Interventions to improve cancer survivorship among Indigenous Peoples and communities: a systematic review with a narrative synthesis

PURPOSE

The purpose of this systematic review is to synthesize the evidence on the types of interventions that have been utilized by Indigenous Peoples living with cancer, and report on their relevance to Indigenous communities and how they align with holistic wellness.

METHODS

A systematic review with narrative synthesis was conducted.

RESULTS

The search yielded 7995 unique records; 27 studies evaluating 20 interventions were included. The majority of studies were conducted in USA, with five in Australia and one in Peru. Study designs were cross-sectional (n=13); qualitative (n=5); mixed methods (n=4); experimental (n=3); and quasi-experimental (n=2). Relevance to participating Indigenous communities was rated moderate to low. Interventions were diverse in aims, ingredients, and outcomes. Aims involved (1) supporting the healthcare journey, (2) increasing knowledge, (3) providing psychosocial support, and (4) promoting dialogue about cancer. The main ingredients of the interventions were community meetings, patient navigation, arts, and printed/online/audio materials. Participants were predominately female. Eighty-nine percent of studies showed positive influences on the outcomes evaluated. No studies addressed all four dimensions of holistic wellness (physical, mental, social, and spiritual) that are central to Indigenous health in many communities.

CONCLUSION

Studies we found represented a small number of Indigenous Nations and Peoples and did not meet relevance standards in their reporting of engagement with Indigenous communities. To improve the cancer survivorship journey, we need interventions that are relevant, culturally safe and effective, and honoring the diverse conceptualizations of health and wellness among Indigenous Peoples around the world.

Patient Perspectives on Managing Type 1 Diabetes During High-Performance Exercise: What Resources Do They Want?

OBJECTIVE

Athletes with type 1 diabetes face unique challenges that make it difficult for health care providers to offer concise recommendations for diabetes management. Moreover, little is known about patient preferences for diabetes management during high-level and competitive exercise. We undertook a qualitative study to understand patient perspectives on managing type 1 diabetes during exercise.

METHODS

A qualitative design using focus groups was selected. Samples of 5-10 participants per group were recruited to participate in one of three 1.5-hour sessions focusing on experiences in managing diabetes, supports, and desired resources. Sessions were audiotaped and transcribed verbatim. Data were analyzed iteratively among team members.

RESULTS

The study included 21 participants (10 male and 11 female) with a mean age of 41 years. Most participants used trial and error to manage their blood glucose around exercise. Frequent monitoring of blood glucose was a common strategy and a challenge during exercise. Hypoglycemia after exercise and adrenaline-fueled hyperglycemia during exercise were the most prevalent concerns. Most participants relied on themselves, an endocrinologist, or the Internet for support but said they would prefer to rely more on peers with type 1 diabetes and mobile apps. Peer support or mentorship was strongly supported with recommendations for moving forward.

CONCLUSION

This study highlights the individualized nature of balancing glycemic control in athletes and athletes' heavy self-reliance to develop strategies. Expanding the availability of resources such as peer mentoring and mobile apps could potentially support athletes with type 1 diabetes.

Experiences of practice facilitators working on the Improved Delivery of Cardiovascular Care project: Retrospective case study

OBJECTIVE

To examine the barriers to and facilitators of practice facilitation experienced by participants in the Improving Delivery of Cardiovascular Care (IDOCC) project.

DESIGN

Case studies of practice facilitators' narrative reports.

SETTING

Eastern Ontario.

PARTICIPANTS

Primary care practices that participated in the IDOCC project.

MAIN OUTCOME MEASURES

Cases were identified by calculating sum scores in order to determine practices' performance relative to their peers. Two case exemplars were selected that scored within ± 1 SD of the total mean score, and a qualitative analysis of practice facilitators' narrative reports was conducted using a 5-factor implementation framework to identify barriers and facilitators. Narratives were divided into 3 phases: planning, implementation, and sustainability.

RESULTS

Barriers and facilitators fluctuated over the intervention's 3 phases. Site A reported more barriers (n = 47) than facilitators (n = 38), while site B reported a roughly equal number of barriers (n = 144) and facilitators (n = 136). In both sites, the most common barriers involved organizational and provider factors and the most common facilitators were associated with innovation and structural factors.

CONCLUSION

Both practices encountered various barriers and facilitators throughout the IDOCC's 3 phases. The case studies reveal the complex interactions of these factors over time, and provide insight into the implementation of practice facilitation programs.

Improved Delivery of Cardiovascular Care (IDOCC): Findings from Narrative Reports by Practice Facilitators

Practice facilitation can help family physicians adopt evidence-based guidelines. However, many practices struggle to effectively implement practice changes that result in meaningful improvement. Building on our previous research, we examined the barriers to and enablers of implementation perceived by practice facilitators (PF) in helping practices to adopt the Improved Delivery of Cardiovascular Care (IDOCC) program, which took place at 84 primary care practices in Ottawa, Canada between April 2008 and March 2012. We conducted a qualitative analysis of PFs’ narrative reports using a multiple case study design. We used a combined purposeful sampling approach to identify cases that 1) reflected experiences typical of the broader sample and 2) presented sufficient breadth of experience from each project step and family practice model. Sampling continued until data saturation was reached. Team members conducted a qualitative analysis of reports using an open and axial coding style and a constant comparative approach. Barriers and enablers were divided into five constructs: structural, organizational, provider, patient, and innovation. Narratives from 13 practice sites were reviewed. A total of 8 barriers and 11 enablers were consistently identified across practices. Barriers were most commonly reported at the organizational (n = 3) and structural level, (n = 2) while enablers were most common at the innovation level (n = 6). While physicians responded positively to PFs’ presence and largely supported their recommendations for practice change, organizational and structural aspects such as lack of time, minimal staff engagement, and provider reimbursement remained too great for practices to successfully implement practice-level changes.

Trial Registration: ClinicalTrials.gov, NCT00574808

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Eight Barriers and 11 enablers to practice facilitation emerged across constructs.

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Barriers were most common at the structural (n = 3) and organizational (n = 2) levels.

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The majority of enablers occurred at the innovation level (n = 6).

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The Chaudoir framework provided a comprehensive picture of barriers and enablers.

Contrast monitoring techniques in CT pulmonary angiography: An important and underappreciated contributor to breast dose

OBJECTIVE

The aims of our study were to evaluate the contribution of contrast-monitoring techniques to breast dose in pregnant and non-pregnant women, and to investigate the effect of a reduced peak kilovoltage (kV) monitoring scan protocol on breast dose and Computed Tomography Pulmonary Angiography (CTPA) diagnostic quality.

MATERIALS AND METHODS

Single center retrospective study of 221 female patients undergoing a reduced kV 80kV contrast-monitoring CTPA protocol compared to 281 patients using the conventional 120kV contrast-monitoring protocol (Siemens Somatom Definition AS+). 99 pregnant patients analyzed separately. ImPACT dosimetry software was used to calculate dose. Group subsets were evaluated to assess CTPA diagnostic quality.

RESULTS

The contrast-monitoring component of a CTPA study constituted 27% of the overall breast dose when using a standard 120kV protocol compared to only 7% of the overall breast dose in the 80kV study group. The dose to the breast from the contrast-monitoring component alone was reduced by 79% in the non-pregnant patients (0.36mGy±0.37 versus 1.7mGy±1.02; p<0.001), and by 88% in the pregnant population (0.25mGy±0.67 versus 2.24mGy±1.61; p<0.001). There was no statistical difference in CTPA diagnostic quality or timing.

CONCLUSION

Despite a short scan length and relatively small DLP, contrast-monitoring techniques (test-bolus or bolus-tracked) set at 120kV can account for 27% of the overall breast dose accrued from a CTPA study. By decreasing the kilovoltage of the contrast-monitoring component, a significant reduction in breast dose for pregnant and non-pregnant female patients can be achieved without affecting CTPA quality or timing.

Understanding Audit and Feedback to Support Falls Prevention and Pain Management in Home Health Care

Audit and feedback (A&F) is commonly used to improve health care; yet enormous variability exists in effectiveness and little is known about A&F in home health care. This article explores A&F as a strategy to support evidence-based care for falls prevention and pain management. We use interviews to describe how A&F is currently used and explore how it can support patient care. Thirteen interviews were conducted with a multidisciplinary sample and descriptively analyzed. Findings showed that data were audited by frontline staff but were inconsistently fed back to the front line, and the meaning of data depended on the context and participants’ roles. Findings suggest A&F should include indicators to benchmark patient outcomes, target actionable processes of care, and be tailored to provider groups.

Perceptions of physical activity, activity preferences and health among a group of adult women in urban Ghana: a pilot study

BACKGROUND

Obesity and other lifestyle-related chronic diseases impact urban West African women at high rates. Physical activity (PA) can improve these health outcomes but there is little published data on the associated psychosocial predictors in this population.

OBJECTIVES

We aimed to explore preliminary associations between perceptions of PA, PA behaviours, and health in a group of Ghanaian women.

METHODS

Non-experimental, cross-sectional case study using a mixed-methods approach. Focus groups and in-depth interviews with a convenience sample of Ghanaian women, fitness trainers and clergy comprised the qualitative phase. A self-administered survey (n=218) comprised the quantitative phase. Constant comparative method, logistic regression, component and factor analyses were used for analysis.

RESULTS

Women viewed activities of daily living like housework as PA; rarely utilized organized fitness facilities; understood "rigorous" PA as professional male athleticism; and took interest in socialized PA. Mean age was 49.4 years. Mean body mass index was 30.3 kg/m2. The majority (75.9 %) reported exercising sometimes or often. Half (48.4%) reported a lifestyle-related chronic disease. "Weight loss," "health concerns" and "increased energy," were top motivators for PA. "Can't find the time," "work/family obligations," and "don't have a facility" were top barriers. Presence of hypertension, hypercholesterolemia and prior weight loss correlated with the slimming motivator (adjusted odds ratio 2.59, p=0.008; AOR 3.56, p=0.012; AOR 3.36, p=<0.001).

CONCLUSION

Among those surveyed, PA motivators and barriers were associated with demographics, PA exposure, and health status. Further research on unique PA perceptions, behaviours and health could catalyze health promotion through culturally relevant fitness programming.

A scoping study of cultural interventions to treat addictions in Indigenous populations: methods, strategies and insights from a Two-Eyed Seeing approach

Background

This paper describes the methods, strategies and insights gained from a scoping study using a “Two-Eyed Seeing” approach. An evolving technique, Two-Eyed Seeing respects and integrates the strengths of Indigenous knowledge and Western sciences, often “weaving back and forth” between the two worldviews. The scoping study was used to inform a tool for measuring the impact of culturally based addictions treatment services on wellness in Indigenous populations. It formed part of a three-year study, Honouring Our Strengths: Indigenous Culture as Intervention in Addictions Treatment. The scoping study identified and mapped literature on cultural interventions in addictions treatment, and described the nature, extent and gaps in literature.

Methods

Using a Two-Eyed Seeing approach, we adapted, applied and enhanced a common framework of scoping studies. In the end stage of the scoping review process, an Ad Hoc Review Group, led by our project Elder, reviewed and interpreted Indigenous and Western understandings within the mapped information. Elements of the scoping study were joined with results from community focus groups with staff at treatment centres.

Results

Two-Eyed Seeing contributed differently at each stage of the scoping study. In early stages, it clarified team expertise and potential contributions. At the mid-point, it influenced our shift from a systematic to a scoping review. Near the end, it incorporated Western and Indigenous knowledge to interpret and synthesize evidence from multiple sources.

Conclusions

This paper adds to the collective work on augmenting the methodology of scoping studies. Despite the challenges of a Two-Eyed Seeing approach, it enables researchers using scoping studies to develop knowledge that is better able to translate into meaningful findings for Indigenous communities.

Research as Cultural Renewal: Applying Two-Eyed Seeing in a Research Project about Cultural Interventions in First Nations Addictions Treatment

This article explores the application of two-eyed seeing in the first year of a three-year study about the effectiveness of cultural interventions in First Nations alcohol and drug treatment in Canada. Two-eyed seeing is recognized by Canada's major health research funder as a starting point for bringing together the strengths of Indigenous and Western ways of knowing. With the aim of developing a culture-based measurement tool, our team carried out an Indigenous-centred research process with our interpretation of two-eyed seeing as a guiding principle. This enabled us to engage in a decolonizing project that prioritized Indigenous methodologies and ways of knowing and knowledge alongside those of Western science. By concentrating on Indigenous governance in the research process, our project supported efforts at Indigenous cultural renewal. Two illustrations are offered, our team's reconceptualization of Western derived understandings of data collection through Indigenous storytelling and our research grant timeframe with Indigenous knowledge gardening. This article contributes to the Indigenous research and policy literature which is lacking documentation about how Indigenous communities and research teams are benefitting from two-eyed seeing.

Cultural interventions to treat addictions in Indigenous populations: findings from a scoping study

Background

Cultural interventions offer the hope and promise of healing from addictions for Indigenous people.^a However, there are few published studies specifically examining the type and impact of these interventions. Positioned within the Honouring Our Strengths: Culture as Intervention project, a scoping study was conducted to describe what is known about the characteristics of culture-based programs and to examine the outcomes collected and effects of these interventions on wellness.

Methods

This review followed established methods for scoping studies, including a final stage of consultation with stakeholders. The data search and extraction were also guided by the “PICO” (Patient/population, Intervention, Comparison, and Outcome) method, for which we defined each element, but did not require direct comparisons between treatment and control groups. Twelve databases from the scientific literature and 13 databases from the grey literature were searched up to October 26, 2012.

Results

The search strategy yielded 4,518 articles. Nineteen studies were included from the United States (58%) and Canada (42%), that involved residential programs (58%), and all (100%) integrated Western and culture-based treatment services. Seventeen types of cultural interventions were found, with sweat lodge ceremonies the most commonly (68%) enacted. Study samples ranged from 11 to 2,685 clients. Just over half of studies involved quasi-experimental designs (53%). Most articles (90%) measured physical wellness, with fewer (37%) examining spiritual health. Results show benefits in all areas of wellness, particularly by reducing or eliminating substance use problems in 74% of studies.

Conclusions

Evidence from this scoping study suggests that the culture-based interventions used in addictions treatment for Indigenous people are beneficial to help improve client functioning in all areas of wellness. There is a need for well-designed studies to address the question of best relational or contextual fit of cultural practices given a particular place, time, and population group. Addiction researchers and treatment providers are encouraged to work together to make further inroads into expanding the study of culture-based interventions from multiple perspectives and locations.

Understanding whole systems change in health care: the case of nurse practitioners in Canada

Nurse practitioners (NPs) were introduced into the Canadian health system almost half a century ago. Despite early evidence of their effectiveness, it took decades to establish a substantial critical mass of NPs. Using the NP as a case study exemplar, we adopted a whole system change perspective to understand what else besides evidence was needed to ensure the success of desirable health systems innovations. We identified elements of whole systems change to analyze literature on the NP movement in terms of leverages, blockages, and system dynamics. Results suggest that evidence was only one of many factors shaping the uptake of NP services as part of larger, ongoing, adaptive whole systems change. The changes required to integrate the NP role within the health system reflect a socio-ecological perspective that may be used to understand sustainable health systems innovation and improvement.

The role of nursing best practice champions in diffusing practice guidelines: a mixed methods study

BACKGROUND

While the importance of nursing best practice champions has been widely promoted in the diffusion of evidence-based practice, there has been little research about their role. By learning more about what champions do in guideline diffusion, the nursing profession can more proactively manage and facilitate the role of champions while capitalizing on their potential to be effective leaders of the health care system.

AIM

To determine how nursing best practice champions influence the diffusion of Best Practice Guideline recommendations.

METHODS

A mixed method sequential triangulation design was used involving two phases: (1) key informant interviews with 23 champions between February and July 2006 and (2) a survey of champions (N= 191) and administrators (N= 41) from September to October 2007. Qualitative findings informed the development of surveys and were used in interpreting quantitative information collected in phase 2.

RESULTS

Most interview and survey participants were female, employed full-time, and had worked in practice for over 20 years. Qualitative and quantitative findings suggest that champions influence the use of Best Practice Guideline recommendations most readily through: (1) dissemination of information about clinical practice guidelines, specifically through education and mentoring; (2) being persuasive practice leaders at interdisciplinary committees; and (3) tailoring the guideline implementation strategies to the organizational context.

CONCLUSIONS AND IMPLICATIONS

Our research suggests that nursing best practice champions have a multidimensional role that is well suited to navigating the complexities of a dynamic health system to create positive change. Understanding of this role can help service organizations and the nursing profession more fully capitalize on the potential of champions to influence and implement evidence-based practices to advance positive patient, organizational, and system outcomes.

Transition from specialist to primary diabetes care: a qualitative study of perspectives of primary care physicians

Background

The growing prevalence of diabetes and heightened awareness of the benefits of early and intensive disease management have increased service demands and expectations not only of primary care physicians but also of diabetes specialists. While research has addressed issues related to referral into specialist care, much less has been published about the transition from diabetes specialists back to primary care. Understanding the concerns of family physicians related to discharge of diabetes care from specialist centers can support the development of strategies that facilitate this transition and result in broader access to limited specialist services. This study was undertaken to explore primary care physician (PCP) perspectives and concerns related to reassuming responsibility for diabetes care after referral to a specialized diabetes center.

Methods

Qualitative data were collected through three focus groups. Sessions were audio-taped and transcribed verbatim. Data were coded and sorted with themes identified using a constant comparison method. The study was undertaken through the regional academic referral center for adult diabetes care in Ottawa, Canada. Participants included 22 primary care physicians representing a variety of referral frequencies, practice types and settings.

Results

Participants described facilitators and barriers to successful transition of diabetes care at the provider, patient and systems level. Major facilitators included clear communication of a detailed, structured plan of care, ongoing access to specialist services for advice or re-referral, continuing education and mentoring for PCPs. Identified provider barriers were gaps in PCP knowledge and confidence related to diabetes treatment, excessive workload and competing time demands. Systems deterrents included reimbursement policies for health professionals and inadequate funding for diabetes medications and supplies. At the PCP-patient interface, insufficient patient confidence or trust in PCP's ability to manage diabetes, poor motivation and "non-compliance" emerged as potential patient barriers to transition. Incongruence between PCP attitudes and expectations related to diabetes self-management and those of patients who had attended a multidisciplinary specialist center was also observed.

Conclusion

This study underlines the breadth of PCP concerns related to transition of diabetes care and the importance of this topic to them. While tools that promote timely information flow and care planning are cornerstones to successful transition, and may be sufficient for some practitioners, appropriately resourced decision support and education strategies should also be available to enhance PCP capacity and readiness to resume diabetes care after referral to a specialist center. Characteristics of the patient-care provider relationship that impact discharge were identified and are worthy of further research.

Just-in-time information improved decision-making in primary care: a randomized controlled trial

BACKGROUND

The "Just-in-time Information" (JIT) librarian consultation service was designed to provide rapid information to answer primary care clinical questions during patient hours. This study evaluated whether information provided by librarians to answer clinical questions positively impacted time, decision-making, cost savings and satisfaction.

METHODS AND FINDING

A randomized controlled trial (RCT) was conducted between October 2005 and April 2006. A total of 1,889 questions were sent to the service by 88 participants. The object of the randomization was a clinical question. Each participant had clinical questions randomly allocated to both intervention (librarian information) and control (no librarian information) groups. Participants were trained to send clinical questions via a hand-held device. The impact of the information provided by the service (or not provided by the service), additional resources and time required for both groups was assessed using a survey sent 24 hours after a question was submitted. The average time for JIT librarians to respond to all questions was 13.68 minutes/question (95% CI, 13.38 to 13.98). The average time for participants to respond their control questions was 20.29 minutes/question (95% CI, 18.72 to 21.86). Using an impact assessment scale rating cognitive impact, participants rated 62.9% of information provided to intervention group questions as having a highly positive cognitive impact. They rated 14.8% of their own answers to control question as having a highly positive cognitive impact, 44.9% has having a negative cognitive impact, and 24.8% with no cognitive impact at all. In an exit survey measuring satisfaction, 86% (62/72 responses) of participants scored the service as having a positive impact on care and 72% (52/72) indicated that they would use the service frequently if it were continued.

CONCLUSIONS

In this study, providing timely information to clinical questions had a highly positive impact on decision-making and a high approval rating from participants. Using a librarian to respond to clinical questions may allow primary care professionals to have more time in their day, thus potentially increasing patient access to care. Such services may reduce costs through decreasing the need for referrals, further tests, and other courses of action.

TRIAL REGISTRATION

Controlled-Trials.com ISRCTN96823810.

Framework for primary care organizations: the importance of a structural domain

Purpose

Conceptual frameworks for primary care have evolved over the last 40 years, yet little attention has been paid to the environmental, structural and organizational factors that facilitate or moderate service delivery. Since primary care is now of more interest to policy makers, it is important that they have a comprehensive and balanced conceptual framework to facilitate their understanding and appreciation. We present a conceptual framework for primary care originally developed to guide the measurement of the performance of primary care organizations within the context of a large mixed-method evaluation of four types of models of primary care in Ontario, Canada.

Methods

The framework was developed following an iterative process that combined expert consultation and group meetings with a narrative review of existing frameworks, as well as trends in health management and organizational theory.

Results

Our conceptual framework for primary care has two domains: structural and performance. The structural domain describes the health care system, practice context and organization of the practice in which any primary care organization operates. The performance domain includes features of health care service delivery and technical quality of clinical care.

Conclusion

As primary care evolves through demonstration projects and reformed delivery models, it is important to evaluate its structural and organizational features as these are likely to have a significant impact on performance.

Chronic exposure to 2,5-hexanedione impairs the glutamate-nitric oxide-cyclic GMP pathway in cerebellar neurons in culture and in rat brain in vivo

2,5-Hexanedione is a neurotoxic metabolite of hexane. The mechanisms of its neurotoxicity remain unclear. We assessed whether chronic exposure to 2,5-hexanedione affects the glutamate-nitric oxide-cGMP pathway in primary cultures of cerebellar neurons and/or in the cerebellum of rats. Chronic exposure of cultured cerebellar neurons to 2,5-hexanedione (200 microM) reduced by approximately 50% NMDA-induced formation of cGMP. Activation of soluble guanylate cyclase by nitric oxide was reduced by 46%. This treatment reduced the content of neuronal nitric oxide synthase and soluble guanylate cyclase in neurons by 23 and 20%, respectively. In the cerebellum of rats chronically exposed to 2,5-hexanedione (in the drinking water) NMDA-induced formation of cGMP was reduced by 55% as determined by in vivo brain microdialysis. Activation of soluble guanylate cyclase by nitric oxide was reduced by 65%. The content of neuronal nitric oxide synthase and of soluble guanylate cyclase was reduced by 25 and 21%, respectively, in the cerebellum of these rats. The effects are the same in both systems, indicating that cultured neurons are a good model to study the mechanisms of neurotoxicity of 2,5-hexanedione. These results indicate that chronic exposure to 2,5-hexanedione affects the glutamate-nitric oxide-cGMP pathway at different steps both in cultured neurons and in cerebellum of the animal in vivo. The alteration of this pathway may contribute to the neurotoxic effects of 2,5-hexanedione.

Endogenous sex hormone levels in postmenopausal women with Alzheimer's disease

A cross-sectional study examined whether there was a difference in endogenous serum sex hormone levels between community-dwelling postmenopausal women with Alzheimer's disease (AD) and healthy controls. Total morning levels of serum estrone, estradiol, androstenedione, testosterone, and cortisol were measured in 52 nondepressed women with AD and 60 postmenopausal women who were neither depressed nor cognitively impaired. Estradiol was undetectable in 35.7% of cases, but detectable hormone was found in 96-100% of cases otherwise. After adjustment for potential confounds, serum levels were significantly higher for estrone (P = 0.0057) and androstenedione (P = 0.02), but not testosterone (P = 0.086) or estradiol (P = 0.59), in subjects with AD. Sex hormone levels did not correlate with cognitive scores in either group. Although the failure to detect estradiol in a third of cases limits the conclusions that can be drawn for this hormone, the possibility that AD is associated with abnormalities in certain serum sex hormone levels should be considered and warrants further research.

Qualitative studies. Their role in medical research

OBJECTIVE

To define qualitative research in terms of its philosophical roots, the questions it addresses, its methods and analyses, and the type of results it can offer.

DATA SOURCES

MEDLINE and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched for the years January 1985 to April 1998. The search strategy consisted of "textword" terms that searched in the "title" field of both databases. Qualitative research and evaluation textbooks in health and the social sciences were also used.

QUALITY OF EVIDENCE

The information on qualitative research is based on the most recent and valid evidence from the health and social science fields.

MAIN MESSAGE

Qualitative research seeks to understand and interpret personal experience to explain social phenomena, including those related to health. It can address questions that quantitative research cannot, such as why people do not adhere to a treatment regimen or why a certain health care intervention is successful. It uses many methods of data collection, including participant observation, case studies, and interviews, and numerous approaches to data analysis that range from the quasistatistical to the intuitive and inductive.

CONCLUSIONS

Qualitative research, a form of research completely different from quantitative research, can provide important insights into health-related phenomena and can enrich further research inquiries.

Effect of enalapril therapy on left ventricular mass and volumes in asymptomatic chronic, severe mitral regurgitation secondary to mitral valve prolapse

Quantitative 2-dimensional and Doppler echocardiography was used to assess the longitudinal effects of angiotensin-converting enzyme inhibition in asymptomatic patients with chronic, severe mitral regurgitation due to mitral valve prolapse. Over a 6-month period, angiotensin-converting enzyme inhibition therapy resulted in significant reductions in left ventricular volumes and mass in association with a minor reduction in regurgitant fraction.

Progress in the moral reasoning of baccalaureate nursing students between program entry and exit

Changes in moral reasoning between entry into and exit from a baccalaureate nursing program and the relationship between student characteristics and moral reasoning at entry and exit were explored in this descriptive study. The moral reasoning of four cohorts of students was measured using the Defining Issues Test (DIT). Admission grade point average, prior college credits, and gender accounted for 10% of the variance in DIT P% scores at entry and 14% of the variance at exit from the program. Female students had significantly higher moral reasoning scores than men. Age did not contribute significantly to explaining DIT score variance. DIT P% scores at entry for all four cohorts were within the range of reported norms for college students. Exit scores for all four cohorts were between the normative means for undergraduate students and graduate students. DIT P% score gains between entry and exit were significant for all four cohorts. Students whose entry scores were in the lowest categories had the greatest mean gains.

Block of HFS-induced LTP in the dentate gyrus by 1S,3S-ACPD: further evidence against LTP as a model for learning

We have previously shown that block of high-frequency stimulation (HFS) induced long-term potentiation (LTP) of synaptic transmission in area CA1 by (1S,3S)-1-aminocyclopentane-1,3-dicarboxylic acid (1S,3S-ACPD; 5 microliters of a 20 mM solution), an agonist at group II metabotropic glutamate receptors, did not prevent animals from learning a spatial task. Here we show that the same dose of 1S,3S-ACPD also blocked the induction of HFS-induced LTP of the slope of the excitatory postsynaptic potential and of the amplitude of the population spike in the dentate gyrus. We conclude that HFS-induced LTP in the dentate gyrus is not a good model for memory formation.

Event-related potential prolongation in Alzheimer's disease signifies frontal lobe impairment: evidence from SPECT imaging

BACKGROUND

The N2 and P3 components of auditory event-related potentials (ERPs) and single-photon emission computed tomographic (SPECT) images are separate independent biological markers of cerebral function and are abnormal in Alzheimer's disease (AD). The relationship between ERP N2 and P3 latencies and regional cerebral perfusion abnormalities in AD is unknown.

METHODS

ERP and SPECT data were obtained one week apart in 18 patients with "probable" AD of mild or moderate severity, and 12 healthy age-matched elderly controls. Average premotor frontal, anterior temporal, inferior parietal, and occipital cortical/cerebellar perfusion ratios were calculated from the SPECT data and correlations with ERP N2 and P3 latencies derived for AD and control groups separately.

RESULTS

ERP N2 latency was correlated significantly with the average frontal perfusion ratio (r = -.59; p < .009), but correlations with average temporal, parietal, and occipital ratios were nonsignificant in the AD group. Similarly, ERP P3 latency was correlated significantly with the average frontal perfusion ratio (r = -.65; p < .004), but not with the other perfusion ratios in the AD group. In the control group, a partial correlation between the average frontal perfusion ratio and the ERP N2 latency was noted (r = -.52; p < .09), but no other ERP/SPECT correlations approached statistical significance.

CONCLUSION

ERP N2 and P3 latency delay in AD is a function of differential frontal lobe hypoperfusion.

Clinical application of electrophysiological markers in the differential diagnosis of depression and very mild Alzheimer's disease

BACKGROUND

Current evidence indicates that, on their own, neither flash visual evoked responses (FVEPs) nor event related potentials (ERPs) are sufficiently useful to the clinician in the very early stages of memory dysfunction. However, the possibilities for the combined use of these measures has not been fully explored.

METHODS

This study examined the clinical utility of combined FVEP and ERP-P300 component latencies as predictive markers in 16 patients with Alzheimer's disease, 15 patients with depression, and 21 control subjects.

RESULTS

There were significant group differences in FVEP P2 latency (P = 0.004) between the controls and both the depressive patients and those with very mild Alzheimer's disease. There were no statistically significant group differences for the ERP component (N2/P300) amplitudes or latencies. The P300 component latency was positively correlated with both the FVEP N2 and FVEP P2 component latencies in the patients with Alzheimer's disease but not in the control subjects or the depressed patients. A discriminant function, using two ERP and two FVEP component measures, gave an overall correct classification rate for dementia of 78%. In this study of very mildly impaired patients the FVEP latencies provided a more sensitive marker for the presence of cognitive dysfunction than P300 latency delay.

CONCLUSIONS

The findings support the use of multimodal evoked potentials in the differential diagnosis of very mild Alzheimer's disease and normal aging.

The Clinical Evaluation Tool: A Measure of the Quality of Clinical Performance of Baccalaureate Nursing Students

This article describes an approach to the evaluation of students' clinical performance. Specifically, the paper describes: (a) the history of the evaluation of clinical performance in nursing education; (b) the development of the Clinical Evaluation Tool (CET), an instrument designed to measure the clinical performance of nursing students across settings; and (c) the relationships between basic baccalaureate nursing students' scores on the CET and the following variables: age, college credits earned prior to entry to the program, grade point average at entry, college aptitude, and moral reasoning.

Primary auditory pathway and reticular activating system dysfunction in Alzheimer's disease

Patients with Alzheimer's disease (AD) have pathologic involvement of several important components of the primary auditory pathway, including the inferior colliculus, medial geniculate body, primary auditory cortex, and secondary auditory cortex. The main components of the brainstem auditory evoked response (BAER) and middle latency response (MLR) reflect the function of portions of the primary auditory pathway, including those affected pathologically in AD. The amplitude of the P1 component of the MLR reflects the degree of neuronal activity of midbrain portions of the ascending reticular activating system (ARAS) with cortical cholinergic projections. To determine whether there is dysfunction of the primary auditory pathway and ARAS in AD, we compared simultaneous BAER and MLR component latency and amplitude measurements in patients with mild-moderate AD (n = 35) and age-matched healthy elderly controls (n = 34). There were significant latency delays in brainstem transmission time (BAER I-V interpeak latency; p < 0.05) and in primary auditory cortex evoked potential generation (MLR Pa latency; p < 0.05) in the AD group compared with controls. In addition, there was a significant reduction in the P1 component amplitude of the MLR in the AD group (p < 0.01). These results indicate dysfunction of the primary auditory pathway and ARAS in patients with mild-moderate AD and support the hypothesis that impairment of auditory function and of arousal are intrinsic features of AD.

Increased left ventricular mass after thoracotomy and pericardiotomy. A role for relief of pericardial constraint?

BACKGROUND

Myocardial stretch and increased ventricular filling can lead to increased rates of myocardial protein synthesis. In animal studies, left ventricular mass increases after pericardiectomy, suggesting relief of a biologically meaningful restraining role and a resultant stimulus for growth. The present study was designed to test the hypothesis that combined thoracotomy and pericardiotomy leads to left ventricular hypertrophy in patients with normal left ventricular ejection fraction undergoing elective bypass surgery.

METHODS AND RESULTS

Twenty-five patients with normal left ventricular ejection fraction without active myocardial ischemia underwent Doppler and quantitative two-dimensional echocardiography 1 day before and 6 weeks and 7 months after elective coronary artery bypass surgery. The pericardium was left widely incised in all patients. Left ventricular end-systolic volume, end-diastolic volume, stroke volume, ejection fraction, end-systolic circumferential wall stress, and mass were measured. Left ventricular end-diastolic volume index increased from 51 +/- 11 mL/m2 to 62 +/- 14 mL/m2 (p < 0.05) at 6 weeks and to 66 +/- 14 mL/m2 (p < 0.05 versus baseline, p = NS versus 6 weeks) at 7 months. Left ventricular mass index increased from 109 +/- 23 g/m2 to 127 +/- 24 g/m2 (p < 0.05) at 6 weeks and to 131 +/- 23 g/m2 (p < 0.05 versus baseline, p = NS versus 6 weeks) at 7 months. There were no changes in systolic or diastolic blood pressures, end-systolic circumferential wall stress, or end-systolic volume.

CONCLUSIONS

Patients with normal left ventricular ejection fraction develop increases in left ventricular end-diastolic volume and mass after coronary artery bypass surgery. These findings support the hypothesis that the increase in left ventricular end-diastolic volume associated with thoracotomy and pericardiotomy leads to myocardial growth and an increase in left ventricular mass.

Parkinson's dementia and Alzheimer's dementia: an evoked potential comparison

Auditory endogenous event-related potentials (ERPs) and flash visual evoked potentials (VEPs) were recorded in 26 elderly patients with idiopathic Parkinson's disease (PD), 14 with dementia and 12 non-demented, 16 elderly patients with Alzheimer dementia (AD) and 15 cognitively intact controls. ERP P3 and flash-VEP N2, P2 and delta (P2-P1) latency measures were significantly increased in the demented PD group compared with controls. The ERP P3 latency was also significantly delayed in the AD group compared with controls, but the differences in the flash-VEP measures from controls were not significant. No significant differences were noted between the PD groups, except for a significantly shorter flash-VEP N1 latency in the demented PD group; this was also the only significant evoked potential difference between the AD and PD dementia groups, which were otherwise electrophysiologically similar.

The effects of trans-ACPD on long-term potentiation in the rat hippocampal slice

Trans-ACPD, a metabotropic glutamate receptor agonist, enhanced both the short-term potentiation (STP) at 1 and 5 min, and long-term potentiation (LTP) at 20 min, following tetanic stimulation, of the population, excitatory postsynaptic potential (epsp) recorded from CA1 of the rat hippocampal slice. The enhancement of both STP and LTP also occurred in the presence of the protein kinase inhibitor sphingosine, indicating that the enhancement is most likely to occur through the inositol phosphate rather than the protein kinase limb following receptor activation and phosphoinositide hydrolysis. LTP of the low frequency population epsp was not induced by t-ACPD, even at 100 microM. The metabotropic glutamate receptor may have an important role in LTP induction or modulation.

Inhibition of an N-methyl-D-aspartate induced short-term potentiation in the rat hippocampal slice

The effects of the phorbol ester 4 beta-phorbol-12,13 dibutyrate (PDBu) and the protein kinase (PK) inhibitors H-7 and sphingosine were investigated on the short-term potentiation (STP) of the population excitatory postsynaptic potential (EPSP) induced by perfusion of N-methyl-D-aspartate (NMDA) in the stratum radiatum of CA1 of the rat hippocampal slice. Bath perfusion of 130 microM NMDA for 10 s caused an initial depression of the population EPSP followed by a STP, which averaged 46% and lasted 16 min. PDBu (100 nM) perfused for 2 h completely inhibited the NMDA induced STP, suggesting that the stimulation of PKC inhibited an NMDA receptor activated process which induced the STP. The protein kinase inhibitors H-7 and sphingosine did not alter the NMDA induced STP.

The effects of external calcium on the N-methyl-D-aspartate induced short-term potentiation in the rat hippocampal slice

The effect of altered extracellular Ca concentration was studied on the N-methyl-D-aspartate (NMDA) induced short-term potentiation (STP) of the population excitatory post-synaptic potential recorded from the stratum radiatum of CA1 of the rat hippocampal slice. Perfusion of 130 microM of NMDA for 10 s in control media containing 2.0 mM extracellular Ca evoked an STP with a maximum amplitude of 46% and a duration of 16 min. Perfusion of media containing a reduced Ca concentration of 0.8 mM or 1.0 mM did not alter the amplitude or time course of the STP. However, raising the Ca concentration to 3.0 mM or 4.0 mM caused a significant reduction in the amplitude of the STP to 23% and 2% respectively. The abolition of the NMDA induced STP in 4 mM Ca could not have been produced by response saturation since an identical long-term potentiation (LTP) was produced in this high Ca media as in the control media. These studies show that the NMDA induced STP has a very different Ca dependency to LTP.

Dandelion dermatitis

7 subjects, each giving a history suggesting dandelion dermatitis, were patch tested with extracts of dandelion as well as with other common members of the Compositae and to the sesquiterpene-lactone-mix. All were positive to dandelion extracts but only 2 reacted to the sesquiterpene-lactone-mix. Although the mix is a useful screening test for chrysanthemum dermatitis, it may miss dandelion allergy.