Barriers to learning from reflection: a study of the use of groupwork with post-registration nurses

There are few studies which describe the use of groups to facilitate reflection and even fewer which evaluate the effectiveness of such groups. Much of the literature discussing the techniques used to facilitate reflection suggests that learners willingly engage in such processes and find them enjoyable. This paper reports on a qualitative study of the use of groups to develop learning through reflection on a part-time post-registration diploma programme for nurses. The findings suggest that there are many barriers to learning which must be overcome before practitioners can use the opportunities to reflect on and learn from their experience. It is also contended that such learning may not necessarily be an enjoyable experience. The findings suggest that previous educational experience and the current culture in which nurses and midwives work, impose tremendous barriers to reflecting on, and learning from, experience. In particular these affect the willingness of learners to expose themselves to the judgement of others and their ability to be open to taking responsibility for their own learning. Other barriers to learning in groups are the effects of other group members, their commitment or resistance to shared learning, the ways in which group members interact with each other and facilitation styles.

An evaluation of process and outcomes from learning through reflective practice groups on a post-registration nursing course

An evaluation of process and outcomes from learning through reflective practice groups on a post-registration nursing course Small groups were set up purposefully on a part-time post-registration Diploma in Professional Studies in Nursing programme to enable students to reflect on and learn from experience. The use of these groups was qualitatively evaluated by the use of in-depth interviews. Although there were many barriers to such learning, some students made significant developments in their critical thinking ability and underwent perspective transformations that led to changes in attitudes and behaviour. These are identified as an increased professionalism, greater autonomy in decision making, more self-confidence to challenge the status quo and make their own judgements, and a less rule-bound approach to their practice. The processes by which these changes occurred are identified as support and challenge within the groups offered by both the facilitators and other group members.

Effect of hepatobiliary disease, chronic hepatitis C and hepatitis B virus infections and interferon-alpha on porphyrin profiles in plasma, urine and faeces

BACKGROUND

Documentation of the profiles of porphyrins in hepatobiliary disease is limited. Strong associations of hepatitis B and C virus infections with porphyria cutanea tarda have suggested causal relationships. This study aimed to determine the nature of porphyrin abnormalities in hepatobiliary disease and the effect of interferon-alpha on porphyrin profiles.

METHODS

Total porphyrins were measured in the plasma, urine and faeces of 83 patients with hepatobiliary disease (37 hepatitis C, 20 hepatitis B, 26 other causes) and 12 clinical controls, and porphyrin profiles were determined by high-performance liquid chromatography.

RESULTS

Porphyrins were elevated in the plasma of 11 and urine of 23 patients with hepatobiliary disease, as a result of elevated coproporphyrin I. This was reflected in increased coproporphyrin I:III ratios. Abnormal total porphyrin levels had a significant negative correlation with plasma albumin, and a positive correlation with bilirubin and alkaline phosphatase, but not with aminotransferases. Total urinary porphyrins were elevated in three control patients, but coproporphyrin I:III ratios were normal. Although not seen in plasma or urine, porphyrins that are specific for porphyria cutanea tarda were found in the faeces of six patients, but this occurred with similar frequency in hepatitis B or C infection (four of 50) as in the clinical controls (two of 12). Interferon-alpha had no effect during or after therapy in six patients with hepatitis C.

CONCLUSIONS

Reduced biliary excretion of coproporphyrin I occurs in more severe cholestasis and/or hepatic dysfunction. A causal relationship between viral liver disease and porphyria cutanea tarda which is unlikely to be precipitated by interferon-alpha, is not supported.

Inhibition of platelet aggregation with glyceryl trinitrate and xanthine oxidoreductase

Xanthine oxidoreductase (XOR) is a mammalian enzyme that possesses a series of redox centers, which use either NAD(+) or molecular oxygen for oxidation of the purines xanthine and hypoxanthine to uric acid. The ability of XOR to act as an NADH oxidase is a less well recognized function of the enzyme, and it is this function that we used to explore the metabolism of glyceryl trinitrate. The antiplatelet effect of nitric oxide (NO) on platelet aggregation was used as a bioassay to assess the bioconversion of glyceryl trinitrate to NO by XOR. The thromboxane mimetic U46619, 2 microM, was used to stimulate platelet aggregation in platelet-rich plasma prepared from healthy drug-free human volunteers. All incubations were carried out at 37 degrees C for 2 min after the addition of U46619. XOR produced a dose-dependent antiaggregant effect when incubated with glyceryl trinitrate (GTN), 220 microM. This did not occur when GTN or XOR was incubated with platelet-rich plasma independently. The antiaggregant effect of XOR plus GTN was dose dependently inhibited by allopurinol, with an IC(50) of 100 microM. The addition of superoxide dismutase (SOD), 100 U/ml produced a shift to the left in the antiaggregant dose-response curve for XOR. The IC(50) for XOR at 200 U/l without SOD was decreased to 80 U/l with SOD. Oxyhemoglobin, an extracellular NO scavenger, produced a dose-dependent, noncompetitive inhibition of the antiaggregant effect of XOR plus GTN. These findings suggest that GTN may be reduced to NO in vitro by the enzyme XOR in sufficient amounts to inhibit platelet aggregation.

Assessment of multiplex fluorescent PCR for screening single cells for trisomy 21 and single gene defects

A great majority of patients seeking preimplantation genetic diagnosis (PGD) are women >35 years of age. In addition to being carriers for single gene defects, these women also have a higher risk of having children with Down's syndrome (trisomy 21). For these patients, it would be advantageous if a diagnostic test for trisomy 21 was developed, which could be used in conjunction with tests for single gene defects. Here, we assessed the feasibility of developing an accurate genetic test for diagnosing trisomy 21 and the mutation causing spinal muscular atrophy (SMA) in single cells using multiplex fluorescence polymerase chain reaction (PCR). Single- and two-round PCR were developed using a combination of primers for the survival motor neuron (SMN) gene exons 7 and 8 and two chromosome 21 short tandem repeats (STRs), D21S226 and D21S11. After only 36 cycles, 88 and 68% of normal single cells were screened for SMA mutations and trisomy 21 respectively. In multiplex PCR using only two primers (SMN exon 7 and D21S11) instead of four, the efficiency of SMA diagnosis was increased to 93%. In the same reactions, the D21S11 alleles were detected in 83% of the normal single cells. Clinical applications of this assay should enable detection of those embryos that have inherited three heterozygous alleles and, therefore, benefit many PGD patients who are at an increased risk of Down's syndrome.

Impact of sex on inheritance of ankylosing spondylitis: a cohort study

BACKGROUND

Ankylosing spondylitis is a genetically determined and commonly familial disorder. Men and women differ in their susceptibility to ankylosing spondylitis, with about 2.5 men affected for every woman with the disease. We investigated the influence of the sex of the index case on disease penetrance within families.

METHODS

The ages at which 50% and 75% of patients were diagnosed with ankylosing spondylitis were ascertained from a database of 4400 cases. Index patients with children or siblings who were old enough to have obtained a diagnosis (50% and 75% rates) were assessed for prevalence of disease among relatives. Confirmation of diagnosis for affected relatives was sought for all offspring and a random 25% selection of siblings.

FINDINGS

Ankylosing spondylitis was more prevalent among children (odds ratio 1.9 [95% CI 1.2-3.0], p<0.005) and siblings (1.5 [1.2-1.9], p<0.0001) of female index cases than among those of male cases. Analyses restricted to index cases with a young age at onset (< or = 21 years) indicated that children of women had an even higher incidence of ankylosing spondylitis (7.2 [1.5-34], p=0.013) than did children of men at similar age at onset. 38% of children of female cases had disease compared with 8% of male cases. There was no difference in sex distribution among affected children or siblings of female patients with ankylosing spondylitis. By contrast, the sons and brothers of male patients had a higher prevalence of the disease (odds ratio 2.6 [1.4-5.2], p=0.003) than did daughters and sisters (1.7 [1.3-2.2], p<0.0001).

INTERPRETATION

The influence of female sex is greater than that of male sex in determining increased susceptibility to ankylosing spondylitis in children. The striking maternal effect is greatest for women with young age at onset, which is not seen in men. The sex ratio of affected children depends on the sex of the affected parent.

Aortic valve area: measurement by transesophageal echocardiography and prediction by left ventricular outflow tract area

We compared three techniques of aortic valve area (AVA) measurement using transesophageal echocardiography (TEE) and determined if AVA can be predicted from simple patient or echocardiographic measurements. AVA was simultaneously measured with direct planimetry, the continuity equation and with a novel technique combining stroke volume using thermodilution and continuous wave Doppler. Using planimetry as the reference in patients with normal valves, left ventricular outflow tract area (LVOTA), lean body mass (LBM), body surface area (BSA) and height were assessed as predictors of AVA. All three methods of AVA measurement showed close agreement and can be used interchangeably. Both LVOTA and LBM were predictors of AVA, but LVOTA was better. BSA and height were not acceptable as predictors of AVA. TEE can be used to measure AVA either with planimetry, the continuity equation, or in combination with thermodilution. LVOTA was the best predictor of AVA.

A comparison of epidural ropivacaine infusion alone and in combination with 1, 2, and 4 microg/mL fentanyl for seventy-two hours of postoperative analgesia after major abdominal surgery

Our aim in this prospective, randomized, double-blinded study was to compare the analgesic effectiveness and side effects of epidural infusions with ropivacaine 2 mg/mL alone (Group R; n = 60) and in combination with fentanyl 1 microg/mL (R1F; n = 59), 2 microg/mL (R2F; n = 62), and 4 microg/mL (R4F; n = 63) for up to 72 h after major abdominal surgery. Effective epidural neural blockade was established before surgery; postoperatively, the infusion rate was titrated to a maximum of 14 mL/h for analgesia. No additional analgesics other than acetaminophen were permitted during the infusion. The median of individual visual analog scale score with coughing were <20 mm for all groups (0 = no pain, 100 = worst pain) and was significantly lower (P < 0.01) for Group R4F at rest and with coughing (compared with Group R). Infusions were discontinued due to inability to control pain in significantly fewer patients in Group R4F (16%) than the other groups (34% to 39%; P < 0.01). For all groups, >90% of patients had no detectable motor block after 24 h. Hypotension, nausea, and pruritus were more common with the larger dose of fentanyl. We conclude that, after major abdominal surgery, an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL provided significantly more effective pain relief over a 3-day period than ropivacaine alone or ropivacaine with lower concentrations of fentanyl.

IMPLICATIONS

Postoperative epidural analgesic infusions are widely used, but there is little information regarding optimal strengths of opioid with local anesthetic. In this blinded, prospective study, we compared four different epidural infusion solutions for efficacy and side effects over a clinically useful postoperative period and conclude that an epidural infusion of ropivacaine 2 mg/mL with fentanyl 4 microg/mL was most effective.

Landed XRD/XRF analysis of prime targets in the search for past or present Martian life

Mars landers seeking evidence for past or present life will be guided by information from orbital mapping and from previous surface exploration. Several target options have been proposed, including sites that may harbor extant life and sites most likely to preserve evidence of past life These sites have specific mineralogic characteristics. Extant life might be gathered around the sinters and associated mineral deposits of rare active fumaroles, or held within brine pockets and inclusions in a few evaporite-mineral deposits. Possibilities for fossilization include deltaic and lake-bottom sediments of once-flooded craters, sinters formed by ancient hot-spring deposits, and the carbonate deposits associated with some evaporite systems. However, the highly varied mineralogy of fossil occurrences on Earth leads to the inference that Mars, an equally complex planet, could host a broad variety of potential fossilizing deposits. The abundance of volcanic systems on Mars and evidence for close associations between volcanism and water release suggest possibilities of organism entrapment and mineralization in volcaniclastic deposits, as found in some instances on Earth. Thus the targets being considered for exploration include a wide variety of unique deposits that would be characterized by silica or various nonsilicate minerals. Beyond these "special" deposits and in the most general case, an ability to distinguish mineralized from uncemented volcanic detritus may be the key to success in finding possible fossil-bearing authigenic mineralogies. A prototype miniaturized X ray diffraction/X ray fluorescence (XRD/XRF) instrument has been evaluated with silica, carbonate, and sulfate minerals and with a basalt, to examine the capabilities of this tool in mineralogic and petrologic exploration for exobiological goals. This instrument. CHEMIN (chemical and mineralogical analyzer), is based on an innovative low-power X ray tube, transmission geometry, and CCD collection and discrimination of diffracted and fluoresced X rays. The ability to accumulate and integrate the entire circumference of each complete Debye diffraction ring compensates for poor powder preparations, as might be produced by robotic sampling systems. With CHEMIN, a wide range of minerals can be uniquely identified. Using Rietveld analysis of the XRD results, mineral quantification is also possible. Expanded capabilities in phase analysis and constrained data solutions using quantitative XRD and XRF are within reach.

Screening the thoracic aorta for atheroma: a comparison of manual palpation, transesophageal and epiaortic ultrasonography

Accurate detection of atheroma within the thoracic aorta is an important part of most stroke prevention strategies in cardiac surgery. The thoracic aorta was divided into six zones corresponding to sites of surgical manipulation. Zones 1-3, proximal, mid and distal ascending aorta, zones 4-5, proximal and distal arch and zone 6, proximal descending aorta. This study compares the accuracy of atheroma detection by manual palpation, epiaortic (EPI) and transesophageal (TEE) ultrasonography in 70 patients.

RESULTS

Using EPI as the reference method for zones 1-4, 14/70 patients were identified with moderate or severe atheroma. The frequency of atheroma was age related with the youngest at 55 years. Compared with EPI, manual palpation correctly detected moderate or severe atheroma in 7/14 patients (p=0.0058) and TEE in only 4/14 patients (p= 0.0002). For TEE, adequate imaging was only obtained in 41/70 in zone 3 and 30/70 in zone 4. Adequate imaging of zones 5-6 was obtained in all patients using TEE. Of 68 patients with adequate imaging of all zones, 36 had moderate or severe atheroma in zones 5-6. The positive predictive value for zones 1-4 based on atheroma in zones 5-6 was 39%. Of 32 patients with nil or mild atheroma in zones 5-6, only 1 had moderate or severe atheroma in zones 1-4 (negative predictive value 94%).

CONCLUSION

Manual palpation and TEE are inaccurate methods of atheroma detection in zones 1-4. Epiaortic ultrasonography is recommended for all patients undergoing cardiac surgery, although the yield will be low for patients < 50 years of age or if there is nil or mild atheroma detected by TEE in zones 5-6.

A phase 2 clinical trial comparing Ro 48-6791, a new short-acting benzodiazepine, with propofol for induction of anaesthesia

A phase 2, single-blinded, randomized, multicentre trial was conducted to compare recovery times from anaesthesia between patients induced with a new short-acting benzodiazepine Ro 48-6791 (Hoffman-La Roche, Sydney, N.S.W.) or propofol. Seventy-six patients were randomly allocated to receive either Ro 48-6791 or propofol for induction followed by a standardized anaesthetic. Alertness and ambulatory function during recovery were scored by a rater blinded to treatment group. Mean time to awakening was longer for the Ro 48-6791 group (15 min), compared with propofol (7 min, P < 0.001), as was mean time to full clinical recovery (116 min vs 75 min respectively, P = 0.002). Both groups showed similar cardiovascular stability following induction, but shorter apnoea times were demonstrated for Ro 48-6791 (48s vs 133, P < 0.001). The longer recovery times with Ro 48-6791 would make this drug a less suitable sole induction agent than propofol for routine use in day stay surgery. Further studies of Ro 48-6791 should pay particular attention to the effect of dose reduction on recovery profile.

Assessment of thoracic aortic atheroma by echocardiography: a new classification and estimation of risk of dislodging atheroma during three surgical techniques

A new classification is described to improve precision of thoracic atheroma reporting. In 68 patients, the thoracic aorta was screened with epiaortic and transesophageal echocardiography. The thoracic aorta is divided into 6 zones corresponding to sites of aortic manipulation. Zones 1-3, proximal, mid and distal ascending aorta, Zones 4-5, proximal and distal arch and Zone 6, proximal descending aorta. Each zone is further sub-divided into anterior, left lateral, posterior and right lateral quadrants. There is a marked increase in moderate and severe atheroma between Zones 1-3 and Zone 4-6 (p<0. 001). There is a difference in atheroma by quadrant with the anterior the most frequent. (p<0.001) Once the grade and location of atheroma was classified, a comparison of the estimation of risk of dislodging atheroma during three surgical methods for care, was performed. Of 50 quadrants of atheroma, the composite arterial pedicle Y graft CABG would manipulate 5, Aortocoronary CABG with single aorta cross clamp, 16, and Aortocoronary CABG with aortic partial occlusion clamp, 21. This classification of 6 zones and 4 quadrants within each zone will increase the precision of atheroma reporting and allow better comparison of stroke reduction interventions.

A study of laboratory based faecal occult blood testing in Melbourne, Australia. The Faecal Occult Blood Testing Study Group

Faecal occult blood tests (FOBT) are widely used in clinical practice and are under increasing scrutiny as a tool for colorectal cancer screening. However, there is little information regarding the quality of testing performed in pathology laboratories. Therefore, we asked 13 pathology laboratories in Melbourne, Australia, to test coded contrived faecal samples prepared from a composite stool specimen which had been spiked to various concentrations of haemoglobin. The samples were provided to the laboratories in two forms: (i) on/in the sample collection device appropriate for the faecal occult blood test they normally used; and (ii) as a moist faecal sample. Some variation in threshold analytical sensitivity between laboratories for the same FOBT was observed for Hemoccult SENSA, ColoRectal, Hematest, MonoHaem and Hemolex suggesting that, at least for those tests, technician training could be improved. Two tests, Hematest and an in-house FOBT did not perform as well as the other FOBT. When samples were sent in moist form, Hemoccult SENSA (P = 0.0002), ColoRectal (P = 0.02) and MonoHaem (P = 0.04) had significantly lower overall positivity rates; for Hemolex the decrease was not significant (P = 0.3). The lower positivity rate with moist samples is important, given that 11 of the 13 laboratories in the study stated that they receive at least some samples in moist form. Thus, technician training and laboratory procedure need to be reviewed to maximize the benefits of faecal occult blood testing in clinical practice, especially with its expanding role in colorectal cancer screening.

Quantitative assessment of the rheumatoid synovial microvascular bed by gadolinium-DTPA enhanced magnetic resonance imaging

OBJECTIVE

To examine the relation between rate of synovial membrane enhancement, intra-articular pressure (IAP), and histologically determined synovial vascularity in rheumatoid arthritis, using gadolinium-DTPA enhanced magnetic resonance imaging (MRI).

METHODS

Dynamic gadolinium-DTPA enhanced MRI was performed in 31 patients with knee synovitis (10 patients IAP study, 21 patients vascular morphometry study). Rate of synovial membrane enhancement was quantified by line profile analysis using the image processing package ANALYZE. IAP was measured using an intra-compartmental pressure monitor system. Multiple synovial biopsy specimens were obtained by a blind biopsy technique. Blood vessels were identified immunohistochemically using the endothelial cell marker QBend30 and quantified (blood vessel numerical density and fractional area).

RESULTS

Median blood vessel numerical density and fractional area were 77.5/mm2 (IQR; 69.3-110.7) and 5.6% (IQR; 3.4-8.5) respectively. The rate of synovial membrane enhancement (median 2.74 signal intensity units/s, IQR 2.0-3.8) correlated with both blood vessel numerical density (r = 0.46, p < 0.05) and blood vessel fractional area (r = 0.55, p < 0.02). IAP did not influence the rate of enhancement.

CONCLUSIONS

Gadolinium-DTPA enhanced MRI may prove to be a valuable technique for evaluating drugs that influence angiogenesis.