Developing patient-centred care: an ethnographic study of patient perceptions and influence on quality improvement

BACKGROUND

Understanding quality improvement from a patient perspective is important for delivering patient-centred care. Yet the ways patients define quality improvement remains unexplored with patients often excluded from improvement work. We examine how patients construct ideas of 'quality improvement' when collaborating with healthcare professionals in improvement work, and how they use these understandings when attempting to improve the quality of their local services.

METHODS

We used in-depth interviews with 23 'patient participants' (patients involved in quality improvement work) and observations in several sites in London as part of a four-year ethnographic study of patient and public involvement (PPI) activities run by Collaborations for Leadership in Applied Health Research and Care for Northwest London. We took an iterative, thematic and discursive analytical approach.

RESULTS

When patient participants tried to influence quality improvement or discussed different dimensions of quality improvement their accounts and actions frequently started with talk about improvement as dependent on collective action (e.g. multidisciplinary healthcare professionals and the public), but usually quickly shifted away from that towards a neoliberal discourse emphasising the role of individual patients. Neoliberal ideals about individual responsibility were taken up in their accounts moving them away from the idea of state and healthcare providers being held accountable for upholding patients' rights to quality care, and towards the idea of citizens needing to work on self-improvement. Participants portrayed themselves as governed by self-discipline and personal effort in their PPI work, and in doing so provided examples of how neoliberal appeals for self-regulation and self-determination also permeated their own identity positions.

CONCLUSIONS

When including patient voices in measuring and defining 'quality', governments and public health practitioners should be aware of how neoliberal rationalities at the heart of policy and services may discourage consumers from claiming rights to quality care by contributing to public unwillingness to challenge the status quo in service provision. If the democratic potential of patient and public involvement initiatives is to be realised, it will be crucial to help citizens to engage critically with how neoliberal rationalities can undermine their abilities to demand quality care.

Patient and public attitudes towards informed consent models and levels of awareness of Electronic Health Records in the UK

BACKGROUND

The development of Electronic Health Records (EHRs) forms an integral part of the information strategy for the National Health Service (NHS) in the UK, with the aim of facilitating health information exchange for patient care and secondary use, including research and healthcare planning. Implementing EHR systems requires an understanding of patient expectations for consent mechanisms and consideration of public awareness towards information sharing as might be made possible through integrated EHRs across primary and secondary health providers.

OBJECTIVES

To explore levels of public awareness about EHRs and to examine attitudes towards different consent models with respect to sharing identifiable and de-identified records for healthcare provision, research and planning.

METHODS

A cross-sectional questionnaire survey was administered to adult patients and members of the public in primary and secondary care clinics in West London, UK in 2011. In total, 5331 individuals participated in the survey, and 3157 were included in the final analysis.

RESULTS

The majority (91%) of respondents expected to be explicitly asked for consent for their identifiable records to be accessed for health provision, research or planning. Half the respondents (49%) did not expect to be asked for consent before their de-identified records were accessed. Compared with White British respondents, those from all other ethnic groups were more likely to anticipate their permission would be obtained before their de-identified records were used. Of the study population, 59% reported already being aware of EHRs before the survey. Older respondents and individuals with complex patterns of interaction with healthcare services were more likely to report prior awareness of EHRs. Individuals self-identifying as belonging to ethnic groups other than White British, and those with lower educational qualifications were less likely to report being aware of EHRs than White British respondents and respondents with degree-level education, respectively. Those who reported being aware of EHRs were less likely to say they expected explicit consent to be sought before use of their de-identified record.

CONCLUSIONS

A large number of patients remain unaware of EHRs, while preference for implicit consent is stronger among those who report previous awareness. Differences in awareness levels and consent expectations between groups with different socio-demographic characteristics suggest that public education and information campaigns should target specific groups to increase public awareness and ensure meaningful informed consent mechanisms.

Anal heterosex among young people and implications for health promotion: a qualitative study in the UK

OBJECTIVE

To explore expectations, experiences and circumstances of anal sex among young people.

DESIGN

Qualitative, longitudinal study using individual and group interviews.

PARTICIPANTS

130 men and women aged 16-18 from diverse social backgrounds.

SETTING

3 contrasting sites in England (London, a northern industrial city, rural southwest).

RESULTS

Anal heterosex often appeared to be painful, risky and coercive, particularly for women. Interviewees frequently cited pornography as the 'explanation' for anal sex, yet their accounts revealed a complex context with availability of pornography being only one element. Other key elements included competition between men; the claim that 'people must like it if they do it' (made alongside the seemingly contradictory expectation that it will be painful for women); and, crucially, normalisation of coercion and 'accidental' penetration. It seemed that men were expected to persuade or coerce reluctant partners.

CONCLUSIONS

Young people's narratives normalised coercive, painful and unsafe anal heterosex. This study suggests an urgent need for harm reduction efforts targeting anal sex to help encourage discussion about mutuality and consent, reduce risky and painful techniques and challenge views that normalise coercion.

Patient and public views on electronic health records and their uses in the United kingdom: cross-sectional survey

Background

The development and implementation of electronic health records (EHRs) remains an international challenge. Better understanding of patient and public attitudes and the factors that influence overall levels of support toward EHRs is needed to inform policy.

Objective

To explore patient and public attitudes toward integrated EHRs used simultaneously for health care provision, planning and policy, and health research.

Methods

Cross-sectional questionnaire survey administered to patients and members of the public who were recruited from a stratified cluster random sample of 8 outpatient clinics of a major teaching hospital and 8 general practices in London (United Kingdom).

Results

5331 patients and members of the public responded to the survey, with 2857 providing complete data for the analysis presented here. There were moderately high levels of support for integrated EHRs used simultaneously for health care provision, planning and policy, and health research (1785/2857, 62.47%), while 27.93% (798/2857) of participants reported being undecided about whether or not they would support EHR use. There were higher levels of support for specific uses of EHRs. Most participants were in favor of EHRs for personal health care provision (2563/2857, 89.71%), with 66.75% (1907/2857) stating that they would prefer their complete, rather than limited, medical history to be included. Of those “undecided” about integrated EHRs, 87.2% (696/798) were nevertheless in favor of sharing their full (373/798, 46.7%) or limited (323/798, 40.5%) records for health provision purposes. There were similar high levels of support for use of EHRs in health services policy and planning (2274/2857, 79.59%) and research (2325/2857, 81.38%), although 59.75% (1707/2857) and 67.10% (1917/2857) of respondents respectively would prefer their personal identifiers to be removed. Multivariable analysis showed levels of overall support for EHRs decreasing with age. Respondents self-identifying as Black British were more likely to report being undecided or unsupportive of national EHRs. Frequent health services users were more likely to report being supportive than undecided.

Conclusions

Despite previous difficulties with National Health Service (NHS) technology projects, patients and the public generally support the development of integrated EHRs for health care provision, planning and policy, and health research. This support, however, varies between social groups and is not unqualified; relevant safeguards must be in place and patients should be guided in their decision-making process, including increased awareness about the benefits of EHRs for secondary uses.

Effects of community participation on improving uptake of skilled care for maternal and newborn health: a systematic review

BACKGROUND

Despite a broad consensus that communities should be actively involved in improving their own health, evidence for the effect of community participation on specific health outcomes is limited. We examine the effectiveness of community participation interventions in maternal and newborn health, asking: did participation improve outcomes? We also look at how the impact of community participation has been assessed, particularly through randomised controlled trials, and make recommendations for future research. We highlight the importance of qualitative investigation, suggesting key areas for qualitative data reporting alongside quantitative work.

METHODS AND FINDINGS

Systematic review of published and 'grey' literature from 1990. We searched 11 databases, and followed up secondary references. Main outcome measures were the use of skilled care before/during/after birth and maternal/newborn mortality/morbidity. We included qualitative and quantitative studies from any country, and used a community participation theoretical framework to analyse the data. We found 10 interventions. Community participation had largely positive impacts on maternal/newborn health as part of a package of interventions, although not necessarily on uptake of skilled care. Interventions improving mortality or use of skilled care raised awareness, encouraged dialogue and involved communities in designing solutions-but so did those showing no effect.

DISCUSSION

There are few high-quality, quantitative studies. We also lack information about why participation interventions do/do not succeed - an area of obvious interest for programme designers. Qualitative investigation can help fill this information gap and should be at the heart of future quantitative research examining participation interventions - in maternal/newborn health, and more widely. This review illustrates the need for qualitative investigation alongside RCTs and other quantitative studies to understand complex interventions in context, describe predicted and unforeseen impacts, assess potential for generalisability, and capture the less easily measurable social/political effects of encouraging participation.

Survey of patient and public perceptions of electronic health records for healthcare, policy and research: study protocol

Background

Immediate access to patients’ complete health records via electronic databases could improve healthcare and facilitate health research. However, the possible benefits of a national electronic health records (EHR) system must be balanced against public concerns about data security and personal privacy. Successful development of EHR requires better understanding of the views of the public and those most affected by EHR: users of the National Health Service. This study aims to explore the correlation between personal healthcare experience (including number of healthcare contacts and number and type of longer term conditions) and views relating to development of EHR for healthcare, health services planning and policy and health research.

Methods/design

A multi-site cross-sectional self-complete questionnaire designed and piloted for use in waiting rooms was administered to patients from randomly selected outpatients’ clinics at a university teaching hospital (431 beds) and general practice surgeries from the four primary care trusts within the catchment area of the hospital. All patients entering the selected outpatients clinics and general practice surgeries were invited to take part in the survey during August-September 2011. Statistical analyses will be conducted using descriptive techniques to present respondents’ overall views about electronic health records and logistic regression to explore associations between these views and participants’ personal circumstances, experiences, sociodemographics and more specific views about electronic health records.

Discussion

The study design and implementation were successful, resulting in unusually high response rates and overall recruitment (85.5%, 5336 responses). Rates for face-to-face recruitment in previous work are variable, but typically lower (mean 76.7%, SD 20). We discuss details of how we collected the data to provide insight into how we obtained this unusually high response rate.

Evaluating social and behavioural impacts of English smoke-free legislation in different ethnic and age groups: implications for reducing smoking-related health inequalities

OBJECTIVE

To explore social and behavioural impacts of English smoke-free legislation (SFL) in different ethnic groups.

DESIGN

A longitudinal, qualitative panel study of smokers using in-depth interviews conducted before and after introduction of SFL.

PARTICIPANTS

A purposive sample of 32 smokers selected from three ethnic groups in deprived London neighbourhoods with approximately equal numbers of younger and older, male and female respondents.

RESULTS

SFL has had positive impacts with half smoking less and three quitting. Although there were no apparent differences in smoking and quitting behaviours between groups, there were notable differences in the social impacts of SFL. The greatest negative impacts were in smokers over 60 years, potentially increasing their social isolation, and on young Somali women whose smoking was driven more underground. In contrast, most other young adult smokers felt relatively unaffected by SFL, describing unexpected social benefits. Although there was high compliance, reports of illegal smoking were more frequent among young, ethnic minority smokers, with descriptions of venues involved suggesting they are ethnically distinct and well hidden. Half of respondents reported stopping smoking in their own homes after SFL, but almost all were Somali or Turkish. White respondents tended to report increases in home smoking.

DISCUSSION

Although our study suggests that SFL can lead to reductions in tobacco consumption, it also shows that impacts vary by ethnicity, age and sex. This study highlights the importance of understanding the meaning of smoking in different social contexts so future tobacco control interventions can be developed to reduce health and social inequalities.

Factors associated with sexual risk behaviour among young people in Ukraine

We used data from a behavioural survey of Ukrainian men and women aged 14-24 to examine the relationship between nine potential risk factors and two HIV risk outcomes: non-use of condom at last sex, and multiple sexual partnerships. Younger age at first sex was positively associated with both health risk outcomes, and condom non-use at first sex was associated with subsequent non-use of condoms at last sex. There were regional differences in frequencies of both HIV risk behaviours. Compared with those who reported living in the place they were born, not living permanently at the current place of residence was associated with a fivefold increase in the odds of multiple partnership for women but not for men. Alcohol and drug use were associated with higher odds of multiple partnership and the effect was greater among women than among men. The data analysed are cross-sectional so cannot establish causality. More studies are needed to confirm these results and investigate causal relationships between the possible risk factors and the two health risk behaviours.

Factors that shape young people's sexual behaviour: a systematic review

BACKGROUND

Since nearly half of new HIV infections worldwide occur among young people aged 15-24 years, changing sexual behaviour in this group will be crucial in tackling the pandemic. Qualitative research is starting to reveal how social and cultural forces shape young people's sexual behaviour and can help explain why information campaigns and condom distribution programmes alone are often not enough to change it. We undertook a systematic review to identify key themes emerging from such research, to help inform policymakers developing sexual health programmes, and guide future research.

METHODS

We reviewed 268 qualitative studies of young people's sexual behaviour published between 1990 and 2004. We developed a method of comparative thematic analysis in which we coded each document according to themes they contained. We then identified relations between codes, grouping them accordingly into broader overall themes. Documents were classified as either primary or secondary depending on their quality and whether they contained empirical data. From the 5452 reports identified, we selected 246 journal articles and 22 books for analysis.

FINDINGS

Seven key themes emerged: young people assess potential sexual partners as "clean" or "unclean"; sexual partners have an important influence on behaviour in general; condoms are stigmatising and associated with lack of trust; gender stereotypes are crucial in determining social expectations and, in turn, behaviour; there are penalties and rewards for sex from society; reputations and social displays of sexual activity or inactivity are important; and social expectations hamper communication about sex. The themes do not seem to be exclusive to any particular country or cultural background, and all themes were present, in varying degrees, in all countries assessed.

INTERPRETATION

This study summarises key qualitative findings that help in understanding young people's sexual behaviour and why they might have unsafe sex; policymakers must take these into account when designing HIV programmes. Considerable overlap exists between current studies, which indicates the need to broaden the scope of future work.

Impact on contraceptive practice of making emergency hormonal contraception available over the counter in Great Britain: repeated cross sectional surveys

OBJECTIVE

To examine the impact on contraceptive practice of making emergency hormonal contraception available over the counter.

DESIGN

Analysis of data on contraceptive practice for women aged 16-49 years in the period 2000-2 from the Omnibus Survey, a multipurpose survey in which around 7600 adults living in private households are interviewed each year.

SETTING

Private households in Great Britain.

MAIN OUTCOME MEASURES

Use of different types of contraception and rates of unprotected sex.

RESULTS

After emergency hormonal contraception was made available over the counter, levels of use of different types of contraception by women aged 16-49 remained similar. No significant change occurred in the proportion of women using emergency hormonal contraception (8.4% in 2000, 7.9% in 2001, 7.2% in 2002) or having unprotected sex. A change did, however, occur in where women obtained emergency hormonal contraception; a smaller proportion of women obtained emergency hormonal contraception from physicians and a greater proportion bought it over the counter. No significant change occurred in the proportion of women using more reliable methods of contraception, such as the oral contraceptive pill, or in the proportion of women using emergency hormonal contraception more than once during a year.

CONCLUSIONS

Making emergency hormonal contraception available over the counter does not seem to have led to an increase in its use, to an increase in unprotected sex, or to a decrease in the use of more reliable methods of contraception.

What is heterosexual coercion? Interpreting narratives from young people in Mexico City

Freedom from sexual coercion is frequently cited as essential for good sexual health. Sexual experiences cannot usually be observed directly, and interpretation of interview data is therefore crucial in our understanding of sexual behaviour. This paper explores the ways in which narratives can be used to understand sexual experiences, using coercion as a specific example. The narratives examined are from interviews with young people in low-income areas of Mexico City. This study demonstrates that sexual coercion is impossible to define objectively. In addition, the concept of coercion is focused too much on women, excluding men's negative sexual experiences, and can include events that the 'victims' do not see as coercive. Coercion is a highly subjective and fluid concept, limiting its value as a defining element of sexual health. An alternative way of conceptualising coercive experiences is suggested.

Gendered communication among young people in Mexico: implications for sexual health interventions

Effective communication between partners is crucial for good sexual health, but is often difficult to achieve. This qualitative study shows how gendered communication can act as an important barrier to successful dialogue between men and women. Both content and manner of speaking are often gendered: not only can topics of conversation be socially defined as more or less appropriate for a speaker according to his or her sex, but men and women can also differ systematically in terms of the phrases and words they use. This may lead to a lack of the common forms of expression that are needed for effective communication. The study examines communication about sexuality among young men and women in low-income areas of Mexico City. The relationship between gender stereotypes of sexual behaviour and the gendered nature of communication strategies is explored. The negative consequences of gendered communication for effective dialogue between men and women are illustrated. Interventions that can enhance communication between men and women would be expected to have a positive impact on sexual health. This paper argues that research and interventions intended to improve sexual health may instead inadvertently reinforce communication barriers not only by failing to address the social pressures that exacerbate gendered communication, but also more insidiously, by using language that actively contributes to these pressures. An example of an intervention that avoids this problem is the Mexican programme "Gente Joven" ("Young People").

Do unintended pregnancies carried to term lead to adverse outcomes for mother and child? An assessment in five developing countries

This paper investigates whether children later reported as having been unwanted or mistimed at conception will, when compared with children reported as wanted, show adverse effects when the following criteria are applied: receipt of antenatal care before the sixth month of gestation, supervised delivery, full vaccination of the child, and child growth (stunting). The study uses data from five recent Demographic and Health Survey enquiries in Bolivia, Egypt, Kenya, Peru, and the Philippines. In Peru, children unwanted at conception were found to have significantly worse outcomes than other children, but in the other countries, a systematic effect was found only for receipt of antenatal care. Weak measurement of the complex concept of wantedness may have contributed to these results. Birth order of the child, with which wantedness is inextricably linked, has more powerful and pervasive effects, with first-born and second-born children being much less likely to show adverse effects.

Relationships between contraception and abortion: a review of the evidence

CONTEXT

The relationship between levels of contraceptive use and the incidence of induced abortion continues to provoke heated discussion, with some observers arguing that use of abortion decreases as contraceptive prevalence rises and others claiming that increased use of family planning methods causes abortion incidence to rise.

METHODS

Abortion trends are examined in countries with reliable data on abortion and with contraceptive prevalence information from two points in time showing increases in contraceptive use. The role of changes in fertility in mediating the relationship between abortion and contraception is also explored.

RESULTS

In seven countries--Kazakhstan, Kyrgyz Republic, Uzbekistan, Bulgaria, Turkey, Tunisia and Switzerland--abortion incidence declined as prevalence of modern contraceptive use rose. In six others--Cuba, Denmark, Netherlands, the United States, Singapore and the Republic of Korea--levels of abortion and contraceptive use rose simultaneously. In all six of these countries, however, overall levels of fertility were falling during the period studied. After fertility levels stabilized in several of the countries that had shown simultaneous rises in contraception and abortion, contraceptive use continued to increase and abortion rates fell. The most clear-cut example of this trend is the Republic of Korea.

CONCLUSIONS

Rising contraceptive use results in reduced abortion incidence in settings where fertility itself is constant. The parallel rise in abortion and contraception in some countries occurred because increased contraceptive use alone was unable to meet the growing need for fertility regulation in situations where fertility was falling rapidly.

Polarized infrared emissivity for a rough water surface

The polarization state of infrared emission from water at large viewing angles is explained mathematically by a polarization-dependent emissivity. To provide polarized emissivity values for a wind-roughened water surface in a convenient format, this electronic paper provides interactive tables and plots of polarized water emissivity for the spectral range of 3-15 microm. The rough surface is modeled as a collection of specular facets with slopes given by a Gaussian distribution. The interactive electronic format provides a tutorial on emission polarization and it allows readers to copy the desired numbers and paste them into their electronic applications without the difficulty of transcribing numbers from printed tables.

Cranial vascular effects of zolmitriptan, a centrally active 5-HT1B/1D receptor partial agonist for the acute treatment of migraine

The anti-migraine drug zolmitriptan is a novel 5-HT1B/1D receptor partial agonist which, unlike sumatriptan, has been shown to cross the intact blood-brain barrier. In this study we examined whether or not the ability to access the cerebro-vascular intima affects the way in which a centrally-active 5-HT1B/1D receptor agonist influences cranial haemodynamics. The effects of zolmitriptan on carotid arterial blood flow distribution were studied in anaesthetised cats using radiolabelled microspheres. Zolmitriptan (10-1000 microg kg(-1) i.v.) selectively reduced arteriovenous-anastomotic (AVA) conductance producing a maximum decrease of 92.5+/-2.3%. The drug also produced a modest reduction in extra-cerebral conductance (23.9+/-6.5% maximum reduction at 30 microg kg(-1), i.v.), but was without effect on cerebral conductance. Using laser doppler flowmetry in anaesthetised cats, zolmitriptan (1-30 microg kg(-1), i.v.) produced dose-dependent decreases in ear microvascular conductance (15+/-5 to 60+/-6%) which mirrored decreases in carotid arterial conductance (12+/-11 to 61+/-5%). By contrast, zolmitriptan at doses up to 1000 microg kg(-1) was without effect on cerebral microvascular conductance. Although zolmitriptan crosses the blood-brain barrier and can therefore access the cerebro-vascular intima, this study suggests that this property does not adversely affect cerebrovascular function.

Vascular 5-HT1-like receptors mediating vasoconstriction and vasodilatation: their characterization and distribution in the intact canine cardiovascular system

1. In anaesthetized dogs, intra-left atrial administration of 5-hydroxytryptamine (5-HT) and selected tryptamine analogues (5-carboxamidotryptamine, 5-CT; 5-methyl tryptamine, 5-MT; alpha-methyl 5-hydroxytryptamine, alpha-HT; sumatriptan, Sum) in the presence of ketanserin and MDL72222 (5-HT2 and 5-HT3 receptor antagonists, respectively), produced dose-related changes in carotid, coronary and renal vascular conductance mediated by vascular 5-HT1-like receptors. 2. In the carotid vascular bed, 5-HT, 5-MT, alpha-HT and Sum were vasoconstrictors with a rank order of potency (comparing ED50 values) of 5-HT = Sum > 5-MT > alpha-HT. By contrast in this vascular bed, 5-CT was a potent vasodilator. 3. In the coronary vascular bed, 5-HT, 5-CT, 5-MT and alpha-HT were vasodilators with a rank order of potency (comparing ED50 values) of 5-CT > 5-HT > 5-MT > alpha-HT. In this vascular bed, Sum was without effect. 4. In the renal vascular bed, 5-HT, 5-CT, 5-MT, alpha-HT and Sum were vasoconstrictors with a rank order of potency (comparing ED50 values) of 5-CT > 5-HT > Sum > 5-MT > alpha-HT. 5. The coronary (and carotid) vasodilator responses to 5-CT were antagonized by the 5-HT1-like receptor antagonists, spiperone (1 mg kg-1) and methiothepin (0.1 mg kg-1), whereas the renal vasoconstrictor responses to this tryptamine analogue were antagonized only by methiothepin. 6. It is concluded from these studies that agonist finger-printing in vivo, using tryptamine analogues,identifies and confirms the functional presence of at least two pharmacologically distinct subtypes of the 5-HT1-like receptor in the intact canine cardiovascular system. These two subtypes are located on the vascular smooth muscle and mediate direct vasoconstriction and vasodilatation responses in vivo.7. In addition, these studies confirm that the distribution of these subtypes within the major vascular beds, shows a marked heterogeneity. The carotid vascular responses to the tryptamine analogue sindicate the presence of both the vasodilator and the vasoconstrictor subtypes. The coronary vascular responses to these analogues are, however, consistent with presence of the vasodilator subtype, only. By contrast, the renal vascular responses to these analogues indicates only the presence of the vasoconstrictor subtype.

Selective 5-lipoxygenase inhibitor BW A4C does not influence progression of tissue injury in a canine model of regional myocardial ischaemia and reperfusion

The effects of BW A4C, a selective arachidonate 5-lipoxygenase (5-LO) inhibitor, on the progression of myocardial tissue injury were examined in anaesthetised, open-chest beagle dogs subjected to 90-min occlusion of the left anterior descending coronary artery (LAD) followed by 120-min reperfusion. Regional myocardial blood flow (RMBF, microspheres), segment shortening (sonomicrometry), and infarct size (tetrazolium stain) as an index of tissue injury were measured. Control animals (group 1, n = 11) received an infusion of vehicle [50% vol/vol glycofurol and distilled water, 47 ml at 12 ml h-1, intravenously (i.v.)] beginning 15 min before ischaemia and continuing until the end of reperfusion. Treated animals received either 10 (group 2, n = 11) or 50 micrograms kg-1 min-1 (group 3, n = 5) BW A4C i.v. in the same period. The infarct/risk zone ratio (I/R) in group 1 (24.1 +/- 6.0%) was not significantly different from that of group 2 (28.0 +/- 8.4%) or group 3 (46.1 +/- 6.7%). The close inverse relationship observed in controls between I/R ratio and collateral flow was not altered by either dose of BW A4C. Segment shortening during ischaemia (-0.2 +/- 2.7, -2.4 +/- 1.7, and -1.5 +/- 1.7%) and reperfusion (4.9 +/- 2.8, 1.0 +/- 1.8, and -1.0 +/- 1.9%) and during an isoprenaline infusion to unmask stunned myocardium (14.7 +/- 3.0, 14.7 +/- 2.6, and 7.4 +/- 1.7%) were not significantly different between groups 1, 2, and 3.(ABSTRACT TRUNCATED AT 250 WORDS)