs were independently evaluated by two neuroradiologists on 3 T and 7 T SWI images with similar and additionally increased spatial resolution at 7 T. Inter- and intraobserver reliability was assessed using the interclass correlation coefficient (ICC). Count and diameter of TMB were evaluated with Wilcoxon signed rank test.
Susceptibility weighted imaging revealed a total of 485 TMBs (range 1-190, median 25) at 3 T, 584 TMBs (plus 20%, range 1-262, median 30.5) at 7 T with similar spatial resolution, and 684 TMBs (plus 41%, range 1-288, median 39.5) at 7 T with 10-times higher spatial resolution. Hemorrhagic DAI appeared significantly larger at 7 T compared to 3 T (p = 0.005). Inter- and intraobserver correlation regarding the counted TMB was high and almost equal 3 T and 7 T.
7 T SWI improves the depiction of small hemorrhagic DAI compared to 3 T and may be supplementary to lower field strengths for diagnostic in inconclusive or medicolegal cases.
PMCID: PMC4368671  PMID: 25793614
11.  Practice and research in Australian massage therapy: a national workforce survey 
Massage is the largest complementary medicine profession in Australia, in terms of public utilisation, practitioner distribution, and number of practitioners, and is being increasingly integrated into the Australian health care system. However, despite the increasing importance of massage therapists in Australian health care delivery, or the increased practice and education obligations this may entail, there has been little exploration of practice, research, and education characteristics of the Australian massage therapist workforce.
To identify practice, research, and education characteristics among the Australian massage therapist workforce.
The Australian massage therapy profession.
301 randomly selected members of the Association of Massage Therapists (Australia).
Research Design
A 15-item, cross-sectional telephone survey.
Main Outcomes Measures
Massage therapists’ demographic information, practice characteristics, and education and research characteristics.
Most respondents (73.8%) worked 20 hours per week or less practising massage, nearly half of all respondents (46.8%) treated fewer than 10 massage clients per week, and over three-quarters (81.7%) of respondents were self-employed. Massage therapy was the sole source of income for just over half (55.0%) of the study respondents. Only 5.7% of respondents earned over the average wage ($50,000) through their massage activities. Nearly half of all respondents (43.3%) reported regularly exceeding their continuing professional education (CPE) quota mandated by their professional association. However, 21.1% reported struggling to achieve their CPE quota each year. Over one-third of respondents (35.6%) were not interested in acquiring further CPE points beyond minimum requirements. Respondents were significantly more likely to have an active approach to research if they had higher income (p = .015). Multivariate analysis showed factors associated with access to CPE to be the only significant predictors for increased CPE.
The massage profession in Australia remains largely part-time and practitioners earn less than the average Australian wage. The factors that underlie research and education involvement appear to be highly individualised and, therefore, policies targeting specific groups may be arbitrary and ineffective.
PMCID: PMC4455611  PMID: 26082824
Massage; workforce survey; professional education; research; Australia
12.  Tobacco brief intervention training for chiropractic, acupuncture, and massage practitioners: protocol for the CAM reach study 
Tobacco use remains the leading cause of morbidity and mortality in the US. Effective tobacco cessation aids are widely available, yet underutilized. Tobacco cessation brief interventions (BIs) increase quit rates. However, BI training has focused on conventional medical providers, overlooking other health practitioners with regular contact with tobacco users. The 2007 National Health Interview Survey found that approximately 20% of those who use provider-based complementary and alternative medicine (CAM) are tobacco users. Thus, CAM practitioners potentially represent a large, untapped community resource for promoting tobacco cessation and use of effective cessation aids. Existing BI training is not well suited for CAM practitioners’ background and practice patterns, because it assumes a conventional biomedical foundation of knowledge and philosophical approaches to health, healing and the patient-practitioner relationship. There is a pressing need to develop and test the effectiveness of BI training that is both grounded in Public Health Service (PHS) Guidelines for tobacco dependence treatment and that is relevant and appropriate for CAM practitioners.
The CAM Reach (CAMR) intervention is a tobacco cessation BI training and office system intervention tailored specifically for chiropractors, acupuncturists and massage therapists. The CAMR study utilizes a single group one-way crossover design to examine the CAMR intervention’s impact on CAM practitioners’ tobacco-related practice behaviors. Primary outcomes included CAM practitioners’ self-reported conduct of tobacco use screening and BIs. Secondary outcomes include tobacco using patients’ readiness to quit, quit attempts, use of guideline-based treatments, and quit rates and also non-tobacco-using patients’ actions to help someone else quit.
CAM practitioners provide care to significant numbers of tobacco users. Their practice patterns and philosophical approaches to health and healing are well suited for providing BIs. The CAMR study is examining the impact of the CAMR intervention on practitioners’ tobacco-related practice behaviors, CAM patient behaviors, and documenting factors important to the conduct of practice-based research in real-world CAM practices.
PMCID: PMC4320589  PMID: 25524595
Tobacco cessation; Brief intervention; Training; Communication; Acupuncture; Chiropractic; Massage therapy; System intervention; Longitudinal study; Qualitative study
13.  The role of counsellors in general practice. A qualitative study. 
Counselling services in general practice are now widespread but little is known about their nature or role. We therefore carried out in-depth telephone interviews with a representative sample of 72 general practitioners and 60 of their counsellors who had participated in a previous national survey of counselling services in England and Wales. Our aim was to gain greater insight into the functioning of these services in order to determine the most appropriate focus for future research and development. Interviews were semi-structured and focused on service initiation and duration; counsellors' background and training; working arrangements including sources of funding; types of clients; communication between general practitioners and counsellors; perceived advantages and disadvantages to general practitioners, counsellors, and clients; goals, barriers, and proposed changes. Approximately two thirds of counsellors were employed by district health authorities and attached to practices. One third were employed by the practice with the financial assistance of family health services authorities. Practice-employed counsellors appeared a relatively new service innovation whose growth was facilitated by the general practitioner contract of 1991. Practice-employed counsellors were preferred to practice-attached staff in that general practitioners had greater control over the selection of counsellors and their working arrangements. Problems with interprofessional communication were noted in relation to counsellors' wishes to maintain patient confidentiality by not exchanging information about patients with general practitioners. Counsellors received referrals principally from general practitioners and occasionally from other primary health care staff. Self-referral by patients was rare. The problems for which patients were most commonly referred were: stress/anxiety, relationship problems, depression, and bereavement. The principal therapeutic styles were Rogerian counselling, behavioural therapy, and psychodynamic psychotherapy. A quarter described their style as 'eclectic'. Individual, not group, therapy was the norm. Sessions were usually 50 minutes in duration. However, waiting list times, the frequency of sessions, and overall duration of therapy varied enormously. Overall 28% of counsellors held no formal qualification in counselling or in any of the psychotherapies. Counsellors and general practitioners were generally satisfied with the service and identified a wide range of benefits with few disadvantages. The principal problem was said to be that demand exceeded capacity and the principal change proposed was expansion of the service. The findings provide the most comprehensive account to date of the present state and likely future direction of counselling services in general practice and point to the need to: 1. Evaluate the cost-effectiveness of counselling in the management of common psychiatric disorders such as anxiety and depression 2. Establish a national policy for the training and accreditation of counsellors working in general practice settings 3. Educate general practitioners about the organization and role of counselling services with particular attention to interprofessional communication and the maintenance of patient confidentiality.
PMCID: PMC2560396  PMID: 9080766
14.  The Intersection of Massage Practice and Research: Community Massage Therapists as Research Personnel on an NIH-funded Effectiveness Study 
Few NIH funded studies give community massage therapists the opportunity to become study personnel. A recent NIH/NCCAM-funded study investigating chronic low back pain (CLBP) recruited, trained, and utilized community massage practitioners (CMPs) as study personnel. This study’s aim was to determine whether health-related outcomes for CLBP improve when patients are referred from primary care to select CAM modalities including massage therapy (MT). The purpose of this paper is to report the results of the study’s three massage practice-driven study objectives which were to: 1) identify challenges and solutions to recruiting and retaining ample CMPs, 2) develop a practice-informed protocol reflecting real-world MT, and 3) determine the extent to which CMPs comply with rigorous research methodology in their clinical practices as study personnel.
Eligible CMPs in urban and rural Kentucky counties were identified through licensure board records, professional organizations, and personal contact opportunities. Interested CMPs completed 6 CE hours of research and Human Subjects Protection training and agreed to comply with a study protocol reflecting MT as practiced. Once trained, study CMPs were matched with study participants to provide and document up to 10 MT sessions per participant.
Utilizing prominent MT community members proved invaluable to CMP recruitment and protocol development. CMP recruitment challenges included mixed interest, low number of available rural CMPs, busy clinic schedules, and compensation. Ethics CE credits were offered to encourage CMP interest. A total of 28 Kentucky licensed massage therapists with 5–32 years of experience completed study training. A total of 127 CLBP patients consented to participate (n = 104 for MT). Twenty-five CMPs were assigned CLBP patients and provided 1–10 treatments for 94 study participants. Treatment documentation was provided by CMPs for 97% of treatments provided.
When recruitment, retention, and protocol compliance challenges are met, CMPs are valuable study personnel for practice-based research reflecting real-world MT practice.
PMCID: PMC4051806  PMID: 24920968
practice-based research networks; chronic low back pain; licensed massage therapists; methods; clinical trial; real-world massage practice
15.  Investigation of benefits and costs of an ophthalmic outreach clinic in general practice. 
BACKGROUND: With the advent of general practitioner fundholding, there has been growth in outreach clinics covering many specialties. The benefits and costs of this model of service provision are unclear. AIM: A pilot study aimed to evaluate an outreach model of ophthalmic care in terms of its impact on general practitioners, their use of secondary ophthalmology services, patients' views, and costs. METHOD: A prospective study, from April 1992 to March 1993, of the introduction of an ophthalmic outreach service in 17 general practices in London was undertaken. An ophthalmic outreach team, comprising an ophthalmic medical practitioner and an ophthalmic nurse, held clinics in the practices once a month. Referral rates to Edgware General Hospital ophthalmology outpatient department over one year from the study practices were compared with those from 17 control practices. General practitioners' assessments of the scheme and its impact on their knowledge and practice of ophthalmology were sought through a postal survey of all partners and interviews with one partner in each practice. Patient surveys were conducted using self-administered structured questionnaires. A costings exercise compared the outreach model with the conventional hospital ophthalmology outpatient clinic. RESULTS: Of 1309 patients seen by the outreach team in the study practices, 480 (37%) were referred to the ophthalmology outpatient department. The annual referral rate to this department from control practices was 9.5 per 10,000 registered patients compared with 3.8 per 10,000 registered patients from study practices. A total of 1187 patients were referred to the outpatient department from control practices. An increase in knowledge of ophthalmology was reported by 18 of 47 general practitioners (38%). Nineteen (40%) of 47 general practitioners took advantage of the opportunity for inservice training with the outreach team; they were more likely to change their routine practice for ophthalmic care or referral criteria for patients with cataracts or diabetes than those who did not attend for inservice training. The outreach scheme was popular with patients, for whom ease of access and familiarity of surroundings were major advantages. The cost per patient seen in the outreach clinics (48.09 pounds) was about three times the cost per patient seen in the outpatient department (15.71 pounds). CONCLUSION: The model of ophthalmic outreach care in this pilot study was popular with patients and general practitioners and appeared to act as an effective filter of demand for care in the hospital setting. However, the educational impact of the scheme was limited. Although the unit costs (per patient) of the outreach scheme compared unfavourably with those of conventional outpatient treatment, potential health gains from this more accessible model of care require further exploration.
PMCID: PMC1239466  PMID: 8745862
16.  Designing Consumer Health Technologies for the Treatment of Patients With Depression: A Health Practitioner's Perspective 
The consumer health technologies used by patients on a daily basis can be effectively leveraged to assist them in the treatment of depression. However, because treatment for depression is a collaborative endeavor, it is important to understand health practitioners’ perspectives on the benefits, drawbacks, and design of such technologies.
The objective of this research was to understand how patients and health practitioners can effectively and successfully influence the design of consumer health treatment technologies for treating patients with depression.
A group of 10 health practitioners participated in individual semistructured contextual interviews at their offices. Health practitioners rated an a priori identified list of depression indicators using a 7-point Likert scale and generated a list of depression indicators. Finally, health practitioners were asked to rate the perceived usefulness of an a priori identified list of depression treatment technologies using a 7-point Likert scale.
Of the 10 health practitioners interviewed, 5 (50%) were mental health practitioners, 3 (30%) nurses, and 2 (20%) general practitioners. A total of 29 unique depression indicators were generated by the health practitioners. These indicators were grouped into 5 high-level categories that were identified by the research team and 2 clinical experts: (1) daily and social functioning, (2) medication, (3) nutrition and physical activity, (4) demographics and environment, and (5) suicidal thoughts. These indicators represent opportunities for designing technologies to support health practitioners who treat patients with depression. The interviews revealed nuances of the different health practitioners’ clinical practices and also barriers to using technology to guide the treatment of depression. These barriers included (1) technology that did not fit within the current practice or work infrastructure, (2) technology that would not benefit the current treatment process, (3) patients forgetting to use the technology, and (4) patients not being able to afford the technology.
In order to be successful in the treatment of depression, consumer health treatment technologies must address health practitioners’ technology concerns early on in the design phase, account for the various types of health practitioners, treatment methods, and clinical practices, and also strive to seamlessly integrate traditional and nontraditional depression indicators within various health practitioners’ clinical practices.
PMCID: PMC3906692  PMID: 24413087
depression; health care providers; technology; user-computer interface
17.  The Next Frontiers 
This issue of the IJTMB includes articles that represent the scope of therapeutic massage and bodywork (TMB) practice and education. The two research articles represent the testing of deductive hypotheses not commonly seen in the TMB literature: the change in tactile abnormalities of young children with autism using qigong massage, and changes in postural balance from massage to the muscles associated with the mandibular trigeminal nerve. The education editorial opens the IJTMB dialogue on the need, value, and issues of competency-based education relative to hours-based programming.
PMCID: PMC3838307  PMID: 24298294
18.  Current Status and Future Prospects of Clinical Psycholog 
The escalating costs of health care and other recent trends have made health care decisions of great societal import, with decision-making responsibility often being transferred from practitioners to health economists, health plans, and insurers. Health care decision making increasingly is guided by evidence that a treatment is efficacious, effective–disseminable, cost-effective, and scientifically plausible. Under these conditions of heightened cost concerns and institutional–economic decision making, psychologists are losing the opportunity to play a leadership role in mental and behavioral health care: Other types of practitioners are providing an increasing proportion of delivered treatment, and the use of psychiatric medication has increased dramatically relative to the provision of psychological interventions.
Research has shown that numerous psychological interventions are efficacious, effective, and cost-effective. However, these interventions are used infrequently with patients who would benefit from them, in part because clinical psychologists have not made a convincing case for the use of these interventions (e.g., by supplying the data that decision makers need to support implementation of such interventions) and because clinical psychologists do not themselves use these interventions even when given the opportunity to do so.
Clinical psychologists’ failure to achieve a more significant impact on clinical and public health may be traced to their deep ambivalence about the role of science and their lack of adequate science training, which leads them to value personal clinical experience over research evidence, use assessment practices that have dubious psychometric support, and not use the interventions for which there is the strongest evidence of efficacy. Clinical psychology resembles medicine at a point in its history when practitioners were operating in a largely prescientific manner. Prior to the scientific reform of medicine in the early 1900s, physicians typically shared the attitudes of many of today’s clinical psychologists, such as valuing personal experience over scientific research. Medicine was reformed, in large part, by a principled effort by the American Medical Association to increase the science base of medical school education. Substantial evidence shows that many clinical psychology doctoral training programs, especially PsyD and for-profit programs, do not uphold high standards for graduate admission, have high student–faculty ratios, deemphasize science in their training, and produce students who fail to apply or generate scientific knowledge.
A promising strategy for improving the quality and clinical and public health impact of clinical psychology is through a new accreditation system that demands highquality science training as a central feature of doctoral training in clinical psychology. Just as strengthening training standards in medicine markedly enhanced the quality of health care, improved training standards in clinical psychology will enhance health and mental health care. Such a system will (a) allow the public and employers to identify scientifically trained psychologists; (b) stigmatize ascientific training programs and practitioners; (c) produce aspirational effects, thereby enhancing training quality generally; and (d) help accredited programs improve their training in the application and generation of science. These effects should enhance the generation, application, and dissemination of experimentally supported interventions, thereby improving clinical and public health. Experimentally based treatments not only are highly effective but also are cost-effective relative to other interventions; therefore, they could help control spiraling health care costs. The new Psychological Clinical Science Accreditation System (PCSAS) is intended to accredit clinical psychology training programs that offer highquality science-centered education and training, producing graduates who are successful in generating and applying scientific knowledge. Psychologists, universities, and other stakeholders should vigorously support this new accreditation system as the surest route to a scientifically principled clinical psychology that can powerfully benefit clinical and public health.
PMCID: PMC2943397  PMID: 20865146
19.  Barriers to accurate diagnosis and effective management of heart failure in primary care: qualitative study 
BMJ : British Medical Journal  2003;326(7382):196.
To ascertain the beliefs, current practices, and decision making of general practitioners in the diagnosis and management of suspected heart failure in primary care, with a view to identifying barriers to good care.
A qualitative approach using focus groups with 30 general practitioners from four primary care groups. The sampling strategy was stratified and purposive. The contents of interviews were transcribed and analysed according to the principles of “pragmatic variant” grounded theory.
North east England.
Three categories of difficulties contribute to variations in medical practice and to the reasons why general practitioners experience difficulties in diagnosing and managing heart failure. The first is uncertainty about clinical practice, including lack of confidence in establishing an accurate diagnosis and worries about using angiotensin converting enzyme inhibitors, β blockers, and spironolactone in patients who are often elderly and frail, with comorbidity and polypharmacy. The second is a lack of awareness of relevant research evidence in what was perceived to be a complex and rapidly changing therapeutic field. Doubts about the applicability of research findings in primary care, and fear of information overload also emerged. The third category consists of influences of individual preference and local organisational factors. Medical training, negative clinical experiences, and outside agencies influenced the behaviour of general practitioners and professional culture. Local factors included the availability of diagnostic services, resources (such as accessible cardiologists), and interactions between professionals in primary or secondary care, and they seemed to shape the practice and decision making processes in primary care.
The national service framework for coronary heart disease stresses that the substandard care of patients with heart failure is unacceptable. This study identified barriers to be overcome across primary and secondary care in implementation strategies that are specific to the locality and multifaceted. Single strategies—for example, the provision of guidelines—are unlikely to have an impact on clinical outcomes, and new, conjoint models of care need to be explored.
What is already known on this topicHeart failure is a common condition with a high morbidity and mortality and is largely managed in primary careAlthough modern management with accurate diagnosis and treatment improves prognosis considerably, unacceptable variations exist in the clinical application of current guidelines for heart failureWhat this study addsGeneral practitioners expressed a lack of confidence in establishing an accurate diagnosis of left ventricular systolic dysfunction, even if open access echocardiography was availableUncertainty about diagnosis led to poor uptake of evidence based treatment strategies for heart failure patients, and, despite awareness, reluctance to initiate modern treatmentLocal organisational factors around NHS provision of diagnostic services, resources, and interaction between primary and secondary care influence how general practitioners manage heart failureImplementation strategies for heart failure management across primary and secondary care are needed that are specific to their locality and multifaceted
PMCID: PMC140276  PMID: 12543836
20.  Primary Care Research Team Assessment (PCRTA): development and evaluation. 
BACKGROUND: Since the early 1990s the United Kingdom (UK) Department of Health has explicitly promoted a research and development (R&D) strategy for the National Health Service (NHS). General practitioners (GPs) and other members of the primary care team are in a unique position to undertake research activity that will complement and inform the research undertaken by basic scientists and hospital-based colleagues and lead directly to a better evidence base for decision making by primary care professionals. Opportunities to engage in R&D in primary care are growing and the scope for those wishing to become involved is finally widening. Infrastructure funding for research-active practices and the establishment of a range of support networks have helped to improve the research capacity and blur some of the boundaries between academic departments and clinical practice. This is leading to a supportive environment for primary care research. There is thus a need to develop and validate nationally accepted quality standards and accreditation of performance to ensure that funders, collaborators and primary care professionals can deliver high quality primary care research. Several strategies have been described in national policy documents in order to achieve an improvement in teaching and clinical care, as well as enhancing research capacity in primary care. The development of both research practices and primary care research networks has been recognised as having an important contribution to make in enabling health professionals to devote more protected time to undertake research methods training and to undertake research in a service setting. The recognition and development of primary care research has also brought with it an emphasis on quality and standards, including an approach to the new research governance framework. PRIMARY CARE RESEARCH TEAM ASSESSMENT: In 1998, the NHS Executive South and West, and later the London Research and Development Directorate, provided funding for a pilot project based at the Royal College of General Practitioners (RCGP) to develop a scheme to accredit UK general practices undertaking primary care R&D. The pilot began with initial consultation on the development of the process, as well as the standards and criteria for assessment. The resulting assessment schedule allowed for assessment at one of two levels: Collaborative Research Practice (Level I), with little direct experience of gaining project or infrastructure funding Established Research Practice (Level II), with more experience of research funding and activity and a sound infrastructure to allow for growth in capacity. The process for assessment of practices involved the assessment of written documentation, followed by a half-day assessment visit by a multidisciplinary team of three assessors. IMPLEMENTATION--THE PILOT PROJECT: Pilot practices were sampled in two regions. Firstly, in the NHS Executive South West Region, where over 150 practices expressed an interest in participating. From these a purposive sample of 21 practices was selected, providing a range of research and service activity. A further seven practices were identified and included within the project through the East London and Essex Network of Researchers (ELENoR). Many in this latter group received funding and administrative support and advice from ELENoR in order to prepare written submissions for assessment. Some sample loss was encountered within the pilot project, which was attributable largely to conflicting demands on participants' time. Indeed, the preparation of written submissions within the South West coincided with the introduction of primary care groups (PCGs) in April 1999, which several practices cited as having a major impact on their participation in the pilot project. A final sample of 15 practices (nine in the South West and six through ELENoR) underwent assessment through the pilot project. EVALUATION: A formal evaluation of the Primary Care Research Team Assessment (PCRTA) pilot was undertaken by an independent researcher (FM). This was supplemented with feedback from the assessment team members. The qualitative aspect of the evaluation, which included face-to-face and telephone interviews with assessors, lead researchers and other practice staff within the pilot research practices, as well as members of the project management group, demonstrated a positive view of the pilot scheme. Several key areas were identified in relation to particular strengths of research practices and areas for development including: Strengths Level II practices were found to have a strong primary care team ethos in research. Level II practices tended to have a greater degree of strategic thinking in relation to research. Development areas Level I practices were found to lack a clear and explicit research strategy. Practices at both levels had scope to develop their communication processes for dissemination of research and also for patient involvement. Practices at both levels needed mechanisms for supporting professional development in research methodology. The evaluation demonstrated that practices felt that they had gained from their participation and assessors felt that the scheme had worked well. Some specific issues were raised by different respondents within the qualitative evaluation relating to consistency of interpretation of standards and also the possible overlap of the assessment scheme with other RCGP quality initiatives. NATIONAL IMPLEMENTATION OF THE PRIMARY CARE RESEARCH TEAM ASSESSMENT: The pilot project has been very successful and recommendations have been made to progress to a UK scheme. Management and review of the scheme will remain largely the same, with a few changes focusing on the assessment process and support for practices entering the scheme. Specific changes include: development of the support and mentoring role of the primary care research networks increased peer and external support and mentoring for research practices undergoing assessment development of assessor training in line with other schemes within the RCGP Assessment Network work to ensure consistency across RCGP accreditation schemes in relation to key criteria, thereby facilitating comparable assessment processes refinement of the definition of the two groups, with Level I practices referred to as Collaborators and Level II practices as Investigator-Led. The project has continued to generate much enthusiasm and support and continues to reflect current policy. Indeed, recent developments include the proposed new funding arrangements for primary care R&D, which refer to the RCGP assessment scheme and recognise it as a key component in the future R&D agenda. The assessment scheme will help primary care trusts (PCTs) and individual practices to prepare and demonstrate their approach to research governance in a systematic way. It will also provide a more explicit avenue for primary care trusts to explore local service and development priorities identified within health improvement programmes and the research priorities set nationally for the NHS.
PMCID: PMC2560501  PMID: 12049028
21.  Introducing IJTMB’s Trigger Points: Topical Dialogue amongst Therapeutic Massage & Bodywork Practitioners and Educators 
The International Journal of Therapeutic Massage and Bodywork (IJTMB) has as its core a key interest in and mission to develop the practice of therapeutic massage and bodywork by contributing to the field’s body of knowledge. The IJTMB Editorial Board understands that one’s daily practice provides the initial testing ground for the development of practice-based knowledge and, ultimately, expertise. Consequently, this practice-based knowledge and experience provides fertile ground for research ideas that further refine our understanding and come full circle to enhance clinical efficacy. Ultimately, without discourse and knowledge transference, the possibility of growing the body of knowledge for therapeutic massage and bodywork or stimulating research in the field is lost. To facilitate discourse and transference of knowledge within the field of therapeutic massage and bodywork, the IJTMB is launching a new journal component entitled Trigger Points: Topical Dialogue amongst Therapeutic Massage & Bodywork Practitioners and Educators. The purpose of IJTMB’s Trigger Points is to “trigger” the sharing and discussion of knowledge and expertise among therapeutic massage and bodywork practitioners, educators, and researchers about different approaches to treating specific conditions or addressing specific population issues. Each IJTMB issue, starting with this issue, will include a call for responses to the next Trigger Points topic. Publication of the results for each topic will be in the second issue after the initial call for submissions. With your participation, these IJTMB Trigger Points columns will spark dynamic dialogue, perhaps even collaborations, in the therapeutic massage and bodywork field across practitioners, educators, and researchers.
PMCID: PMC4051805  PMID: 24920966
editorial; knowledge translation
22.  Identifying Conflicts of Interest in Therapeutic Massage and Bodywork Research 
Identifying and addressing forms of bias in research are critical to the integrity and value of research. Conflicts of interest are an important aspect of research that must be addressed equally to any other form of research bias. Conflicts of interest occur when the judgment of a party involved in the research, either a researcher or a treatment provider, may be compromised by more than one interest relative to the research. As therapeutic massage and bodywork (TMB) is a younger field of research, some forms or aspects of conflicts of interest may not be understood. This editorial explores the meaning of conflicts of interest, how to increase awareness of them, and facets of research specific to TMB that may create such conflicts. Full disclosure in grant applications and manuscripts is critical to ensure that grantors, reviewers, and users of research are better informed of potential conflicts of interest, can understand the steps taken to manage the conflicts, and ultimately can better assess the research integrity and value.
PMCID: PMC3577639  PMID: 23481665
conflict of interest; editorial; author guidelines; writing
23.  Preoperative symptom type influences the 30-day perioperative outcomes of carotid endarterectomy and carotid stenting in the Society for Vascular Surgery Vascular Registry 
Journal of vascular surgery  2014;60(3):639-644.
The objective of this study was to determine the effect of presenting symptom types on 30-day periprocedural outcomes of carotid endarterectomy (CEA) and carotid artery stenting (CAS) in contemporary vascular practice.
Retrospective review was undertaken of the Society for Vascular Surgery Vascular Registry database subjects who underwent CEA or CAS from 2004 to 2011. Patients were grouped by discrete 12-month preprocedural ipsilateral symptom type: stroke, transient ischemic attack (TIA), transient monocular blindness (TMB), or asymptomatic (ASX). Risk-adjusted odds ratios (ORs) were used to compare the likelihood of the 30-day outcomes of death, stroke, and myocardial infarction (MI) and the composite outcomes of death + stroke and death + stroke + MI.
Symptom type significantly influences risk-adjusted 30-day outcomes for carotid intervention. Presentation with stroke predicted the poorest outcomes (death + stroke + MI composite: OR, 1.3; 95% confidence interval [CI], 0.83–2.03 vs TIA; OR, 2.56; 95% CI, 1.18–5.57 vs TMB; OR, 2.12; 95% CI, 1.46–3.08 vs ASX), followed by TIA (death + stroke + MI composite: OR, 1.97; 95% CI, 0.91–4.25 vs TMB; OR, 1.63; 95% CI, 1.14–2.33 vs ASX). For both CAS and CEA patients, presentation with stroke or TIA predicted a higher risk of periprocedural stroke than in ASX patients. Presentation with stroke predicted higher 30-day risk of death with CAS but not with CEA. MI rates were not affected by presenting symptom type. The 30-day outcomes for the TMB and ASX patient groups were equivalent in both treatment arms.
Presenting symptom type significantly affects the 30-day outcomes of both CAS and CEA in contemporary vascular surgical practice. Presentation with stroke and TIA predicts higher rates of periprocedural complications, whereas TMB presentation predicts a periprocedural risk profile similar to that of ASX disease.
PMCID: PMC4287967  PMID: 25154963
24.  A Cluster-Randomised Trial Evaluating an Intervention for Patients with Stress-Related Mental Disorders and Sick Leave in Primary Care 
PLoS Clinical Trials  2007;2(6):e26.
Mental health problems often affect functioning to such an extent that they result in sick leave. The worldwide reported prevalence of mental health problems in the working population is 10%–18%. In developed countries, mental health problems are one of the main grounds for receiving disability benefits. In up to 90% of cases the cause is stress-related, and health-care utilisation is mainly restricted to primary care. The aim of this study was to assess the effectiveness of our Minimal Intervention for Stress-related mental disorders with Sick leave (MISS) in primary care, which is intended to reduce sick leave and prevent chronicity of symptoms.
Cluster-randomised controlled educational trial.
Primary health-care practices in the Amsterdam area, The Netherlands.
A total of 433 patients (MISS n = 227, usual care [UC] n = 206) with sick leave and self-reported elevated level of distress.
Forty-six primary care physicians were randomised to either receive training in the MISS or to provide UC. Eligible patients were screened by mail.
Outcome Measures:
The primary outcome measure was duration of sick leave until lasting full return to work. The secondary outcomes were levels of self-reported distress, depression, anxiety, and somatisation.
No superior effect of the MISS was found on duration of sick leave (hazard ratio 1.06, 95% confidence interval 0.87–1.29) nor on severity of self-reported symptoms.
We found no evidence that the MISS is more effective than UC in our study sample of distressed patients. Continuing research should focus on the potential beneficial effects of the MISS; we need to investigate which elements of the intervention might be useful and which elements should be adjusted to make the MISS effective.
Editorial Commentary
Background: People who take sick leave from work as a result of mental health problems very often report that the cause is stress-related. Although stress-related sick leave imposes a significant burden on individuals and economies, few evidence-based therapies exist to prevent sick leave in people who are experiencing stress-related mental health problems. The researchers carrying out this study wanted to evaluate the effectiveness of an intervention for stress-related mental health disorders amongst people who had been on sick leave for less than three months. The intervention involved short training sessions for primary health-care practitioners, during which the practitioners were taught how to diagnose stress-related problems; how to provide information to patients and encourage their recovery and active return to work; and how to give advice and monitor patients' recovery. The researchers carried out a cluster-randomized trial evaluating this training program, in which 46 primary care practitioners were assigned by chance to receive either the training program or to practice usual care. Over the course of the trial, 433 patients with elevated levels of distress and sick leave were included in the study, 227 of whom were treated by practitioners receiving the training program and 206 of whom received usual care. These patients were followed up for 12 months and the primary outcome studied in the trial was the length of sick leave taken until full return to work. Secondary outcome measures included patients' reports of distress, depression, and other symptoms as recorded using specific questionnaires.
What the trial shows: In the trial, data on the primary outcome measure was available for 87% of the patients treated by practitioners receiving the training intervention and 84% of the patients receiving usual care. When these outcomes were analyzed, there was no evidence of a benefit of the training program on amount of sick leave taken. Over the course of the study, the severity of patients' self-reported symptoms fell in both groups, but there was no significant difference in symptom severity between the two groups of patients. A subgroup analysis suggested that more practitioners in the intervention group recognized patients as having stress-related mental health problems. Among the group of patients who were diagnosed as having stress-related mental health problems, those who were treated by practitioners in the intervention group seemed to return to work slightly more quickly than those in the usual care group. However, it is not easy to interpret the findings of this secondary analysis.
Strengths and limitations: Strengths of this study include the procedures for cluster randomization, in which primary care practitioners were randomized, rather than patients. This process ensures that only patients assigned to the intervention arm receive the benefits of the intervention, and avoids “contamination” between intervention and control groups. A further strength includes the blinding of researchers who were collecting data to the intervention that each practitioner had received. The findings of the study, however, are difficult to interpret. No effect of the training intervention was found on the study's primary outcome measure; it is possible that the training intervention does indeed have some benefit, but the benefit may not have been found in this particular trial because of the inclusion of patients with a very wide range of problems; in addition the practitioners may have not had the time or ability to apply what they learnt in the training program.
Contribution to the evidence: Very little evidence exists regarding the effects of training interventions for improving care of patients with stress-related mental health problems. The findings of this trial support those of another study carried out in a primary care setting, which found that training interventions do not seem to reduce length of sick leave. However, another study carried out in an occupational health-care setting, in which patients included in the trial had been recognised as having stress-related mental disorders, did find some benefit of an intervention program.
PMCID: PMC1885369  PMID: 17549228
25.  Evaluation of antibiotic therapies for eradication of Helicobacter hepaticus. 
The newly recognized murine pathogen Helicobacter hepaticus is known to colonize the ceca and colons of several strains of mice from a variety of commercial suppliers. Additionally, the organism persistently infects mice, causes a chronic hepatitis, and is linked to hepatic tumors in the A/JCr inbred mouse strain. For this reason, eradication of the organism from infected mouse colonies is desirable. Treatment modalities for eradication of H. hepaticus from the gastrointestinal system consisted of oral administration of various antibiotic combinations previously evaluated for eradication of experimental H. felis gastric infection in mice. A/JCr mice (8 to 10 weeks old) naturally infected with H. hepaticus were divided into six treatment groups of 10 animals each. Animals received monotherapy of amoxicillin, metronidazole, or tetracycline or triple therapy of amoxicillin-metronidazole-bismuth (AMB) or tetracycline-metronidazole-bismuth (TMB). All medications were administered by oral gavage three times daily for 2 weeks. One month after the final treatment, mice were euthanatized and livers, ceca, and colons were cultured for H. hepaticus. All untreated control animals had H. hepaticus isolated from the cecum and/or colon. H. hepaticus was not recovered from the livers, ceca, or colons of the AMB or TMB treatment groups. All animals receiving the various antibiotic monotherapies had H. hepaticus isolated from the cecum and colon. We conclude that at the doses and the route evaluated, AMB and TMB triple therapies are effective for eradication of H. hepaticus in 8- to 10-week old A/JCr mice.
PMCID: PMC162729  PMID: 7574518

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