Describing the value of specialized distance education in pediatric oncology nursing

Working as specialists in a changing environment, advanced practice nurses in pediatric oncology (APN-POs) benefit from specific pediatric oncology education. The graduates of a pediatric nurse practitioner program in pediatric oncology completed a survey about their educational experience and its impact on their current practice. This practitioner program included a subspecialty education in pediatric oncology and an early form of distance learning. The respondents' answers parallel a number of emerging themes in APN-PO practice and education. Employing distance learning methods in providing subspecialty education holds important implications for future APN-PO education and practice and for the health care of communities throughout the country.

Power and influence in clinical effectiveness and evidence-based medicine

BACKGROUND

The need to base clinical interventions on valid findings of research has been a dominant theme in clinical practice during the last quarter of a century. However, there is much evidence showing that research evidence reaches everyday practice slowly. Solutions to this problem include evidence-based practice and implementation by guidelines and audit. Studies of these methods have included surveys of clinicians' views, implementation projects and evaluations of educational interventions, but they have not examined their implications for the power structure of clinical organizations. This is surprising, given the emphasis placed on medical power in sociological studies of health care.

METHODS

A framework derived from management theory defines and summarizes theories of power and influence under the headings: sources of power, overt methods of influence, unseen or covert methods of influence and individual response to influence. This framework is then used to analyse the power and influence possessed and exerted by general practitioners (GPs) and hospital consultants and how these are affected by evidence-based practice and guidelines and audit programmes.

OUTCOMES

GPs are seen as having less expert power than consultants and to be more compliant with externally managed guidelines and audit programmes. It is pointed out that compliance with guidelines and audit programmes helps GPs to meet their contractual requirement to be involved in clinical audit activities. Evidence-based practice, which directly challenges the authority of expert opinion is seen as a threat to the power of consultants, but a potential opportunity for GPs and other clinicians whose status is traditionally lower.

The future general practitioner: out of date and running out of time

In the late 1960s a Royal College of General Practitioners' working party produced a job description for the 'Future General Practitioner', together with an educational programme for vocational training. Despite the perceived success of vocational training, general practice remains academically disadvantaged compared with hospital medicine. Most general practitioners (GPs) have no contact with research or academic general practice, few achieve higher degrees compared with hospital consultants, and there are few academic posts in general practice. Junior doctors perceive general practice as offering less intrinsic job satisfaction than hospital medicine and recruitment is falling. Registrars who have completed vocational training are reluctant to commit themselves to general practice and often drift away from it. Schemes with an academic content, designed to retain doctors in general practice, have been well received but there are few career posts in academic general practice. Primary care groups and clinical governance will radically change the nature of general practice. GPs will no longer be at the centre of the primary health care team. Primary care trusts, serving populations of 100,000 or more at multiple sites, will still employ doctors but much of the traditional GP workload will be undertaken by nurses. Present day vocational training produces GPs without the skills that future 'community generalists' will need. Their training will be longer and their careers more structured than at present. They will use evidence-based practice routinely and be experts in information management, interpreting and managing complex diagnostic and therapeutic problems in the context of rapidly changing health technology.

Decision making, evidence, audit, and education: case study of antibiotic prescribing in general practice

OBJECTIVES

To describe a group general practice's implementation of a decision to prescribe 3 day courses of 200 mg trimethoprim twice daily for urinary tract infections in women and to compare 3 day courses with 5 and 7 day courses.

DESIGN

Record review, audit of trimethoprim prescribing for urinary tract infections, and critical appraisal of evidence originally presented in support of 3 day course.

SETTING

Group general practice in Newcastle upon Tyne.

DATA SOURCES

The records of all female patients aged 12 years and older who were prescribed trimethoprim for uncomplicated urinary tract infections during a 12 month period were reviewed. 271 valid records were identified.

DATA EXTRACTION

Prescribing rates for different courses of trimethoprim, rates of patients returning for second consultations, rates of urine cultures, results of cultures, results of critical appraisal of evidence.

RESULTS

114 of 271 (42%) prescriptions written at the first visit were for 3 day courses. 16 of 114 (14%) patients who had had a 3 day course of treatment returned for a second consultation compared with 6/83 (7.2%) of those who had had a 5 day course and 8/74 (11%) who had had a 7 day course. The difference between 3 day and 5 day courses in rates of returning for second consultations was 6.8% (95% CI -1.7% to 12.6%) and between 3 day and 7 day courses was 3.2% (-3.6% to 10.0%). Appraisal of the original evidence on which the practice based its recommendations showed that it was flawed. Additional evidence was found in the Cochrane Library.

CONCLUSIONS

Our original decision, made by consensus at a meeting of the practice's partners, had not led to a consistent change in practice. We did not find a significant increase in treatment failures among patients treated with the 3 day regimen.

Aggressive multimodality therapy for stage III esophageal cancer: a phase I/II study

BACKGROUND

Stage III advanced locoregional esophageal carcinoma is frequently unresectable and inconsistently represented in therapeutic trials of esophageal cancer.

METHODS

From 1992 to 1998, 34 of 131 total esophageal cancer patients were designated stage III (16 T3N1, 9 T4N0, 9 T4N1) and medically fit to enter a combined modality protocol with continuous infusion 5-fluorouracil (CIS-FU, 300 to 600 mg/m2/day), high-dose external beam irradiation (60 Gy), and interval esophagectomy. Staging before and after induction therapy included computed tomography; endoscopy, and endoscopic ultrasound.

RESULTS

Significant toxicity from induction therapy included death (5/34; 14.7%), pneumonitis (5/34; 14.7%), mucositis (13/34; 38%), and hand-foot syndrome (3/34; 8.8%). In addition to the five deaths, 11 patients did not proceed to operation because of development of esophagorespiratory fistula in 3, distant disease in 2, persistence of T4 stage in 2, progression of comorbidities in 2, and patient refusal in 2. There was a discrepancy between clinical complete response (cCR) at restaging 56% (19/34) and pathologic CR (pCR) noted at the time of operation (8/34; 23.5%). Complete resections were possible in 16 of 18 patients explored. Complications in 4 patients included: death (1), airway injury (1), chylothorax requiring reoperation (1), anastomotic leak (1), recurrent nerve injury with vocal cord paresis (2), and ascaris infection (1). Actuarial survival analysis using the Kaplan-Meier method and log-rank testing showed a 36-month survival of 20% for the group as a whole and 27% for patients restaged cCR (cCR vs PR, p = 0.0046). Treatment failure is predominantly distant, with good local control in resected patients. N0 node status was strongly associated with survival (N0 vs N1 p = 0.0024). There is a trend towards improved survival in the resected group (resected 22% vs nonresected 10% at 3 years, p = 0.17).

CONCLUSIONS

Response rates and survival are commensurate with multiple completed phase II and III trials. These are attained at a higher treatment-related mortality. T4 patients can be successfully resected in selected patients. Even in advanced disease, nodal status is a significant predictor of survival.

Coping behaviors at diagnosis and in adjustment one year later in children with diabetes

The aim of this investigation was to determine the contributions of coping behaviors used at diagnosis to medical (metabolic control) and psychosocial adjustment (self-perceived competence; adjustment) 1 year later. A total of 89 children (8 to 14 years of age; 48% male; 59% White) received follow-up quarterly from diabetes diagnosis to 1 year later. Findings indicated that, in general, although metabolic control worsened over the first year, psychosocial status and coping behaviors were stable. Boys had worse metabolic control than girls. Multiple regression analysis indicated that self-worth at 1 year postdiagnosis was associated with less use of spirituality (beta = -.44), more use of humor (beta = .28), and more positive self-care (beta = .28); and self-care was less likely to be positive in older children (r = .32). These variables accounted for 47% of the variance (39% adjusted) in general self-worth when entry self-worth was controlled. Poorer overall adjustment at 1 year postdiagnosis was associated with more use of avoidance behaviors (beta = -.47) and poorer self-care (beta = -.71); and more use of avoidance was associated with older age. These variables accounted for 62% of the variance (58% adjusted) in adjustment when adjustment at diagnosis was controlled. Poorer metabolic control was associated with more use of avoidance (beta = .30) and female gender (beta = .39), and avoidance behaviors were more common in older children (beta = .12). This model predicted 33% of the variance (25% adjusted) in metabolic control 1 year after diagnosis.