Culturally sensitive psychotherapy for perinatal women: A mixed methods study

OBJECTIVE

There is a critical need to better understand psychological treatments from a culturally sensitive lens. Using a process-oriented model, we examined treatment satisfaction among perinatal patients who received behavioral activation (BA) within a large psychotherapy trial for perinatal depression and anxiety, and explored how to optimize culturally sensitive delivery through a multistakeholder perspective.

METHOD

In this mixed methods study, we estimated treatment satisfaction through mean client satisfaction scores (Client Satisfaction Questionnaire [CSQ]-8) among perinatal participants (N = 417) using one-way analysis of variance. We also conducted semistructured interviews with 20 ethnically diverse perinatal participants, 19 treatment providers, and five clinical leads. We employed content analysis to identify barriers, facilitators, and strategies for delivering culturally sensitive treatment.

RESULTS

CSQ-8 scores were similar across ethnic groups, F(7, 409) = 0.70, p = .67. Most participant interviewees reported that topics of race, ethnicity, and culture were raised during treatment sessions and that providers were able to address these topics in a culturally sensitive way. Despite this, almost all providers and clinical leads reported insufficient training to deliver culturally sensitive psychotherapy. The most-endorsed challenge for participants and providers was apprehension to bring up issues of race and ethnicity during treatment. Key facilitators included provider style, previous training, ongoing training resources, and supervision.

CONCLUSION

BA offers one psychotherapeutic model that uses an idiosyncratic and process-oriented approach that fosters intersectional humility and benefits from cultural humility, comfort, and opportunities. We identify key recommendations to inform culturally sensitive, evidence-based psychological treatments that include explicitly acknowledging and eliciting topics of race, ethnicity, and culture during sessions and supervision and ongoing training and supervision. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A Qualitative Study of Religion and Spirituality in a Perinatal Psychiatry Inpatient Unit in the Southeast USA

Religion and spirituality are important aspects of culture that can interact with mental health. They can also be central components of women's experiences during pregnancy and the postpartum period. This study aims to explore the role of religion and spirituality among women experiencing severe psychopathology during the perinatal period using qualitative interviews of women hospitalized during pregnancy or postpartum on an inpatient unit in the Southeast USA. The average age of participants was 34.2 and all identified as white, aside from one who identified as other. Though religious affiliation was varied, most participants were Christian. Each patient interviewed had a diagnosis of depressive disorder, among other comorbid diagnoses. Three main themes emerged in the subsequent analyses (1) spirituality providing a sense of healing and connectedness above and beyond religion, (2) patients seeking support from religious leaders, and (3) patients experiencing familial pressure to enact religion in a certain way, especially as it relates to child rearing. Clinical implications for each of the themes are explored.

Perinatal mental health around the world: priorities for research and service development in the USA

The perinatal mental health field is growing rapidly, which has yielded innovations in both prevention and treatment. To realise the potential of these innovations to transform clinical practice, further investment in research and clinical service development is required. Clinical services must be expanded by providing increased access to specialty care and education for front-line clinicians. Research is needed to develop a personalised medicine approach to understanding the complex aetiologies of perinatal depression and optimising treatments to promote both remission and long-term recovery. Such initiatives will require policies to prioritise federal research funding and healthcare coverage for perinatal depression.

Procalcitonin in hemodialysis patients presenting with fever or chills to the emergency department

We sought to assess the role of procalcitonin in discriminating severe bacterial infections requiring antibiotic treatment from non-bacterial causes of fever or chills in chronic dialysis patients. Chronic hemodialysis patients who were admitted to the emergency room due to fever and/or chills were recruited to the study. The presence or absence of bacterial infection was defined after recruitment conclusion by an infectious disease specialist who was blinded to procalcitonin results. Procalcitonin levels were compared between infected and non-infected patients. Out of 54 patients recruited, 22 (41%) patients eventually diagnosed with infection. Mean (± SD) procalcitonin values were 4.3 (± 5.5) ng/ml among cases, 1.0 (± 2.0) ng/ml among controls with no infection (p = 0.02). A cutoff PCT value of 1 ng/ml or higher had 77% sensitivity and 59% specificity for the diagnosis of severe infection. Procalcitonin cannot usefully identify hemodialysis patient with bacterial infection.

Limitations of Multicultural Supervision in Clinical Neuropsychology

Method

The authors reviewed the literature regarding general aspects of multicultural supervision in clinical psychology, supervision in clinical neuropsychology, and additionally highlighted the gaps related to supervision in multicultural neuropsychology. Finally, they introduced ideas to address some of the needs in the arena of supervision in multicultural neuropsychology.

Discussion

Available resources that explore, delineate, or evaluate competent multicultural supervision in clinical neuropsychology are absent. Partially, the limited understanding of - and research that focuses on - the influence of diversity in neuropsychological assessment and interventions might explain the lack of resources allotted to competent multicultural supervision in clinical neuropsychology. It is proposed that in clinical, neuropsychology supervisory process (as in therapy supervision) should include a culturally competent supervisor who can assist in the development of self-awareness, knowledge, and skills in order to provide interventions that understand, honor, and respect the clients’ multiple diversity dimensions.

Diagnosing Social Communication Disorder (SCD) in Multicultural Individuals: A Case Study

Objective

Explore the impact of culture, developmental stage, and cognitive functioning in a possible diagnosis of SCD.

Case Description

A 12-year-old South Asian, bilingual/bicultural adolescent male (X) presented with concerns regarding his executive and social functioning skills. His medical history was notable for craniosynostosis - successfully treated with craniofacial surgery at age 1 - and a diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD), combined presentation.

Diagnostic Impressions and Outcomes

X demonstrated superior intellectual performance with some inefficiencies in cognitive processing. Challenges with social interaction were not observed over the course of testing but his mother reported difficulties understanding pragmatic aspects of communication (sexual innuendos in double entendres) and recognizing when conversation had moved to a different topic. He kept a small social circle and preferred the company of older children.

Discussion

In conceptualizing X’s difficulties with social pragmatics, we must keep in mind the socio-cultural context in which he is growing up. He is the son of immigrant parents with South Asian roots. He is at an adolescent developmental stage where he is beginning to explore his individual identity while navigating the differing mores between his South Asian home culture and his American host culture. Therefore, responding to sexual innuendos may be a decision that is fraught with cultural angst over what is appropriate in one context but not the other. His gifted abilities and ADHD may make it difficult for him to remain engaged in the classroom or with similar-aged peers who don’t challenge his intellectual proclivities. His ADHD may also explain his difficulty in recognizing when the topic of conversation has changed. In deciding whether to assign a diagnosis of SCD, it is important to remember these cultural and developmental factors which could explain his difficulties in a normalizing way. These factors should also inform potential therapeutic recommendations.

A simplified blood culture sampling protocol for reducing contamination and costs: a randomized controlled trial

OBJECTIVES

Blood culture contamination carries risks for patients, such as unnecessary antimicrobial therapy and other additional hazards and costs. One method shown to be effective in reducing contamination is initial blood specimen diversion during collection. We hypothesized that initial blood specimen diversion without a designated device or procedure would suffice for reduction in blood culture contamination rate.

METHODS

From 1 September 2017 through to 6 September 2018, we conducted a randomized controlled trial to assess the effect of an initial-specimen diversion technique (ISDT) on the rate of blood-culture contamination by changing the order of sampling using regular vacuum specimen tubes instead of commercially available sterile diversion devices. We included adults from whom the treating physician planned to take blood cultures and additional blood chemistry tests. Additionally, we evaluated the potential economic benefits of an ISDT. This was a researcher-initiated trial, Clinicaltrials.gov NCT03088865.

RESULTS

In all, 756 patients were enrolled. This method, compared with the standard procedure in use at our medical centre, reduced contamination by 66% (95% CI 17%-86%), from 20/400 (5%) with the standard method to 6/356 (1.6%) with the ISDT, without compromising detection of true bloodstream infection and at no additional cost. Hospital-wide implementation of ISDT was associated with a 1.1% saving in hospitalization days.

CONCLUSIONS

We offer this novel approach as a simple, cost-effective measure to reduce risks to patient safety from contaminated blood cultures, without the need for using costly devices.

A theoretical framework for treating perinatal depression using couple-based interventions

Between 10% and 20% of women will experience depression in the perinatal period, which begins during pregnancy and extends into the first year after delivery. Perinatal depression (PD) is associated with significant emotional and social impairments that impact women, their children, and their partners. Although the majority of women with PD do not seek treatment, a considerable proportion of those who engage in treatment do not achieve remission. The couples and depression literature suggests that interpersonal processes are central in the development and maintenance of depressive disorders and thus, as researchers seek safe and effective treatments for perinatal populations, there may be therapeutic benefit in examining the role that partners play in women's recovery. The primary goal of this practice review is to highlight the utility of including partners in treatment for maternal PD and propose a model for practitioners to guide their work with couples within this domain. Specifically, this model involves three key components of treatment: psychoeducation, communication training, and behavioral activation. Each component addresses distinct risk factors for women and couples in the perinatal period in hopes of offering guidance to practitioners for how to address PD symptomology through a dyadic lens. (PsycINFO Database Record

Clinically applicable irreversible electroporation for eradication of micro-organisms

Irreversible electroporation (IRE) damages cell membranes and is used in medicine for nonthermal ablation of malignant tumours. Our aim was to evaluate the antimicrobial effect of IRE. The pathogenic micro-organisms, Staphylococcus aureus, Streptococcus pyogenes, Escherichia coli, Pseudomonas aeruginosa and Candida albicans were subjected to IRE. Survival was measured as a function of voltage and the number of pulses applied. Combined use of IRE and oxacillin for eradication of Staph. aureus was also tested. Log10 reduction in micro-organisms positively correlated with the number of applied pulses. The colony count of Strep. pyogenes and E. coli declined by 3·38 and 3·05 orders of magnitude, respectively, using an electric field of 2000 V and 100 pulses. Killing of Staph. aureus and P. aeruginosa was achieved with a double cycle of IRE (2000, 1500 V and repeated 1250 V respectively) of 50-100 IRE pulses. The addition of subclinical inhibitory concentrations of oxacillin to the Staph. aureus suspension prior to IRE led to total bacterial death, demonstrating synergism between oxacillin and IRE. Our results demonstrate that using IRE with clinically established parameters has a marked in vitro effect on pathogenic micro-organisms and highlights the potential of IRE as a treatment modality for deep-seated infections, particularly when combined with low doses of antibiotics.

SIGNIFICANCE AND IMPACT OF THE STUDY

Irreversible electroporation (IRE) is utilized in interventional radiology to treat cancer patients. In this study we evaluated in vitro the antimicrobial effect of IRE. We demonstrated that using IRE with clinically established parameters has a marked effect on pathogenic micro-organisms and is synergistic to antimicrobials when both are combined. Our results point to the potential of IRE as a treatment modality for deep-seated infections.

Acceptance and commitment therapy for perinatal mood and anxiety disorders: development of an inpatient group intervention

Perinatal mood and anxiety disorders are a leading cause of morbidity and mortality for childbearing women. Current treatments, such as cognitive behavioral therapy and interpersonal therapy, have demonstrated modest success in addressing perinatal psychiatric symptoms; however, additional treatment options are needed to address the limitations of current approaches, particularly for women experiencing moderate to severe perinatal mental illness during pregnancy or postpartum. We discuss the use of acceptance and commitment therapy (ACT) as a promising treatment approach that may be uniquely suited for perinatal women due to its emphasis of values, mindfulness, and acceptance; these psychological constructs notably address the significant psychiatric and behavioral health condition comorbidity, somatic symptoms, and stigma associated with perinatal mood and anxiety disorders. In addition, we describe the development of a four-session ACT-based group intervention at the Perinatal Psychiatry Inpatient Unit at the University of North Carolina at Chapel Hill. Sessions focus on core ACT processes of acceptance, cognitive defusion, present-moment awareness, value identification, and goal setting, and we describe how each of these processes is relevant to the perinatal population. Implications for future clinical applications and research investigations are discussed.

Enhancing protection for vulnerable waters

Governments worldwide do not adequately protect their limited freshwater systems and therefore place freshwater functions and attendant ecosystem services at risk. The best available scientific evidence compels enhanced protections for freshwater systems, especially for impermanent streams and wetlands outside of floodplains that are particularly vulnerable to alteration or destruction. New approaches to freshwater sustainability - implemented through scientifically informed adaptive management - are required to protect freshwater systems through periods of changing societal needs. One such approach introduced in the US in 2015 is the Clean Water Rule, which clarified the jurisdictional scope for federally protected waters. However, within hours of its implementation litigants convinced the US Court of Appeals for the Sixth Circuit to stay the rule, and the subsequently elected administration has now placed it under review for potential revision or rescission. Regardless of its outcome at the federal level, policy and management discussions initiated by the propagation of this rare rulemaking event have potential far-reaching implications at all levels of government across the US and worldwide. At this timely juncture, we provide a scientific rationale and three policy options for all levels of government to meaningfully enhance protection of these vulnerable waters. A fourth option, a 'do-nothing' approach, is wholly inconsistent with the well-established scientific evidence of the importance of these vulnerable waters.

Sensors in the Stream: The High-Frequency Wave of the Present

New scientific understanding is catalyzed by novel technologies that enhance measurement precision, resolution or type, and that provide new tools to test and develop theory. Over the last 50 years, technology has transformed the hydrologic sciences by enabling direct measurements of watershed fluxes (evapotranspiration, streamflow) at time scales and spatial extents aligned with variation in physical drivers. High frequency water quality measurements, increasingly obtained by in situ water quality sensors, are extending that transformation. Widely available sensors for some physical (temperature) and chemical (conductivity, dissolved oxygen) attributes have become integral to aquatic science, and emerging sensors for nutrients, dissolved CO₂, turbidity, algal pigments, and dissolved organic matter are now enabling observations of watersheds and streams at time scales commensurate with their fundamental hydrological, energetic, elemental, and biological drivers. Here we synthesize insights from emerging technologies across a suite of applications, and envision future advances, enabled by sensors, in our ability to understand, predict, and restore watershed and stream systems.

Spectral prediction of sediment chemistry in Lake Okeechobee, Florida

High-resolution diffuse reflectance spectra in the visible and near-infrared wavelengths were used to predict chemical properties of sediment samples obtained from Lake Okeechobee (FL, USA). Chemometric models yielded highly effective prediction (relative percent difference (RPD) = SD/RMSE >2) for some sediment properties including total magnesium (Mg), total calcium (Ca), total nitrogen (TN), total carbon (TC), and organic matter content (loss on ignition (LOI)). Predictions for iron (Fe), aluminum (Al), and various forms of phosphorus (total P (TP), HCl-extractable P (HCl-P), and KCl-extractable P (KCl-P)) were also sufficiently accurate (RPD > 1.5) to be considered useful; predictions for other P fractions as well as all pore water properties were poor. Notably, scanning wet sediments resulted in only a 7 % decline in RPD scores. Moreover, interpolation maps based on values predicted from wet sediment spectra captured the same spatial patterns for Ca, Mg, TC, TN, and TP as maps derived directly from wet chemistry, suggesting that field scanning of perpetually saturated sediments may be a viable option for expediting sample analysis and greatly reducing mapping costs. Indeed, the accuracy of spectral model predictions compared favorably with the accuracy of kriging model predictions derived from wet chemistry observations suggesting that, for some analytes, higher density spatial sampling enabled by use of field spectroscopy could increase the geographic accuracy of monitoring for changes in lake sediment chemical properties.

Cognitive-Behavioral Couple Therapies: Review of the Evidence for the Treatment of Relationship Distress, Psychopathology, and Chronic Health Conditions

Cognitive-behavioral couple therapy (CBCT) is an approach to assisting couples that has strong empirical support for alleviating relationship distress. This paper provides a review of the empirical status of CBCT along with behavioral couple therapy (BCT), as well as the evidence for recent applications of CBCT principles to couple-based interventions for individual psychopathology and medical conditions. Several meta-analyses and major reviews have confirmed the efficacy of BCT and CBCT across trials in the United States, Europe, and Australia, and there is little evidence to support differential effectiveness of various forms of couple therapy derived from behavioral principles. A much smaller number of effectiveness studies have shown that successful implementation in community settings is possible, although effect sizes tend to be somewhat lower than those evidenced in randomized controlled trials. Adapted for individual problems, cognitive-behavioral couple-based interventions appear to be at least as effective as individual cognitive behavioral therapy (CBT) across a variety of psychological disorders, and often more effective, especially when partners are substantially involved in treatment. In addition, couple-based interventions tend to have the unique added benefit of improving relationship functioning. Findings on couple-based interventions for medical conditions are more varied and more complex to interpret given the greater range of target outcomes (psychological, relational, and medical variables).

Do geographically isolated wetlands influence landscape functions?

Geographically isolated wetlands (GIWs), those surrounded by uplands, exchange materials, energy, and organisms with other elements in hydrological and habitat networks, contributing to landscape functions, such as flow generation, nutrient and sediment retention, and biodiversity support. GIWs constitute most of the wetlands in many North American landscapes, provide a disproportionately large fraction of wetland edges where many functions are enhanced, and form complexes with other water bodies to create spatial and temporal heterogeneity in the timing, flow paths, and magnitude of network connectivity. These attributes signal a critical role for GIWs in sustaining a portfolio of landscape functions, but legal protections remain weak despite preferential loss from many landscapes. GIWs lack persistent surface water connections, but this condition does not imply the absence of hydrological, biogeochemical, and biological exchanges with nearby and downstream waters. Although hydrological and biogeochemical connectivity is often episodic or slow (e.g., via groundwater), hydrologic continuity and limited evaporative solute enrichment suggest both flow generation and solute and sediment retention. Similarly, whereas biological connectivity usually requires overland dispersal, numerous organisms, including many rare or threatened species, use both GIWs and downstream waters at different times or life stages, suggesting that GIWs are critical elements of landscape habitat mosaics. Indeed, weaker hydrologic connectivity with downstream waters and constrained biological connectivity with other landscape elements are precisely what enhances some GIW functions and enables others. Based on analysis of wetland geography and synthesis of wetland functions, we argue that sustaining landscape functions requires conserving the entire continuum of wetland connectivity, including GIWs.

Realizing ecosystem services: wetland hydrologic function along a gradient of ecosystem condition

Wetlands provide numerous ecosystem services, from habitat provision to pollutant removal, floodwater storage, and microclimate regulation. Delivery of particular services relies on specific ecological functions, and thus to varying degree on wetland ecological condition, commonly quantified as departure from minimally impacted reference sites. Condition assessments are widely adopted as regulatory indicators of ecosystem function, and for some services (e.g., habitat) links between condition and function are often direct. For others, however, links are more tenuous, and using condition alone to enumerate ecosystem value (e.g., for compensatory mitigation) may underestimate important services. Hydrologic function affects many services cited in support of wetland protection both directly (floodwater retention, microclimate regulation) and indirectly (biogeochemical cycling, pollutant removal). We investigated links between condition and hydrologic function to test the hypothesis, embedded in regulatory assessment of wetland value, that condition predicts function. Condition was assessed using rapid and intensive approaches, including Florida's official wetland assessment tool, in 11 isolated forested wetlands in north Florida (USA) spanning a land use intensity gradient. Hydrologic function was assessed using hydrologic regime (mean, variance, and rates of change of water depth), and measurements of groundwater exchange and evapotranspiration (ET). Despite a wide range in condition, no systematic variation in hydrologic regime was observed; indeed reference sites spanned the full range of variation. In contrast, ET was affected by land use, with higher rates in intensive (agriculture and urban) landscapes in response to higher leaf area. ET determines latent heat exchange, which regulates microclimate, a valuable service in urban heat islands. Higher ET also indicates higher productivity and thus carbon cycling. Groundwater exchange regularly reversed flow direction at all sites in response to rainfall. This buffering effect on regional aquifer levels, an underappreciated service of isolated wetlands, was provided regardless of condition. Intensive landscapes may benefit most from the hydrologic services that wetlands provide because that is where certain services (floodwater storage, microclimate regulation) are realized. While the portfolio of wetland services clearly changes with disturbance, our results support a revised approach to wetland valuation that recognizes the services that accrue from sustained or enhanced functions in these "working wetlands."

Discharge competence and pattern formation in peatlands: a meta-ecosystem model of the Everglades ridge-slough landscape

Regular landscape patterning arises from spatially-dependent feedbacks, and can undergo catastrophic loss in response to changing landscape drivers. The central Everglades (Florida, USA) historically exhibited regular, linear, flow-parallel orientation of high-elevation sawgrass ridges and low-elevation sloughs that has degraded due to hydrologic modification. In this study, we use a meta-ecosystem approach to model a mechanism for the establishment, persistence, and loss of this landscape. The discharge competence (or self-organizing canal) hypothesis assumes non-linear relationships between peat accretion and water depth, and describes flow-dependent feedbacks of microtopography on water depth. Closed-form model solutions demonstrate that 1) this mechanism can produce spontaneous divergence of local elevation; 2) divergent and homogenous states can exhibit global bi-stability; and 3) feedbacks that produce divergence act anisotropically. Thus, discharge competence and non-linear peat accretion dynamics may explain the establishment, persistence, and loss of landscape pattern, even in the absence of other spatial feedbacks. Our model provides specific, testable predictions that may allow discrimination between the self-organizing canal hypotheses and competing explanations. The potential for global bi-stability suggested by our model suggests that hydrologic restoration may not re-initiate spontaneous pattern establishment, particularly where distinct soil elevation modes have been lost. As a result, we recommend that management efforts should prioritize maintenance of historic hydroperiods in areas of conserved pattern over restoration of hydrologic regimes in degraded regions. This study illustrates the value of simple meta-ecosystem models for investigation of spatial processes.

Effects of fetal antiepileptic drug exposure: outcomes at age 4.5 years

OBJECTIVE

To examine outcomes at age 4.5 years and compare to earlier ages in children with fetal antiepileptic drug (AED) exposure.

METHODS

The NEAD Study is an ongoing prospective observational multicenter study, which enrolled pregnant women with epilepsy on AED monotherapy (1999-2004) to determine if differential long-term neurodevelopmental effects exist across 4 commonly used AEDs (carbamazepine, lamotrigine, phenytoin, or valproate). The primary outcome is IQ at 6 years of age. Planned analyses were conducted using Bayley Scales of Infant Development (BSID at age 2) and Differential Ability Scale (IQ at ages 3 and 4.5).

RESULTS

Multivariate intent-to-treat (n = 310) and completer (n = 209) analyses of age 4.5 IQ revealed significant effects for AED group. IQ for children exposed to valproate was lower than each other AED. Adjusted means (95% confidence intervals) were carbamazepine 106 (102-109), lamotrigine 106 (102-109), phenytoin 105 (102-109), valproate 96 (91-100). IQ was negatively associated with valproate dose, but not other AEDs. Maternal IQ correlated with child IQ for children exposed to the other AEDs, but not valproate. Age 4.5 IQ correlated with age 2 BSID and age 3 IQ. Frequency of marked intellectual impairment diminished with age except for valproate (10% with IQ <70 at 4.5 years). Verbal abilities were impaired for all 4 AED groups compared to nonverbal skills.

CONCLUSIONS

Adverse cognitive effects of fetal valproate exposure persist to 4.5 years and are related to performances at earlier ages. Verbal abilities may be impaired by commonly used AEDs. Additional research is needed.

Use of models in identification and prediction of physiology in critically ill surgical patients

BACKGROUND

With higher-throughput data acquisition and processing, increasing computational power, and advancing computer and mathematical techniques, modelling of clinical and biological data is advancing rapidly. Although exciting, the goal of recreating or surpassing in silico the clinical insight of the experienced clinician remains difficult. Advances toward this goal and a brief overview of various modelling and statistical techniques constitute the purpose of this review.

METHODS

A review of the literature and experience with models and physiological state representation and prediction after injury was undertaken.

RESULTS

A brief overview of models and the thinking behind their use for surgeons new to the field is presented, including an introduction to visualization and modelling work in surgical care, discussion of state identification and prediction, discussion of causal inference statistical approaches, and a brief introduction to new vital signs and waveform analysis.

CONCLUSION

Modelling in surgical critical care can provide a useful adjunct to traditional reductionist biological and clinical analysis. Ultimately the goal is to model computationally the clinical acumen of the experienced clinician.

Definition and drivers of acute traumatic coagulopathy: clinical and experimental investigations

BACKGROUND

Acute traumatic coagulopathy (ATC) is an impairment of hemostasis that occurs early after injury and is associated with a 4-fold higher mortality, increased transfusion requirements and organ failure.

OBJECTIVES

The purpose of the present study was to develop a clinically relevant definition of ATC and understand the etiology of this endogenous coagulopathy.

PATIENTS/METHODS

We conducted a retrospective cohort study of trauma patients admitted to five international trauma centers and corroborated our findings in a novel rat model of ATC. Coagulation status on emergency department arrival was correlated with trauma and shock severity, mortality and transfusion requirements. 3646 complete records were available for analysis.

RESULTS

Patients arriving with a prothrombin time ratio (PTr) > 1.2 had significantly higher mortality and transfusion requirements than patients with a normal PTr (mortality: 22.7% vs. 7.0%; P < 0.001. Packed red blood cells: 3.5 vs. 1.2 units; P < 0.001. Fresh frozen plasma: 2.1 vs. 0.8 units; P < 0.001). The severity of ATC correlated strongly with the combined degree of injury and shock. The rat model controlled for exogenously induced coagulopathy and mirrored the clinical findings. Significant coagulopathy developed only in animals subjected to both trauma and hemorrhagic shock (PTr: 1.30. APTTr: 1.36; both P < 0.001 compared with sham controls).

CONCLUSIONS

ATC develops endogenously in response to a combination of tissue damage and shock. It is associated with increased mortality and transfusion requirements in a dose-dependent manner. When defined by standard clotting times, a PTr > 1.2 should be adopted as a clinically relevant definition of ATC.

Algal blooms and the nitrogen-enrichment hypothesis in Florida springs: evidence, alternatives, and adaptive management

Contradictions between system-specific evidence and broader paradigms to explain ecosystem behavior present a challenge for natural resource management. In Florida (U.S.A.) springs, increasing nitrate (NO3-) concentrations have been implicated as the cause of algal overgrowth via alleviation of N-limitation. As such, policy and management efforts have centered heavily on reduction of nitrogen (N) loads. While the N-limitation hypothesis appears well founded on broadly supported aquatic eutrophication models, several observations from Florida springs are inconsistent with this hypothesis in its present simplified form. First, NO3- concentration is not correlated with algal abundance across the broad population of springs and is weakly negatively correlated with primary productivity. Second, within individual spring runs, algal mats are largely confined to the headwater reaches within 250 m of spring vents, while elevated NO3- concentrations persist for several kilometers or more. Third, historic observations suggest that establishment of macroalgal mats often lags behind observed increases in NO3- by more than a decade. Fourth, although microcosm experiments indicate high thresholds for N-limitation of algae, experiments in situ have demonstrated only minimal response to N enrichment. These muted responses may reflect large nutrient fluxes in springs, which were sufficient to satisfy present demand even at historic concentrations. New analyses of existing data indicate that dissolved oxygen (DO) has declined dramatically in many Florida springs over the past 30 years, and that DO and grazer abundance are better predictors of algal abundance in springs than are nutrient concentrations. Although a precautionary N-reduction strategy for Florida springs is warranted given demonstrable effects of nutrient enrichment in a broad suite of aquatic systems worldwide, the DO-grazer hypothesis and other potential mechanisms merit increased scientific scrutiny. This case study illustrates the importance of an adaptive approach that explicitly evaluates paradigms as hypotheses and actively seeks alternative explanations.

Rhinocerebral mucormycosis in patients without predisposing medical conditions: a review of the literature

Rhinocerebral mucormycosis is a rare disease, affecting almost exclusively patients with known predisposing conditions such as diabetes mellitus, immunocompromised status, haemochromatosis or major trauma. Subsequent to a case of rhinocerebral mucormycosis in a 78-year-old woman without any known risk factor, we reviewed the published English-language literature and found an additional 72 cases. Reviewing all the published case series of mucormycosis involving any site, the proportion of apparently normal hosts among cases of rhinocerebral mucormycosis was found to be 9.06% (95% confidence interval 6.7-11.8). These findings suggest that rhinocerebral mucormycosis in patients without known predisposing factors is more prevalent than was previously believed.

Insoles for prevention and treatment of back pain

BACKGROUND

There is lack of theoretical and clinical knowledge of the use of insoles for prevention or treatment of back pain. The high incidence of back pain and the popularity of shoe insoles call for a systematic review of this practice.

OBJECTIVES

To determine the effectiveness of shoe insoles in the prevention and treatment of non-specific back pain compared to placebo, no intervention, or other interventions.

SEARCH STRATEGY

We searched the following databases: The Cochrane Back Group Trials Register and The Cochrane Central Register of Controlled Trials (CENTRAL) to March 2005, and MEDLINE, EMBASE, and CINAHL to February 2007; reviewed reference lists in review articles, guidelines and in the included trials; conducted citation tracking; contacted individuals with expertise in this domain.

SELECTION CRITERIA

We included randomized controlled trials that examined the use of customized or non-customized insoles, for the prevention or treatment of back pain, compared to placebo, no intervention or other interventions. Study outcomes had to include at least one of the following: self-reported incidence or physician diagnosis of back pain; pain intensity; duration of back pain; absenteeism; functional status. Studies of insoles designed to treat limb length inequality were excluded.

DATA COLLECTION AND ANALYSIS

One review author conducted the searches and blinded the retrieved references for authors, institution and journal. Two review authors independently selected the relevant articles. Two different review authors independently assessed the methodological quality and clinical relevance and extracted the data from each trial using a standardized form.

MAIN RESULTS

Six randomized controlled trials met inclusion criteria: Three examined prevention of back pain (2061 participants) and three examined mixed populations (256 participants) without being clear whether they were aimed at primary or secondary prevention or treatment. No treatment trials were found. There is strong evidence that the use of insoles does not prevent back pain. There is limited evidence that insoles alleviate back pain or adversely shift the pain to the lower extremities.

LIMITATIONS

This review largely reflects limitations of the literature, including low quality studies with heterogeneous interventions and outcome measures, poor blinding and poor reporting.

AUTHORS' CONCLUSIONS

There is strong evidence that insoles are not effective for the prevention of back pain. The current evidence on insoles as treatment for low-back pain does not allow any conclusions.High quality trials are required for stronger conclusions.

Retinal nerve fibre layer imaging compared with histological measurements in a human eye

PURPOSE

A feasibility study comparing retinal nerve fibre layer (RNFL) thickness values obtained with imaging devices against RNFL thickness measurements obtained histologically in a human eye.

DESIGN

A single patient scheduled for orbital exenteration, who still possessed a healthy functioning eye.

METHODS

Before surgery, the eye was imaged using optical coherence tomography (OCT) and scanning laser polarimetry (SLP). After orbital exenteration, the globe was sectioned, and 100 equidistant RNFL thickness measurements were obtained for each of four concentric rings centred on the optic disc, with diameters of 3.0, 3.5, 4.0, and 4.5 mm.

RESULTS

RNFL thickness was found to be inversely related to the distance from the centre of the optic disc along each radial meridian. Peripapillary RNFL thickness was found comparable for histology, OCT, and SLP. RNFL thickness measured histologically confirmed a 'double hump' pattern, peaking at the superior and inferior poles. Histologically derived RNFL thickness (microm), at 3.0 and 3.5 mm diameter ring ranged between 30-135 and 25-115 respectively. In comparison, the 3.0 mm diameter GDx data ranged between 25 and 100, and the 3.4 mm diameter OCT data between 40 and 175.

CONCLUSIONS

Imaging data appear qualitatively similar when compared to the histologically derived data. Quantitative differences may be partly due to scaling differences and histological artefacts. The histological analysis approach demonstrated in this study can potentially serve to validate imaging-derived data, as well as help improve our understanding of RNFL loss in glaucoma.

Clinical characteristics of eyes demonstrating atypical patterns in scanning laser polarimetry

PURPOSE

To characterize which clinical features are associated with the occurrence of atypical birefringence patterns (ABP) occasionally seen with scanning laser polarimetry (SLP).

METHODS

Sixty-one subjects, including glaucoma patients, glaucoma suspects, and normal subjects, underwent a full clinical examination, standard visual field (VF) test, and a GDx-VCC SLP examination. One eye was selected from each patient. The magnitude of ABP was determined in two independent ways: using a support vector machine analysis (typical scan score (TSS)) and by a masked experienced observer. We assessed whether the magnitude of ABP was correlated with age, gender, the refractive state of the eye, corneal polarization axis and magnitude, GDx global parameters (TSNIT and NFI), and the VF status, as evident from glaucoma hemifield test (GHT), mean deviation (MD), and the pattern standard deviation (PSD).

RESULTS

Of the 61 study eyes, 27 (44%) showed an ABP, based on a TSS cutoff (<82.5). A very high correlation was found between the TSS score and the masked experienced observer score (r(2)=0.80; P<0.001). The following clinical parameters were found, on bivariate analysis, to be significantly correlated with the presence of an ABP: age (r(2)=0.086; P=0.02); corneal polarization magnitude (r(2)=0.069; P=0.04); TSNIT (r(2)=0.16; P<0.001).

CONCLUSION

The presence and magnitude of ABP did not seem to be closely correlated with most clinical parameters. A low, but statistically significant, correlation was found for age and corneal polarization magnitude (r(2)=0.086 and 0.069, respectively). A low-medium correlation was found for TSNIT (r(2)=0.16); however, we speculate that this might represent a confounding effect, rather than an underlying association. We conclude that none of the clinical parameters investigated in this study appears to be strongly correlated with the presence of an ABP on SLP scans performed using the commercially available GDx-VCC.

Evaluating ecological condition using soil biogeochemical parameters and near infrared reflectance spectra

Rapid, repeatable assessment of ecological condition is critical for quantitative ecosystem monitoring. Soils provide a sensitive, integrative indicator for which sampling and analysis techniques are well defined. We evaluated soil properties as indicators of ecological condition (subjectively classified into minimally/moderately/severely degraded based on vegetative, hydrologic and edaphic cues) at 526 sites within Ft. Benning military installation (Georgia, USA). For each sample, we measured 17 biogeochemical parameters, and collected high-resolution diffuse reflectance spectra using visible/near infrared reflectance spectroscopy (VNIRS). VNIR spectra have been related to numerous soil attributes - we examine them here for diagnosing integrated response (i.e., ecological condition). We used ordinal logistic regression (OLR) and classification trees (CT) to discriminate between condition categories using both sets of predictors (biogeochemistry and spectra). Sixteen biogeochemical parameters were significantly different across condition categories; however, multivariate models greatly improved discrimination ([calibration, validation] accuracy of [69%, 66%] and [96%, 73%] for OLT and CT models, respectively). Important predictors included total C, total P, and Mehlich K/Ca/Mg. VNIR spectra further improved discrimination ([calibration, validation] accuracy of [74%, 70%] and [96%, 75%] for OLR and CT models, respectively). While spectra were comparably effective at discriminating minimally degraded sites, they were significantly more effective at discriminating severely degraded sites. Error rates across confounding factors suggest that watershed of origin and landscape position were the only important confounders, likely due to imbalanced sampling. We conclude that multivariate diagnosis improves accuracy, and that VNIR spectroscopy, which yields substantial cost and logistical improvements over conventional analyses, provides an effective tool for rapid condition diagnosis.

Visible-near infrared reflectance spectroscopy for rapid, nondestructive assessment of wetland soil quality

Recent evidence supports using visible-near infrared reflectance spectroscopy (VNIRS) for sensing soil quality; advantages include low-cost, nondestructive, rapid analysis that retains high analytical accuracy for numerous soil performance measures. Research has primarily targeted agricultural applications (precision agriculture, performance diagnostics), but implications for assessing ecological systems are equally significant. Our objective was to extend chemometrics for sensing soil quality to wetlands. Hydric soils posed two challenges. First, wetland soils exhibit a wider range of organic matter concentrations, particularly in riparian areas where levels range from <1% in sedimentation zones to >90% in backwater floodplains; this may mute spectral responses from other soil fractions. Second, spectral inference of cation concentrations in terrestrial soils is for oxidized species; under reducing conditions in wetlands, oxidation state variability is observed, which strongly affects chroma. Riparian soils (n = 273) from western Florida exhibiting substantial target parameter variability were compiled. After minimal pre-processing, soils were scanned under artificial illumination using a laboratory spectrometer. A multivariate data mining technique (regression trees) was used to relate post-processed reflectance spectra to laboratory observations (pH, organic content, cation concentrations, total N, C, and P, extracellular enzyme activity). High validation accuracy was generally observed (r2(validation) > 0.8, RPD > 2.0, where RPD is the ratio of the standard deviation of an attribute to the observed standard error of validation); where accuracy was lower, categorical models (classification trees) successfully screened samples based on diagnostic functional thresholds (validation odds ratio > 10). Graphical models verified significant association between predictions and observations for all parameters, conditioning on biogeochemical covariates. Visible-near infrared reflectance spectroscopy offers both cost and statistical power advantages; hydric conditions do not appear to constrain application.

Sleep disturbance and nonmalignant chronic pain: a comprehensive review of the literature

Sleep disturbance is an important clinical complaint for individuals with nonmalignant pain conditions. This review is a broad introduction to the literature on sleep disturbance and chronic pain conditions. The article critically reviews studies of sleep disturbance in musculoskeletal pain, arthritis, headache, and fibromyalgia. Current neurobiological hypotheses regarding the pathogenesis of sleep disturbance and chronic pain, common comorbid disorders, and pharmacologic and non-pharmacologic treatments for sleep disturbance are reviewed.

Determination of C1-C4 alkanes by ion mobility spectrometry

Flight instrumentation for the analyses of extraterrestrial environments must often perform under severely restricted conditions. Often, the detection and identification of a multitude of chemical species is required to fulfill the scientific objectives of the mission. It is therefore important that the analytical instrumentation have universal response. The gas chromatograph-ion mobility spectrometer (GC-IMS) has the potential to provide the sample separation, identification and sensitivity necessary for a successful analysis. However, the IMS has poor sensitivity for the C1-C4 alkanes. The abundance of these molecules at various extraterrestrial sites is often of great importance to exobiologists. This study focuses on optimizing IMS sample ionization mechanisms for the C1-C4 alkanes and other hydrocarbons of interest to exobiology.

Somatotopy of the motor cortex after long-term spinal cord injury or amputation

Certain brain-computer interface (BCI) methods use intrinsic signals from the motor cortex to control neuroprosthetic devices. The organization of the motor pathways in those populations likely to use neuroprosthetic devices, therefore, needs to be determined; there is evidence that following disease or injury the representation of the body in the motor cortex may change. In this study, functional MRI measures of somatotopy following spinal cord injury (SCI) showed evidence of changes in limb representations in the motor cortex. Subjects with chronic SCI had unusual cortical patterns of activity when attempting to move limbs below their injury; amputees showed a more normal somatotopy. The functional reorganization may affect optimal implanted electrode placements for invasive BCI methods for these different populations.

Digital radiography in pediatric orthopaedics: a prospective, controlled, and randomized trial

A prospective, controlled, and randomized trial of digital radiography was conducted to evaluate its advantages in children. Matched pairs of radiographs of the feet were taken in 20 children, and pelvic radiographs were taken in another 20 children. Each pair comprised a digital and conventional film. Half of the digital films were made with a 50% radiation dose reduction. The films were scored for quality. Statistically significant advantages were seen for the digital radiographs as compared with the conventional technique. Visualization of soft tissue and bony detail was enhanced in both foot and pelvic radiographs. This was true even with a 50% dose reduction in many of the parameters scored. We conclude that digital radiography offers advantages over conventional radiography, and recommend its use.

Attitudes toward physician-nurse collaboration: a cross-cultural study of male and female physicians and nurses in the United States and Mexico

BACKGROUND

Inter-professional collaboration between physicians and nurses, within and between cultures, can help contain cost and insure better patient outcomes. Attitude toward such collaboration is a function of the roles prescribed in the culture that guide professional behavior.

OBJECTIVES

The purpose of the study was to test three research hypotheses concerning attitudes toward physician-nurse collaboration across genders, disciplines, and cultures.

METHOD

The Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration was administered to 639 physicians and nurses in the United States (n = 267) and Mexico (n = 372). Attitude scores were compared by gender (men, women), discipline (physicians, nurses), and culture (United States, Mexico) by using a three-way factorial analysis of variance design.

RESULTS

Findings confirmed the first research hypothesis by demonstrating that both physicians and nurses in the United States would express more positive attitudes toward physician-nurse collaboration than their counterparts in Mexico. The second research hypothesis, positing that nurses as compared to physicians in both countries would express more positive attitudes toward physician-nurse collaboration, was also supported. The third research hypothesis that female physicians would express more positive attitudes toward physician-nurse collaboration than their male counterparts was not confirmed.

CONCLUSIONS

Collaborative education for medical and nursing students, particularly in cultures with a hierarchical model of inter-professional relationship, is needed to promote positive attitudes toward complementary roles of physicians and nurses. Faculty preparation for collaboration is necessary in such cultures before implementing collaborative education.

Surgery for carotid artery stenosis following neck irradiation

Carotid angioplasty and stenting (CAS) is being promoted for patients with carotid artery stenosis who have received neck irradiation. We reviewed our experience with carotid endarterectomy (CEA) following neck irradiation to determine if indeed postoperative and long-term problems were an issue in these patients. Over the past 13 years, 10 patients with a history of neck irradiation underwent 11 procedures. The average time interval between radiation treatment and surgery was 14 years (range 1-44). All carotid arteries were repaired with a standard endarterectomy, eight of which were patched. Three patients had undergone a radical neck dissection on the side ipsilateral to the carotid lesion. They received a pectoral myocutaneous flap (PMF) to protect the carotid artery and optimize wound healing. The lack of perioperative complications and of morbidity indicate that carotid reconstruction for patients with previous neck irradiation is safe and durable. Until long-term favorable results with CAS are available for these patients, operative intervention should remain the standard treatment.

Event-related potentials as a function of movement parameter variations during motor imagery and isometric action

Neuroimaging and electrophysiological studies have shown that executed action and motor imagery activate common neuronal substrates, leading to the hypothesis that movement preparation and motor imagery are functionally equivalent processes. This study further tested the functional equivalence hypothesis by determining whether electrocortical patterns associated with variations in motor control parameters are similar during imagined and executed actions. Event-related potentials (ERPs) were recorded from the supplementary motor/premotor area (SMA/PMA; FCz site) and primary motor area (M1; C3, C4 sites) during an executed and an imagined, cued, discrete isometric contraction task while target force (TF; low, moderate) and rate of force development (RFD; slow, rapid) were varied. For M1, the correlation of ERPs between moderate- and low force-executions was near zero and N2 amplitude was greater for moderate than low force executions, indicating that M1 activity is related to TF. Rapid executions were greater in amplitude and longer in latency than slow executions and the ERPs for rapid- and slow-executions were negatively correlated, indicating that M1 activity is also related to RFD. There were no differences in N2 amplitude and a zero correlation between execution and imagined actions of similar TF and RFD, indicating that neither TF or RFD are represented in M1 activity during imagery. For SMA/PMA, there was a moderate correlation between moderate- and low force-executions and larger N2 amplitude for moderate- than for low force-executions, indicating that TF may be related to SMA/PMA electrocortical activity. ERP patterns were uncorrelated between rapid- and slow-execution at FCz, but N2 amplitude was the same, making it unclear whether the RFD parameter is represented in FCz activity. The correlational and N2 amplitude analyses demonstrate that patterns of electrocortical activity at SMA/PMA are nearly isomorphic during executed and imagined actions as TF and RFD are varied. These results provide evidence that patterns of electrocortical activity associated with variations in the parameters of executed action are similar during motor imagery at SMA/PMA but not at M1.

Cognitive and behavioral problems in children with centrotemporal spikes

Atypical features in benign epilepsy of childhood with centrotemporal spikes (BECTS) are not uncommon. There are children with BECTS who do not have a benign outcome in terms of neuropsychologic functioning. BECTS have been linked with Landau-Kleffner syndrome (LKS) and continuous spikes and waves during slow sleep (CSWS). At the Medical College of Georgia from January 1988 to June 1999, 78 children, ages 2-16 years, were identified to have electroencephalogram evidence of centrotemporal spikes. Their medical records were reviewed for developmental history, behavioral problems, and school performance. Children with structural lesions/other epileptic syndromes were excluded. Fifty-six demonstrated a history of clinical seizures compatible with BECTS and 22 demonstrated centrotemporal spikes without clinical seizures. Among all children with centrotemporal spikes, 9% (n = 7) were diagnosed with mild intellectual disability (intelligence quotient < 70), 10% (n = 8) with borderline functioning, 31% (n = 24) with behavioral problems, and 17% (n = 13) with specific learning disabilities. Three children with BECTS experienced language delay and regression. Seizure control for BECTS usually is achieved without much difficulty, with excellent long-term prognosis. However, the data presented indicate that a large number of BECTS patients exhibit learning or behavior problems that require intervention. A small number may demonstrate language outcome similar to children with LKS and CSWS.

On the reliability, validity, and cognitive structure of the Thurstone Word Fluency Test

The Thurstone Word Fluency Test (TWFT) is a widely used neuropsychological instrument. However, data regarding its psychometric properties are lacking. The results of the present study suggest that the TWFT possesses excellent test-retest and inter-rater reliability, in addition to good construct validity. However, its criterion validity is limited by its lack of specificity and sensitivity. The present study also suggests that the TWFT is a complex cognitive task, and that successful TWFT performance depends upon a constellation of cognitive abilities, including attention/concentration, psychomotor speed, and memory. Finally, the relationship between verbal IQ and TWFT letter association value was examined. While the TWFT appears to be useful in detecting the presence of cerebral dysfunction, it is of less value in localizing such dysfunction. It is argued that the TWFT should not be used as a neuropsychological screening instrument, but rather, is best used within the context of a thorough neuropsychological examination.

Developmental progression of clock face drawing in children

The clock drawing test has been routinely administered by many neuropsychologists as part of their testing battery with the adult population. Our study investigated the development of clock face drawing in normal children ages 6 to 12 years. Conceptualization of time and construction of the clock face were assessed by an adapted scoring system developed as part of the investigation. As a group, the results indicated an upward progression with regard to the concept of time through age 8 and clock construction through age 12. Results further demonstrated that number reversals were more frequent among left-handers but were no longer evident by age 7 regardless of handedness. It also was determined that left visuospatial neglect specific to the upper quadrant was relatively common in 6- and 7-year olds but not evidenced by age 8. Given the pattern of the findings, it is likely that the neglect was secondary to poor planning and not a visuo-spatial deficit. In general, development of clock face drawing most closely paralleled that of frontal lobe maturation. Implications of these findings and the usefulness of clock face drawing with the pediatric population are presented.

Cortical potentials during imagined movements in individuals with chronic spinal cord injuries

A closed-loop model of motor control predicts that central deafferentation should disrupt cortical motor processes when imagining movements of paralyzed limbs. To test this prediction, event-related potentials (ERP) were recorded from the supplementary motor area and the primary sensorimotor area in individuals with paraplegia or quadriplegia as well as able-bodied controls during executed/attempted and imagined movements of the hand and foot. The cross-correlation of ERPs generated during hand movement and imagery was slightly negative for controls, moderate and positive for paraplegics, and high and positive for quadriplegics. The cross-correlation between foot movement and imagery was moderate for controls, moderate to high for paraplegic and high for quadriplegic groups. For hand tasks, ERPs were uncorrelated between controls and quadriplegics; for the foot tasks, the correlations were low between controls and both paraplegics and quadriplegics. Amplitudes and latencies of the ERP were also compared between movement and imagery and between the three injury groups. A biphasic waveform appears prior to and during movements in controls that is absent during imagery and when attempting/imagining movements of paralyzed limbs. Two hypotheses are proposed to explain the differences in cortical processing between movement and imagery and between injury groups. First, cortical motor processes are altered by the absence of kinesthetic feedback during attempted movement of a deafferented limb as well as during imagery. Second, inhibitory processes, present during imagined movements of an intact limb, may be weakened by a spinal cord injury (SCI) so that movement and imagery processes appear isomorphic. While the absence of kinesthetic feedback from deafferented limbs likely contributes to some variability in motor processing, the influence of an SCI on movement inhibition requires further testing.

Verbal fluency in children: developmental issues and differential validity in distinguishing children with attention-deficit hyperactivity disorder and two subtypes of dyslexia

Previous research studies have shown that in adults, verbal fluency is impaired after lesion to the frontal lobes and left temporal lobe. More recently, there have been a few studies reported which indicated that in children, like adults, left hemisphere and frontal lesions result in pronounced effects on verbal fluency. The present study examined developmental differences in verbal fluency within a sample of 130 normal children, aged 6 to 12 years. Additionally, the same verbal fluency test was administered to two subgroups of children with developmental dyslexia and a group of children with attention-deficit/hyperactivity disorder (ADHD). Analysis of variance (ANOVA) revealed significant between-group differences by age in the normal children. Further, ANOVA demonstrated that the verbal fluency measure was clinically useful in differentiating the Language Disorder/Dysphonetic Dyslexic subgroup from the Visual-Spatial/Dyseidetic Dyslexic subgroup and the ADHD group, with the latter two groups performing within the average range.

Psychometric properties of an attitude scale measuring physician-nurse collaboration

This study examined the psychometric properties of an assessment tool for measuring attitudes toward physician-nurse collaboration. A survey addressing areas of responsibility, expectations, shared learning, decision making, authority, and autonomy was administered to first-year medical and nursing students. Factor analysis of the survey indicated that the survey measured four underlying constructs of shared education and collaborative relationships, caring as opposed to curing, nurse's autonomy, and physician's authority. A scale was developed in which 15 items of the survey with large factor loadings were included. The alpha reliability estimates of the scale for medical and nursing students were .84 and .85, respectively. The mean of the scale was significantly higher for nursing than medical students. Results supported the construct validity and reliability of the scale. This scale can be used to evaluate the effectiveness of programs developed to foster physician-nurse collaboration, and to study group differences on attitudes toward interpersonal collaboration.