Validity, trustworthiness and rigour: reasserting realism in qualitative research

AIM

This paper challenges recent sceptical approaches to the possibility of validating qualitative research and underlines the benefits of adopting a realist approach to validity.

BACKGROUND

In recent discussion about the methodological bases for qualitative research it has been argued that, because different methodologies take different approaches to validity, attempts to develop a common set of validation criteria are futile. On the basis of this sceptical view, a number of strategies for judging qualitative research have been proposed. These include suggestions that: it should be judged according to aesthetic or rhetorical criteria, rather than epistemological validity; responsibility for appraisal should move from researchers to readers; each methodology should be assessed individually according to its own merits.

DISCUSSION

None of these suggestions provide a viable alternative to validity, defined as the extent to which research reflects accurately that to which it refers. Because the form of research does not determine its content, replacement of epistemology by aesthetics is unsustainable. Because research reports mediate between writer and reader, a one-sided approach to this relationship constitutes a false dichotomy. If we accept the criterion of practitioner confidence as a means of judging methodological approaches, this involves rejection of judgement according to a methodology's own merits.

CONCLUSION

If qualitative research is actually about something, and if it is required to provide beneficial information, then a realist approach to validity holds out greatest promise.

The use of contrast-enhanced ultrasound in the characterisation of focal liver lesions

PURPOSE

To determine the potential application of contrast-enhanced ultrasound in the characterisation of focal liver lesions encountered in radiological practice at a district general hospital.

MATERIALS & METHODS

Retrospective analysis of 68 sequential patients undergoing contrast-enhanced ultrasound (CEUS) of liver. All patients were referred for CEUS following identification of 1 or more focal liver lesions on conventional ultrasound or CT imaging. After baseline US examination (Acuson), a bolus of 1.0-2.4 ml of SonoVue (Bracco, UK) was administered intravenously. CEUS images were obtained during arterial, portal venous and delayed phases. Patients were followed up for a mean period of 6 months. The CEUS diagnosis was compared to that indicated by other imaging modalities, histopathology, and clinical follow up.

RESULTS

CEUS correctly identified malignant liver lesions in 19 patients, with the final diagnosis confirmed by histopathology in 5 cases and clinico-radiological follow up in 14 cases. 47 patients were correctly identified with benign liver lesions on CEUS imaging, with all these cases confirmed on clinico-radiological follow up. In the detection of malignancy, the sensitivity was 95.0% and the specificity was 97.9%.

CONCLUSIONS

In our experience to date, contrast-enhanced ultrasound imaging is highly accurate in characterising malignant and benign focal liver lesions. It therefore has significant potential for utilisation in most general radiology departments.

Operational competency development in E and F grade nursing staff: preparation for management

There is limited literature for operational management competency development in E and F grade nursing staff. These grades of nursing staff have to take over from G grade nurses ward managers on a regular basis. With human resources doing less of the operational management and taking more of an advisory role, nursing staff are now required to deal with disciplinary procedures and other management issues in a more consistent manner. Therefore, this development programme in a Scottish primary care NHS psychiatric service was designed to enable E and F grade nurses to take over from ward managers and to enable ward managers to 'succession plan' for times when they will be absent. The literature is reviewed, the background to the development programme described and the design of the development programme is explained. The results from both the pilot study (n=13) and first group (n=8) through the course are presented, evaluated discussed.

Genetic determinants of normal variation in coagulation factor (F) IX levels: genome-wide scan and examination of the FIX structural gene

BACKGROUND

High-normal and elevated plasma FIX activity (FIX:C) levels are associated with increased risk for venous- and possibly arterial-thrombosis.

OBJECTIVE

Because the broad normal range for FIX:C involves a substantial unknown genetic component, we sought to identify quantitative-trait loci (QTLs) for this medically important hemostasis trait.

METHODS

We performed a genome-wide screen and a resequencing-based variation scan of the known functional regions of every distinct FIX gene (F9) in the genetic analysis of idiopathic thrombophilia project (GAIT), a collection of 398 Spanish-Caucasians from 21 pedigrees.

RESULTS

We found no evidence for linkage (LOD scores <1.5) despite genotyping more than 540 uniformly-spaced microsatellites. We identified 27 candidate F9 polymorphisms, including three in cis-elements responsible for the increase in FIX:C that occurs with aging, but found no significant genotype-specific differences in mean FIX:C levels (P-values > or = 0.11) despite evaluating every polymorphism in GAIT by marginal multicovariate measured-genotype association analysis.

CONCLUSIONS

The heritable component of interindividual FIX:C variability likely involves a collection of QTLs with modest effects that may reside in genes other than F9. Nevertheless, because the alleles of these 27 polymorphisms exhibited a low overall degree of linkage disequilibrium, we are currently defining their haplotypes to interrogate several highly-conserved non-exonic sequences and other F9 segments not examined here.

Angiostatin and plasminogen share binding to endothelial cell surface actin

Previous studies from this laboratory have demonstrated that plasminogen binds to endothelial cell surface-associated actin via its kringles in a dose-dependent and specific manner. The purpose of this study was to determine whether angiostatin, a proteolytic fragment of plasminogen, shares binding properties with plasminogen. Our results indicated that like plasminogen, angiostatin bound to actin in a time-, concentration-, and kringle-dependent manner. Furthermore, this binding was significantly inhibited by excess plasminogen, suggesting that both proteins shared binding motifs on the actin molecule. Fluorescence studies demonstrated that angiostatin bound to intact endothelial cells through its kringles, and this binding was also inhibited by plasminogen but not by unrelated proteins. Ligand blot analyses on endothelial cell lysates indicated that angiostatin interacted with a 42 kDa protein, which was identified as actin. Furthermore, an anti-actin antibody inhibited binding of angiostatin to endothelial cells by approximately 25%. These results suggest that angiostatin and plasminogen share binding to endothelial cell surface actin and, therefore, that angiostatin has the potential to inhibit plasmin-dependent processes such as cell migration-movement.

Achieving maximum ROI from corporate databases: exploiting your databases with integrated querying for better decision-making

In order to increase the rate of drug discovery, pharmaceutical and biotechnology companies spend billions of dollars a year assembling research databases. Current trends still indicate a falling rate in the discovery of New Molecular Entities (NMEs). It is widely accepted that the data need to be integrated in order for it to add value. The degree to which this must be achieved is often misunderstood. The true goal of data integration must be to provide accessible knowledge. If knowledge cannot be gained from these data, then it will invalidate the business case for gathering it. Current data integration solutions focus on the initial task of integrating the actual data and to some extent, also address the need to allow users to access integrated information. Typically the search tools that are provided are either restrictive forms or free text based. While useful, neither of these solutions is suitable for providing full coverage of large numbers of integrated structured data sources. One solution to this accessibility problem is to present the integrated data in a collated manner that allows users to browse and explore it and also perform complex ad-hoc searches on it within a scientific context and without the need for advanced Information Technology (IT) skills. Additionally, the solution should be maintainable by 'in-house' administrators rather than requiring expensive consultancy. This paper examines the background to this problem, investigates the requirements for effective exploitation of corporate data and presents a novel effective solution.

Willingness of dentists in Jordan to treat HIV-infected patients

Reluctance of dentists to treat human immunodeficiency virus (HIV) positive patients represents a major concern. Many efforts have been extended towards the documentation of the extent of this reluctance and speculation of factors that influence it.

OBJECTIVES

Assess the willingness of dentists in Jordan to treat HIV-infected patients.

MATERIALS AND METHODS

Two hundred and forty-two general dental practices were surveyed for their willingness to provide treatment of toothache and routine dental care of an HIV-infected individual.

RESULTS

Only 15% of the dental practices were willing to provide such care. Willingness to provide treatment did not seem to be influenced by financial factors or the local prevalence of HIV disease.

CONCLUSION

Present data suggest that HIV-infected individuals will have difficulty in obtaining dental health care in Jordan.

Knowledge and clinical expertise regarding oral cancer among Brazilian dentists

The aim of the present work was to assess the knowledge and attitudes of Brazilian General Dental Practitioners with regard to aspects of the aetiology, early diagnosis and prevention of oral cancer relevant for general dental practice. A convenience sample of 129 dentists in Brazil was randomly selected and asked to complete a questionnaire. Results of bi-variated analysis revealed that a self-perceived good knowledge regarding relevant aspects of oral cancer was statistically significantly associated with male gender (Chi square=4.59, P<0.05). Simple logistic regression revealed that male professionals were 2.9 times more knowledgeable than their female colleagues (OR=2.9, 1.1-8.1 95% CI, P=0.037), although, this association was not statistically significant when adjusted for age using multiple regression analysis (OR=2.7, 0.9-7.5 95% CI, P=0.059). There were no significant differences in relevant knowledge and attitudes of private compared with public dentists. Importantly, General Dental Practitioners who spent more than half of time of a patient's initial consultation undertaking a clinical examination were the more likely to detect oral cancer (Chi square=4.245, P=0.039) than those who set aside little time examining their patients. It is concluded that the knowledge of dentists in Brazil regarding relevant aspects of oral cancer is suboptimal, and may not be associated with any examined social-demographic variables. Further research is required to clarify the role of continuing professional education in improving the knowledge and attitudes of dentists relevant to oral cancer in Brazil.

Oral and dental aspects of chronic renal failure

The present article reviews, in detail, the current knowledge of the oral and dental aspects of chronic renal failure (CRF). Worldwide, increasing numbers of persons have CRF; thus, oral health care staffs are increasingly likely to provide care for patients with such disease. Chronic renal failure can give rise to a wide spectrum of oral manifestations, affecting the hard or soft tissues of the mouth. The majority of affected individuals have disease that does not complicate oral health care; nevertheless, the dental management of such individuals does require that the clinician understand the multiple systems that can be affected. The clinician should also consider the adverse side-effects of drug therapy and appropriate prescribing, in view of compromised renal clearance.

Enfuvirtide: a new class of antiretroviral therapy for HIV infection

Enfuvirtide is the first of a new class of antiretroviral agents recently approved for the treatment of human immunodeficiency virus (HIV)-1 infection. Present available data suggest that enfuvirtide may be a promising agent for the control of HIV infection in patients who have previously received reverse transcriptase inhibitor and protease inhibitor regimens and who are either intolerant to such drugs and/or who have gone into virological failure. Perhaps the greater limitation to the clinical use of enfuvirtide is the cost, limiting its use in the developing world.

Review article: orofacial granulomatosis

Orofacial granulomatosis is an uncommon clinicopathological entity describing patients who have oral lesions characterized by persistent and/or recurrent labial enlargement, oral ulcers and a variety of other orofacial features, who on lesional biopsy have lymphoedema and non-caseating granulomas. The aetiology of oral lesions with non-caseating granulomas includes oral Crohn's disease (some patients with oral lesions will develop typical bowel symptoms of Crohn's disease in ensuing months to years), tooth-associated infections, sarcoidosis and food or contact allergies. Treatment of orofacial granulomatosis is not reliably effective and may not be always necessary, although most patients do require some medical intervention.

Is there a relationship between risk assessment and observation level?

The literature is divided into two sections, one on assessment and one on observation, with only one study that tries to make any connection between them. This study, conducted in both acute and forensic areas, attempts to show that there are some direct relationships between assessment criteria and observation levels in both these areas. An instrument was designed and implemented prospectively to collect data about both assessment criteria and the resulting decisions about observation level. Logistic Regression Analysis, descriptive, and inferential statistics, such as Chi-square and cross-tabulations, were used to analyse the data. The results showed that there is a relationship between the risk assessment and the enhanced observation level that patients are placed on at the time of admission. The nature of the relationship was limited to seven variables from the 12 in the risk assessment used. This implies that the variables may be different in risk assessment content and extent in each clinical area and we can speculate that there may be individual profiles of the assessment-observation level relationship in each clinical area.

Nevoid basal cell carcinoma syndrome: a review of the literature

The nevoid basal cell carcinoma syndrome (NBCCS) or Gorlin-Goltz Syndrome is an autosomal dominant disorder principally characterized by cutaneous basal cell carcinomas, multiple keratocysts, and skeletal anomalies. The present report reviews current knowledge of this disorder that has profound relevance to specialists in Oral and Maxillo-Facial Surgery, Oral Medicine and Radiology.

Oral healthcare of clients with learning disability: changes following relocation from hospital to community

OBJECTIVE

To investigate changes in the oral healthcare of adults with learning disability after transference from long stay hospital care to community-based care.

SUBJECTS

Adults with learning disability who were former residents of a single long stay hospital and who had been resettled into the community during the period April 1995 to April 1998.

DESIGN

Structured questionnaire with a covering letter sent to community-based carers. Hospital notes were reviewed to assess oral healthcare received as in-patients.

RESULTS

There was a 68% response rate to the questionnaire from community-based carers with details obtained from 106 out of a possible 157 subjects. As residents in the hospital, all subjects were examined regularly by a dentist--yearly for edentulous and six-monthly for dentate individuals. However, attendance patterns were less regular as residents in the community. In the community, individuals were also less likely to receive operative dental treatment. Although oral hygiene regimes were generally on a daily basis only 37% of the subjects and/or their carers had received oral health education from dental professionals in the community.

CONCLUSION

Changes from institutional living to community-based housing for adults with learning disability may be associated with changes in dental attendance and treatment patterns.

Down syndrome: lip lesions (angular stomatitis and fissures) and Candida albicans

BACKGROUND

The incidence of angular cheilitis (angular stomatitis, perleche, commissural fissures) appears to be increased in people with Down syndrome (DS). Lip fissures are also (in our clinical impression) a fairly regular feature, yet this is scarcely mentioned in the literature.

OBJECTIVES

To establish the incidence of angular cheilitis and lip fissures in a substantial group of patients with DS and to examine the relationship with Candida albicans.

PATIENTS AND METHODS

The prevalence of orofacial soft tissue lesions was investigated in a group of 77 DS patients. Swabs were taken from lip lesions, palate and tongue and inoculated on Sabouraud's agar discs for the isolation of C. albicans, identified with commercially available kits.

RESULTS

Lip fissures were seen in at least one-quarter of DS patients. Angular cheilitis was also found in a similar percentage.

CONCLUSIONS

C. albicans was isolated from a substantial proportion of lesions tested, and was present more frequently than in those without lip lesions, but it is uncertain whether this represents cause or effect.

The modulation of matrix metalloproteinase and ADAM gene expression in human chondrocytes by interleukin-1 and oncostatin M: a time-course study using real-time quantitative reverse transcription-polymerase chain reaction

OBJECTIVE

Previous studies have reported elevated levels of interleukin-1 (IL-1) and oncostatin M (OSM) in rheumatoid joints, as well as the synergistic degradation of human articular cartilage by this cytokine combination. The present study was undertaken to investigate the ability of IL-1 and OSM to modulate gene expression of matrix metalloproteinase (MMP), ADAM, and ADAM-TS (ADAM with thrombospondin motifs) family members in human chondrocytes.

METHODS

T/C28a4 human chondrocytes were stimulated for 2-48 hours with IL-1 and/or OSM. Total RNA was harvested, reverse transcribed, and assessed by real-time polymerase chain reaction for the expression of various MMP, ADAM, and ADAM-TS messenger RNAs (mRNA). Results were normalized to 18S ribosomal RNA.

RESULTS

IL-1 and OSM synergized to markedly induce the expression of the collagenases MMP-1, MMP-8, and MMP-13 as well as MMP-3, an activator of proMMPs. Expression of mRNA for MMPs 1, 3, and 13 was induced early, whereas that of MMP-8 mRNA occurred late. Gene expression of MMP-14, an MMP that degrades collagen and activates proMMP-13, was elevated by this combination. IL-1 and OSM also synergized to induce gene expression of the aggrecanase ADAM-TS4, but not ADAM-TS5.

CONCLUSION

These data indicate that the potent cartilage-degrading properties of the combination of IL-1 and OSM are potentially mediated by a synergistic induction of the aggrecan-degrading enzyme ADAM-TS4 and the collagen-degrading enzymes MMP-1, MMP-8, MMP-13, and MMP-14, although differences in the magnitude of response and in the time course of induction were observed. A role for MMPs 3 and 14 in the activation of proMMPs may also be implicated.

Molecular characterization of vancomycin-resistant Enterococci repopulating the gastrointestinal tract following treatment with a novel glycolipodepsipeptide, ramoplanin

We characterized baseline and repopulating stool isolates recovered during a phase II trial of ramoplanin for the treatment of patients with stool carriage of vancomycin-resistant enterococci (VRE). Repopulation with a strain with a related genotype was found in 74, 60, and 53% of individuals in groups treated with placebo, 100 mg of ramoplanin, and 400 mg of ramoplanin, respectively. All ramoplanin-treated patients with a culture positive for VRE at day 7 had a relapse caused by a genotypically related isolate. In ramoplanin-treated patients, antibiotics with activities against anaerobic organisms were associated with positive cultures on day 7 (relative risk [RR] = 8.8; P = 0.004), and the avoidance of such antibiotics was significantly associated with culture negativity through day 21 (RR = 0.16; P = 0.02).

Investigation of the criminal and conditional release profiles of Canadian federal offenders as a function of psychopathy and age

Using the Psychopathy Checklist-Revised (PCL-R; R. D. Hare, 1991) diagnostic cut-off score of 30, the complete criminal career and community release profiles of 317 Canadian federal offenders (224 low scorers and 93 scoring within the psychopathic range) were investigated. Adult crimes were coded according to age at commission as well as either violent, nonviolent, or nonsexually violent. Changes in performance following release into the community also were examined. Results indicated that offenders scoring within the psychopathic range consistently committed more violent and nonviolent crimes than their counterparts for about three decades, spanning their late adolescence to their late 40s. Numbers of nonviolent criminal offenses committed by high PCL-R scorers declined considerably after age 30 relative to violent offenses, which declined and then rebounded in the late 30s before a major reduction was evidenced. Throughout adulthood, high PCL-R scorers failed during community release significantly faster than did low scorers. Importantly, from a risk management perspective, the release performance of low PCL-R scorers improved with age, whereas the opposite was seen for high scorers. Further, offenders scoring high on the PCL-R did not show a lower charge to conviction ratio with age, suggesting that they may not have been getting better at manipulating the legal system.

Increased effective lung volume following lung volume reduction surgery in emphysema

STUDY OBJECTIVES

Lung volume reduction surgery (LVRS) for emphysema has a variable effect on spirometry with improvement linked to increases in lung elastic recoil. The mechanism by which recoil increases following LVRS has not been described completely. This study examines preoperative and postoperative pulmonary function to describe a mechanism for changes in airflow obstruction.

DESIGN

Change in pulmonary function following LVRS. Setting : Public teaching hospital in Australia.

PATIENTS

Patients with severe emphysema and pulmonary function measurements made before and after LVRS.

MEASUREMENTS

Routine pulmonary function testing performed with ventilated lung alveolar volume (VA) derived from the gas transfer measurement used as a proxy for the effective lung volume.

RESULTS

Pulmonary function tests from 36 consecutive patients with measurements made at the same laboratory were analyzed. The mean FEV(1) was 29.1% predicted presurgery and increased following LVRS from 0.900 L (SD, 0.427 L) to 1.283 L (SD, 0.511 L; p < 0.0001) and TLC (143% predicted) decreased from 8.19 L (SD, 1.492 L) to 7.07 L (SD, 1.52 L; p < 0.0001; n = 35). The mean VA increased by 0.674 L (SD, 0.733 L) from 4.04 to 4.72 L (p < 0.0001; n = 34). The change in FEV(1) correlated well with the change in VA (r = 0.63). The change in FEV(1) in those patients whose VAs did not increase (n = 7) was not significant.

CONCLUSIONS

The increase in VA reflects an increase of functional or ventilating lung volume and is associated with an improvement in spirometry following LVRS.