Exploring the impact educational interventions have on nursing and medical students' attitudes and empathy levels towards people with disability. A systematic review

This systematic review aimed to explore the impact educational interventions have on undergraduate nursing and medical students' attitudes and empathy levels towards people with disability. There are over one billion people with some form of disability currently. A growing body of research reveals that nurses and doctors display negative attitudes including decreased empathy towards people with disability. A systematic review using narrative synthesis of chosen randomized controlled trials was employed. A comprehensive search was completed in June 2021 on six databases (CINAHL, Medline, Science Direct, Health Research Premium - PROQUEST, Scopus. Cochrane Library). The search strategy yielded 21,616 studies and only three randomised controlled trials fulfilled the eligibility criteria. These trials included 125 participants (n = 50 medical students and n = 75 nursing students) and evaluated the effectiveness of a disabled health course, disability education module with bedside teaching and wheelchair workshop intervention. Findings from one study revealed that a disabled health course using affective learning method based on a transformative learning theory significantly improves attitudes to disability amongst nursing students however there was no statistically significant difference in empathy levels. More high-quality randomised controlled trials with greater theoretical and methodological complexity are needed to identify more effective educational approaches that enhance attitude and empathy levels of these key stakeholders.

Determining the need for a breast cancer awareness educational intervention for women with mild/moderate levels of intellectual disability: A qualitative descriptive study

OBJECTIVE

Following a review of the existing body of literature, this study aimed to explore the need for a breast cancer awareness intervention specifically targeted at women with mild/moderate levels of intellectual disability (ID) and provide perspectives on the preferred processes and content underpinning an intervention.

METHODS

A qualitative, descriptive design using semi-structured, individual (n = 5) and focus group (n = 5) interviews were used to engage with a non-probability, purposive sample of key stakeholders (n = 25) including women with mild/moderate levels of ID, caregivers and healthcare professionals. Data were analysed using qualitative content analysis.

RESULTS

Findings highlighted that an educational intervention should focus on breast awareness as opposed to breast cancer awareness. Additionally, findings identified that a combined breast awareness and healthy living intervention could be effective. However, the intervention needs to have a multimodal, hands-on, person-centred approach to learning which is underpinned by theory. Furthermore, integrating the caregivers and healthcare professionals into the intervention is recommended.

CONCLUSION

Findings from this study provide a foundation for developing and implementing a theoretically underpinned, multimodal, breast awareness and healthy living educational intervention for women with mild/moderate levels of ID.

Defining breast cancer awareness and identifying barriers to breast cancer awareness for women with an intellectual disability: A review of the literature

INTRODUCTION

Incidence rates for developing breast cancer are similar for women regardless of intellectual ability. However, women with an intellectual disability present with advanced breast cancers, which often have a poor prognosis.

METHOD

A structured narrative review of the literature was performed to explore the concepts of breast awareness and breast cancer awareness and subsequently, identify barriers to breast cancer awareness encountered by women with an intellectual disability.

RESULTS

A total of 22 studies involving people with varying levels of intellectual disability informed this review. The barriers to breast cancer awareness encountered by women with an intellectual disability include: lack of their understanding, the role of the carer and literacy issues.

CONCLUSION

Identifying the barriers to breast cancer awareness for women with an intellectual disability will help to facilitate breast cancer awareness which has the potential to result in better long-term outcomes through an early diagnosis of breast cancer.

Cancer and breast cancer awareness interventions in an intellectual disability context: A review of the literature

BACKGROUND

Women with an intellectual disability (ID) have a similar risk of developing breast cancer as women in the general population yet present with later stage breast cancers, which have poorer outcomes.

AIM

To identify whether there is a need to develop a breast cancer awareness intervention for women with an ID.

METHODS

Interventions aimed at increasing cancer awareness and breast cancer awareness for people with an ID were identified and critically appraised.

RESULTS

Five interventions to increase cancer awareness or breast cancer awareness in people with an ID were identified.

CONCLUSION

The review highlighted the paucity of theoretically underpinned breast cancer awareness interventions specifically aimed at women with an ID. Facilitating breast cancer awareness for women with an ID could potentially lead to earlier presentation of potential symptoms of breast cancer, earlier treatment, better prognosis and ultimately, improved survival. This article establishes that there is a need for an intervention underpinned by theory to increase breast cancer awareness in women with an ID.

Interventions for fatigue in inflammatory bowel disease

BACKGROUND

Inflammatory bowel disease (IBD) is an umbrella term used to describe a group of chronic, progressive inflammatory disorders of the digestive tract. Crohn's disease and ulcerative colitis are the two main types. Fatigue is a common, debilitating and burdensome symptom experienced by individuals with IBD. The subjective, complex nature of fatigue can often hamper its management. The efficacy and safety of pharmacological or non-pharmacological treatments for fatigue in IBD is not yet established through systematic review of studies.

OBJECTIVES

To assess the efficacy and safety of pharmacological and non-pharmacological interventions for managing fatigue in IBD compared to no treatment, placebo or active comparator.

SEARCH METHODS

A systematic search of the databases Embase, MEDLINE, Cochrane Library, CINAHL, PsycINFO was undertaken from inception to July 2018. A top-up search was run in October 2019. We also searched the Cochrane IBD Group Specialized Register, the Cochrane Central Register of Controlled Trials, ongoing trials and research registers, conference abstracts and reference lists for potentially eligible studies.

SELECTION CRITERIA

Randomised controlled trials of pharmacological and non-pharmacological interventions in children or adults with IBD, where fatigue was assessed as a primary or secondary outcome using a generic or disease-specific fatigue measure, a subscale of a larger quality of life scale or as a single-item measure, were included.

DATA COLLECTION AND ANALYSIS

Two authors independently screened search results and four authors extracted and assessed bias independently using the Cochrane 'Risk of bias' tool. The primary outcome was fatigue and the secondary outcomes included quality of life, adverse events (AEs), serious AEs and withdrawal due to AEs. Standard methodological procedures were used.

MAIN RESULTS

We included 14 studies (3741 participants): nine trials of pharmacological interventions and five trials of non-pharmacological interventions. Thirty ongoing studies were identified, and five studies are awaiting classification. Data on fatigue were available from nine trials (1344 participants). In only four trials was managing fatigue the primary intention of the intervention (electroacupuncture, physical activity advice, cognitive behavioural therapy and solution-focused therapy). Electroacupuncture Fatigue was measured with Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F) (scores range from 0 to 52). The FACIT-F score at week eight was 8.00 points higher (better) in participants receiving electroacupuncture compared with no treatment (mean difference (MD) 8.00, 95% CI 6.45 to 9.55; 1 RCT; 27 participants; low-certainty evidence). Results at week 16 could not be calculated. FACIT-F scores were also higher with electroacupuncture compared to sham electroacupuncture at week eight (MD 5.10, 95% CI 3.49 to 6.71; 1 RCT; 30 participants; low-certainty evidence) but not at week 16 (MD 2.60, 95% CI 0.74 to 4.46; 1 RCT; 30 participants; low-certainty evidence). No adverse events were reported, except for one adverse event in the sham electroacupuncture group. Cognitive behavioural therapy (CBT) and solution-focused therapy Compared with a fatigue information leaflet, the effects of CBT on fatigue are very uncertain (Inflammatory Bowel Disease-Fatigue (IBD-F) section I: MD -2.16, 95% CI -6.13 to 1.81; IBD-F section II: MD -21.62, 95% CI -45.02 to 1.78; 1 RCT, 18 participants, very low-certainty evidence). The efficacy of solution-focused therapy on fatigue is also very uncertain, because standard summary data were not reported (1 RCT, 98 participants). Physical activity advice One 2 x 2 factorial trial (45 participants) found physical activity advice may reduce fatigue but the evidence is very uncertain. At week 12, compared to a control group receiving no physical activity advice plus omega 3 capsules, FACIT-F scores were higher (better) in the physical activity advice plus omega 3 group (FACIT-F MD 6.40, 95% CI -1.80 to 14.60, very low-certainty evidence) and the physical activity advice plus placebo group (FACIT-F MD 9.00, 95% CI 1.64 to 16.36, very low-certainty evidence). Adverse events were predominantly gastrointestinal and similar across physical activity groups, although more adverse events were reported in the no physical activity advice plus omega 3 group. Pharmacological interventions Compared with placebo, adalimumab 40 mg, administered every other week ('eow') (only for those known to respond to adalimumab induction therapy), may reduce fatigue in patients with moderately-to-severely active Crohn's disease, but the evidence is very uncertain (FACIT-F MD 4.30, 95% CI 1.75 to 6.85; very low-certainty evidence). The adalimumab 40 mg eow group was less likely to experience serious adverse events (OR 0.56, 95% CI 0.33 to 0.96; 521 participants; moderate-certainty evidence) and withdrawal due to adverse events (OR 0.48, 95%CI 0.26 to 0.87; 521 participants; moderate-certainty evidence). Ferric maltol may result in a slight increase in fatigue, with better SF-36 vitality scores reported in the placebo group compared to the treatment group following 12 weeks of treatment (MD -9.31, 95% CI -17.15 to -1.47; 118 participants; low-certainty evidence). There may be little or no difference in adverse events (OR 0.55, 95% CI 0.26 to 1.18; 120 participants; low-certainty evidence) AUTHORS' CONCLUSIONS: The effects of interventions for the management of fatigue in IBD are uncertain. No firm conclusions regarding the efficacy and safety of interventions can be drawn. Further high-quality studies, with a larger number of participants, are required to assess the potential benefits and harms of therapies. Future studies should assess interventions specifically designed for fatigue management, targeted at selected IBD populations, and measure fatigue as the primary outcome.

Identification of Research Priorities for Inflammatory Bowel Disease Nursing in Europe: a Nurses-European Crohn's and Colitis Organisation Delphi Survey

BACKGROUND

Robust research evidence should inform clinical practice of inflammatory bowel disease [IBD] specialist nurses, but such research is currently very limited. With no current agreement on research priorities for IBD nursing, this survey aimed to establish topics to guide future IBD nursing research across Europe.

METHODS

An online modified Delphi survey with nurse and allied health professional members of the Nurses European Crohn's and Colitis Organisation [n = 303] was conducted. In Round One, participants proposed topics for research. In Round Two, research topics were rated on a 1-9 scale and subsequently synthesised to create composite research questions. In Round Three, participants selected their top five research questions, rating these on a 1-5 scale.

RESULTS

Representing 13 European countries, 88, 90 and 58 non-medical professionals, predominantly nurses, responded to Rounds One, Two and Three, respectively. In Round One, 173 potential research topics were suggested. In Rounds Two And Three, responders voted for and prioritised 125 and 44 questions, respectively. Round Three votes were weighted [rank of 1 = score of 5], reflecting rank order. The top five research priorities were: interventions to improve self-management of IBD; interventions for symptoms of frequency, urgency and incontinence; the role of the IBD nurse in improving patient outcomes and quality of life; interventions to improve IBD fatigue; and care pathways to optimise clinical outcomes and patient satisfaction.

CONCLUSIONS

The prioritised list of topics gives clear direction for future IBD nursing research. Conducting this research has potential to improve clinical practice and patient-reported outcomes.

Self-reported Symptom Burden in Individuals with Inflammatory Bowel Disease

BACKGROUND AND AIMS

Individuals with inflammatory bowel disease experience debilitating symptoms on a daily basis, but little is known about symptom burden in IBD. The objectives were to (i) identify the most prevalent symptoms and the average number of symptoms experienced; (ii) assess symptom frequency, severity and distress; and (iii) determine the most burdensome symptoms experienced by individuals with inflammatory bowel disease.

METHODS

A cross-sectional descriptive design was used to collect data in a single regional treatment centre in Ireland. A consecutive and unique sample of 247 individuals diagnosed with Crohn's disease and ulcerative colitis completed a modified disease-specific version of the Memorial Symptom Assessment Scale.

RESULTS

Participants reported experiencing a median of 10 symptoms during the last week, but as many as 16 symptoms were experienced by those with active disease. Of the symptoms experienced, lack of energy was identified as the most burdensome symptom. Bowel symptoms of urgency and diarrhoea and irritable bowel syndrome-type symptoms such as feeling bloated and flatulence were also problematic. Worry was ranked the most burdensome psychological symptom experienced. Symptom burden scores varied according to disease type and disease status, with significant differences found between those with active and inactive disease.

CONCLUSIONS

Individuals with inflammatory bowel disease experience a considerable number of symptoms and are burdened by both physical and psychological symptoms, particularly during active disease. Healthcare professionals' focus of assessment needs to be broadened to encompass multiple symptoms. Greater attention needs to be given to fatigue and psychological symptoms.

Identification of sensory attributes, instrumental and chemical measurements important for consumer acceptability of grilled lamb Longissimus lumborum

In this study, important eating quality attributes that influence consumer liking for grilled lamb loin have been identified using preference mapping techniques. The eating quality attributes identified as driving the consumer liking of lamb loin steaks were “tenderness”, “sweet flavour”, “meaty aftertaste”, “roast lamb flavour” and “roast lamb aftertaste”. In contrast, the texture attribute “rubbery” and the flavour attributes “bitter flavour” and "bitter aftertaste" had a negative influence on consumer perceptions. Associations were observed between eating quality and a number of instrumental and chemical measurements. Warner Bratzler Shear Force showed an association with “rubbery” texture and a negative association with “tenderness” and consumer liking scores. The compounds, glucose, glucose-6-phosphate, inosine, inosine monophosphate and adenosine monophosphate were associated with the attributes, “sweet flavour”,“meaty aftertaste”, “roast lamb flavour”, “roast lamb aftertaste” and with consumer scores for liking of lamb which is probably caused by the role some of these compounds play as precursors of flavour and as taste compounds.

Self-management education for cystic fibrosis

BACKGROUND

Self-management education may help patients with cystic fibrosis and their families to choose, monitor and adjust treatment requirements for their illness, and also to manage the effects of illness on their lives. Although self-management education interventions have been developed for cystic fibrosis, no previous systematic review of the evidence of effectiveness of these interventions has been conducted.

OBJECTIVES

To assess the effects of self-management education interventions on improving health outcomes for patients with cystic fibrosis and their caregivers

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register (date of the last search: 22 August 2013).We also searched databases through EBSCO (CINAHL; Psychological and Behavioural Sciences Collection; PsychInfo; SocINDEX) and Elsevier (Embase) and handsearched relevant journals and conference proceedings (date of the last searches: 01 February 2014 ).

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials or controlled clinical trials comparing different types of self-management education for cystic fibrosis or comparing self-management education with standard care or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial eligibility and risk of bias. Three authors extracted data.

MAIN RESULTS

Four trials (involving a total of 269 participants) were included. The participants were children with cystic fibrosis and their parents or caregivers in three trials and adults with cystic fibrosis in one trial. The trials compared four different self-management education interventions versus standard treatment: (1) a training programme for managing cystic fibrosis in general; (2) education specific to aerosol and airway clearance treatments; (3) disease-specific nutrition education; and (4) general and disease-specific nutrition education. Training children to manage cystic fibrosis in general had no statistically significant effects on weight after six to eight weeks, mean difference -7.74 lb (i.e. 3.51 kg) (95% confidence interval -35.18 to 19.70). General and disease-specific nutrition education for adults had no statistically significant effects on: pulmonary function (forced expiratory volume at one second), mean difference -5.00 % (95% confidence interval -18.10 to 8.10) at six months and mean difference -5.50 % (95% confidence interval -18.46 to 7.46) at 12 months; or weight, mean difference - 0.70 kg (95% confidence interval -6.58 to 5.18) at six months and mean difference -0.70 kg (95% confidence interval -6.62 to 5.22) at 12 months; or dietary fat intake scores, mean difference 1.60 (85% confidence interval -2.90 to 6.10) at six months and mean difference 0.20 (95% confidence interval -4.08 to 4.48) at 12 months. There is some limited evidence to suggest that self-management education may improve knowledge in patients with cystic fibrosis but not in parents or caregivers. There is also some limited evidence to suggest that self-management education may result in positively changing a small number of behaviours in both patients and caregivers.

AUTHORS' CONCLUSIONS

The available evidence from this review is of insufficient quantity and quality to draw any firm conclusions about the effects of self-management education for cystic fibrosis. Further trials are needed to investigate the effects of self-management education on a range of clinical and behavioural outcomes in children, adolescents and adults with cystic fibrosis and their caregivers.

Symptom burden: a forgotten area of measurement in inflammatory bowel disease

Inflammatory bowel disease (IBD) collectively known as Crohn's disease and ulcerative colitis are chronic inflammatory diseases of the digestive tract. Periods of active and inactive disease are common along the trajectory of this illness. A range of symptoms such as fatigue, diarrhoea and abdominal pain are experienced and are often very debilitating in nature resulting in significance interference in daily life. Despite this, to date, research in the area of symptoms remains an underexplored topic. This paper aims to discuss current approaches to symptom assessment in IBD and the potential to measure symptom burden in further research, in order to gain a greater understanding into the experiences of individuals with IBD.

Head and neck cancer patients' experiences of percutaneous endoscopic gastrostomy feeding: a Q-methodology study

Head and neck cancer patients are at high risk of malnutrition and its complications and therefore often undergo non-oral nasogastric or percutaneous endoscopic gastrostomy (PEG) nutrition support. However, there is little evidence that either approach is effective in this group. While one possible explanation for these findings relates to the relationship between artificial tube feeding and poor quality of life, there is little research that examines the patient's subjective experience of nutrition support. This study investigated the experiences of PEG tube feeding in head and neck cancer patients undergoing radical treatment. Conventional Q-methodology was used with 15 head and neck cancer patients, who rank-ordered 36 statements according to the extent to which these reflected their experiences of PEG tube feeding. The sorted statements were factor-analysed case-wise to provide clusters of similar experiences. Three perspectives emerged. Factor 1, labelled 'Constructive cognitive appraisal', focused around positive adaptation to, and acceptance of, PEG feeding. Factor 2, labelled 'Cognitive-affective dissonance', reflected ambivalence between cognitive acceptance and affective rejection of the PEG tube. Factor 3, labelled 'Emotion-focused appraisal', was characterised by tube-focused anxiety and fear. The findings broadly confirm Levanthal et al.'s Self-Regulatory Model of coping and support the need for genuine and individualised patient-centred nutritional care.

Self-management education for cystic fibrosis

BACKGROUND

Self-management education may help patients with cystic fibrosis and their families to choose, monitor and adjust treatment requirements for their illness, and also to manage the effects of illness on their lives. Although self-management education interventions have been developed for cystic fibrosis, no previous systematic review of the evidence of effectiveness of these interventions has been conducted.

OBJECTIVES

To assess the effects of self-management education interventions on improving health outcomes for patients with cystic fibrosis and their caregivers

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group Trials Register (date of the last search: 23 February 2011).We also searched databases through EBSCO (CINAHL; Psychological and Behavioural Sciences Collection; PsychInfo; SocINDEX) and Elsevier (EMBASE) and handsearched relevant journals and conference proceedings (date of the last searches: 30th March 2011).

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised controlled trials or controlled clinical trials comparing different types of self-management education for cystic fibrosis or comparing self-management education with standard care or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial eligibility and risk of bias. Three authors extracted data.

MAIN RESULTS

Four trials (involving a total of 269 participants) were included. The participants were children with cystic fibrosis and their parents or caregivers in three trials and adults with cystic fibrosis in one trial. The trials compared four different self-management education interventions versus standard treatment: (1) a training programme for managing cystic fibrosis in general; (2) education specific to aerosol and airway clearance treatments; (3) disease-specific nutrition education; and (4) general and disease-specific nutrition education. Training children to manage cystic fibrosis in general had no statistically significant effects on weight after six to eight weeks, mean difference -7.74 lb (95% confidence interval -35.18 to 19.70). General and disease-specific nutrition education for adults had no statistically significant effects on: pulmonary function (forced expiratory volume at one second), mean difference -5.00 % (95% confidence interval -18.10 to 8.10) at six months and mean difference -5.50 % (95% confidence interval -18.46 to 7.46) at 12 months; or weight, mean difference - 0.70 kg (95% confidence interval -6.58 to 5.18) at six months and mean difference -0.70 kg (95% confidence interval -6.62 to 5.22) at 12 months; or dietary fat intake scores, mean difference 1.60 (85% confidence interval -2.90 to 6.10) at six months and mean difference 0.20 (95% confidence interval -4.08 to 4.48) at 12 months. There is some limited evidence to suggest that self-management education may improve knowledge in patients with cystic fibrosis but not in parents or caregivers. There is also some limited evidence to suggest that self-management education may result in positively changing a small number of behaviours in both patients and caregivers.

AUTHORS' CONCLUSIONS

The available evidence from this review is of insufficient quantity and quality to draw any firm conclusions about the effects of self-management education for cystic fibrosis. Further trials are needed to investigate the effects of self-management education on a range of clinical and behavioural outcomes in children, adolescents and adults with cystic fibrosis and their caregivers.

Magnetic Properties of Self-Assembled Fe Nanoparticle Arrays

The magnetic properties of multilayer arrays of Fe nanoparticles were compared with those of frozen, dilute suspensions of the same particles. The array sample displayed larger coercivity in both hysteretic and remanent magnetization measurements. However, the derivative of the remanent magnetization curve shows a much broader switching field distribution for the arrays than for the dilute sample. Magnetic relaxation measurements show the convergence of the time dependent properties of the samples at large times, and much more rapid relaxation in the arrays at short times.

Structure of Self-Assembled Fe and FePt Nanoparticle Arrays

Arrays were self-assembled by evaporating suspensions of 4 nm FePt or 8 nm Fe nanoparticles. The monolayers had a hexagonal close packed (hcp) structure, but the multilayer structure varied. To identify the multilayer structures, transmission electron microscopy (TEM) images were compared with phase contrast image simulations. The results showed that Fe could be grown as both hcp and face-centered cubic (fcc), or fcc-like, structures. The results of image analysis of the FePt arrays were consistent with fcc structures.

Symptom burden in inflammatory bowel disease: rethinking conceptual and theoretical underpinnings

Symptom control is fundamental to the nursing management of inflammatory bowel disease (IBD). However, symptom control can be problematic for individuals with IBD, which could result in symptom burden. Symptom burden is an evolving concept in the discipline of nursing and to date little is known about how the defining characteristics of this concept have been applied to symptom research in IBD. In this discussion paper, the concept of symptom burden and the theory of unpleasant symptoms are explored as a basis for understanding symptom research in IBD. This is followed by a critical examination of previous symptom research in IBD. Our conclusion is that there is a need to rethink conceptual and theoretical underpinnings of symptom burden when researching IBD to take account of its defining characteristics, namely symptom severity, frequency and duration, quality and distress. Research knowledge on these defining characteristics will be important to inform nursing assessment of symptom burden in clinical practice.

Long-term donepezil treatment in 565 patients with Alzheimer's disease (AD2000): randomised double-blind trial

BACKGROUND

Cholinesterase inhibitors produce small improvements in cognitive and global assessments in Alzheimer's disease. We aimed to determine whether donepezil produces worthwhile improvements in disability, dependency, behavioural and psychological symptoms, carers' psychological wellbeing, or delay in institutionalisation. If so, which patients benefit, from what dose, and for how long?

METHODS

565 community-resident patients with mild to moderate Alzheimer's disease entered a 12-week run-in period in which they were randomly allocated donepezil (5 mg/day) or placebo. 486 who completed this period were rerandomised to either donepezil (5 or 10 mg/day) or placebo, with double-blind treatment continuing as long as judged appropriate. Primary endpoints were entry to institutional care and progression of disability, defined by loss of either two of four basic, or six of 11 instrumental, activities on the Bristol activities of daily living scale (BADLS). Outcome assessments were sought for all patients and analysed by logrank and multilevel models.

FINDINGS

Cognition averaged 0.8 MMSE (mini-mental state examination) points better (95% CI 0.5-1.2; p<0.0001) and functionality 1.0 BADLS points better (0.5-1.6; p<0.0001) with donepezil over the first 2 years. No significant benefits were seen with donepezil compared with placebo in institutionalisation (42% vs 44% at 3 years; p=0.4) or progression of disability (58% vs 59% at 3 years; p=0.4). The relative risk of entering institutional care in the donepezil group compared with placebo was 0.97 (95% CI 0.72-1.30; p=0.8); the relative risk of progression of disability or entering institutional care was 0.96 (95% CI 0.74-1.24; p=0.7). Similarly, no significant differences were seen between donepezil and placebo in behavioural and psychological symptoms, carer psychopathology, formal care costs, unpaid caregiver time, adverse events or deaths, or between 5 mg and 10 mg donepezil.

INTERPRETATION

Donepezil is not cost effective, with benefits below minimally relevant thresholds. More effective treatments than cholinesterase inhibitors are needed for Alzheimer's disease.

Serial passage of Chlamydia spp. in sub-inhibitory fluoroquinolone concentrations

We investigated the in vitro development of fluoroquinolone resistance in Chlamydia trachomatis and Chlamydia (Chlamydophila) pneumoniae grown in McCoy cell monolayers in supplemented Eagle's minimum essential medium. With C. trachomatis, initial passages at sub-inhibitory fluoroquinolone concentrations did not affect fluoroquinolone susceptibility. However, after an initial lag of 10-24 passages (depending upon the fluoroquinolone used), fluoroquinolone resistance developed rapidly. The final fluoroquinolone MIC after a total of 30 passages was >256 times the MIC of the original wild-type strain with ofloxacin or ciprofloxacin passage. Analysis of the quinolone-resistance determining regions of two quinolone-resistant C. trachomatis mutants obtained after 30 passages showed that both isolates had a single serine to isoleucine substitution at amino acid position 83 in GyrA. In stark contrast, with C. pneumoniae no reduced fluoroquinolone susceptibility could be sustained, even after 30 passages with moxifloxacin or ofloxacin. With sparfloxacin passage, some indication of resistance was observed but no viable organisms could be isolated for further investigation. It is possible that fluoroquinolone-resistant C. pneumoniae are less able to survive than wild type, which may explain why resistance does not develop readily.

Examining the boundaries of tailoring: the utility of tailoring versus targeting mammography interventions for two distinct populations

Health messages can be generic, targeted to population subsets or tailored for individual recipients. There has been little examination of which populations need tailored interventions or whether tailored and targeted interventions differ in important ways. We used data from a mammography intervention study in two distinct populations to simulate a comparison of individually tailored versus targeted interventions. Tailored intervention content was based on individual recipients' interview responses. Targeted intervention content was based on composite group responses. For more than 60% in each population group, about two-thirds of tailored message content was a good match with content of the targeted intervention generated by composite group responses; roughly one-third of the content was 'not a good' fit for their intervention needs. Tailored interventions for more than 80% of subjects in each population differed in at least some way from those generated for all other population group members. This simulation is a first step in quantifying the contribution of individual tailoring over group targeting. Future research should examine whether a targeted intervention that is mostly a 'good' match results in behavioral outcomes similar to those of individually tailored interventions and whether particular differences in tailored versus targeted interventions yield significantly more favorable intervention outcomes.

Antiplatelet effects of MK-852, a platelet fibrinogen receptor antagonist, in healthy volunteers

MK-852, a cyclic heptapeptide, is a potent platelet fibrinogen receptor antagonist. When administered to normal healthy male subjects by 1- and 4-hour constant rate intravenous infusions, it provides a generally well-tolerated and reversible means of inhibition of platelet function. At infusion rates of 1 microgram/kg/min for 1 hour and 0.44 microgram/kg/min for 4 hours, respectively, MK-852 extended baseline bleeding time by greater than 2.2-fold and 2.6-fold, inhibited ADP-induced platelet aggregation by 76% and 69%, and inhibited collagen-induced platelet aggregation by 65% and 67%, respectively. The pharmacokinetics of MK-852 include an elimination half-life of approximately 2 hours, total clearance of about 150 ml/min, and volume of distribution of about 18 liters. Examination of the relationship between MK-852 whole-blood concentration in vitro and inhibition of platelet aggregation showed an EC50 of about 55 ng/ml and a Hill coefficient of 1.55. The infusions were generally well tolerated, with no study drug-related changes in blood counts or biochemical profiles.

A tailored multimedia nutrition education pilot program for low-income women receiving food assistance

This article describes the development and pilot evaluation of a tailored multimedia program to improve dietary behavior among 378 low-income women enrolled in the Food Stamp program in Durham, North Carolina. After randomization to intervention or control groups, participants completed a baseline survey and were resurveyed 1-3 months post-intervention. Measures included dietary fat intake assessed using a brief food-frequency questionnaire, stage of change, knowledge of low-fat foods, self-efficacy and eating behavior questions. The computer-based intervention consisted of a tailored soap opera and interactive 'info-mercials' that provided individualized feedback about dietary fat intake, knowledge and strategies for lowering fat based on stage of change. At follow-up, intervention group participants had improved significantly in knowledge (P < 0.001), stage of change (P < 0.05) and certain eating behaviors (P < 0.05) compared to the control group. Both study groups had lowered their reported fat intake markedly at follow-up (P < 0.001), but did not differ significantly from each other. A majority of participants rated the program as very helpful and were interested in using a similar program in the future. The findings of this pilot study suggest that computerized tailored self-help health promotion programs may be effective educational interventions for lower income and minority populations.

Special programs for special groups

Special groups of persons with mental illness require individually tailored programs.

The rehabilitation relationship

A special member-staff relationship is necessary for psychiatric rehabilitation to be effective.

Pyemotes species strongly implicated in an outbreak of dermatitis in a Queensland country hospital

An acute outbreak of itchy papulovesicular dermatitis occurred among nursing home patients in a small Queensland country hospital west of Toowoomba. Mites, Pyemotes species, were found in the immediate environment of the hospital and have been implicated as the causative agent. This case illustrates the importance of examination of environmental specimens for ectoparasites in cases of unexplained dermatoses.

Opportunities for alcohol screening and counseling in primary care

BACKGROUND

The physician can be an important part of a comprehensive strategy to assist persons with alcohol problems. This study was designed to contribute to the development of physician-initiated brief interventions for patients with alcohol problems by incorporating into an existing screening instrument questions that solicit information relevant to behavior change strategies.

METHODS

Adult patients from 12 family practices in North Carolina (N = 2716) completed a self-administered questionnaire assessing alcohol consumption and other health-related behaviors. Alcohol problems were assessed using the four-item CAGE (Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves, or to get rid of a hangover?). For this study, CAGE was adapted to address only the past 12 months. Patient interest in reducing the amount of alcohol consumed was measured using the Transtheoretical Model developed by Prochaska and colleagues. Patients were also asked about their motives for and barriers to reducing consumption.

RESULTS

Five percent of all patients and 9% of patients who reported drinking alcohol gave positive responses on at least two CAGE items. Patients with three or four positive CAGE responses were 74% more likely to report an interest in reducing alcohol consumption than were those with one or two. Intrinsic reasons were the most important motives for reducing consumption. No pattern was found in barriers.

CONCLUSIONS

We found that in the management of patients with alcohol-related problems, there are many clinical opportunities for patient counseling and referral in the family practice setting. Individually tailored brief interventions that take into consideration the patient's interest in, motives for, and barriers to reducing alcohol consumption are likely to be successful for the family practice physician.

MK-383 (L-700,462), a selective nonpeptide platelet glycoprotein IIb/IIIa antagonist, is active in man

BACKGROUND

Fibrinogen-dependent cross-linking of glycoprotein (GP) IIb/IIIa on activated platelets is the final mechanism leading to platelet aggregation. Inhibition of this mechanism may result in a novel antithrombotic agent. We studied the activity of MK-383 (L-700,462), a new, nonpeptide GPIIb/IIIa antagonist, in vitro and in vivo, in man.

METHODS AND RESULTS

MK-383, a nonpeptide tyrosine derivative, dose-dependently inhibited fibrinogen-dependent platelet aggregation, in vitro. Binding of 125I-labeled fibrinogen to activated platelets was prevented in a competitive manner with an IC50 of 10 +/- 4.2 nmol/L. The activity and tolerability of MK-383 were evaluated in a two-part double-blind, placebo-controlled, dose-escalation study in healthy male subjects using 1- and 4-hour intravenous infusions. Effects on ADP- and collagen-induced ex vivo platelet aggregation (APA or CPA) and template bleeding time (TBT) were evaluated. Twenty-four subjects participated in the 1-hour part. Six received placebo and 18 MK-383 in doses ranging from 0.05 to 0.40 microgram.kg-1 x min-1. MK-383 inhibited platelet aggregation and prolonged bleeding time in a dose-dependent manner. APA and CPA were totally inhibited at the end of infusion of 0.4 microgram.kg-1 x min-1 and returned to 55% and 89% of baseline, respectively, at 3 hours after infusion. TBT was prolonged at this dose from 5.0 +/- 1.3 minutes predose to 22.7 +/- 6 minutes at the end of the infusion (P < .01) and was normalized by 3 hours after infusion. In the 4-hour infusion part, 15 subjects received MK-383 (0.1 to 0.2 microgram.kg-1 x min-1), and five received placebo. Complete inhibition of ex vivo platelet aggregation was seen at 0.15 and 0.2 microgram.kg-1 x min-1. At 0.2 microgram.kg-1 x min-1, TBT was prolonged from 4.4 +/- 1.2 to 23.9 +/- 4.3 minutes at the end of infusion (P < .01) and remained slightly prolonged 3 hours after infusion (7.2 +/- 1.8 minutes). No adverse effects were observed in any of the 33 subjects receiving MK-383.

CONCLUSIONS

The results from this study indicate that MK-383 appears to be well tolerated and active in man. It is the first nonpeptide GPIIb/IIIa antagonist that can be used to investigate the antithrombotic potential of this new class of antiplatelet agents.

Free peritoneal tumour cell identification in patients with gastric and colorectal cancer

The finding of free tumour cells within the peritoneum at the time of laparotomy for gastrointestinal cancer is an important indicator of prognosis and may help select treatment. The aim of this study was to improve the methods whereby these cells could be retrieved and identified. Free peritoneal cancer cells were found in 6 out of 18 gastric cancer patients. All 6 patients had tumour invasion through to the serosa and subsequently died of tumour recurrence. None of the 18 Dukes' B and C colorectal cancer patients had free peritoneal cancer cells. Only 2 of a further 5 patients with extensive colorectal tumour spread had positive cytologies. The conventional mucin stain Periodic Acid Schiff (after diastase digestion) and the monoclonal antibody stain B72.3 were the most useful in identifying free peritoneal cancer cells. Peritoneal brushings did not offer any advantages over conventional peritoneal washings in the retrieval of free tumour cells.

Persistence of measles antibody after revaccination

To evaluate persistence of measles antibody after revaccination, antibody levels were measured 6 years after revaccination of 40 hemagglutination-inhibition (HAI) antibody-negative students who had participated in a serosurvey in Massachusetts. Twelve subjects who had been HAI antibody-positive and were not revaccinated were included as a comparison group. Before revaccination, 7 revaccinees had no detectable plaque reduction neutralization (PRN) antibody (group 1) and 33 had low levels of PRN antibody (group 2). Three weeks after revaccination, all in group 1 and 30 (90%) of 33 in group 2 had developed a fourfold or greater rise in PRN antibody. Six years after revaccination, all subjects had PRN-detectable antibody. However, 12 in group 2 (36%) had antibody titers less than or equal to 1:120 compared with none in group 1 (P less than .01). Persons without PRN antibody will respond to revaccination and maintain protective antibody titers. In contrast, persons with low levels of PRN antibody may respond initially to revaccination, but their antibody titers may fall again to low levels.

Successful immunization of infants at 6 months of age with high dose Edmonston-Zagreb measles vaccine. Cite Soleil/JHU Project Team

A group of 2097 Haitian infants 6 to 11 months of age were randomized to receive Schwarz or Edmonston-Zagreb strain measles vaccines containing 10- to 500-fold more vaccine viral particles than standard potency vaccines. No unusual adverse reactions were noted. Edmonston-Zagreb vaccines were more effective than equivalent doses of Schwarz vaccines as measured by the proportion of vaccinated children with measles antibody concentrations greater than or equal to 200 mIU/ml 2 months after vaccination and the persistence of antibody at 18 to 24 months of age. High titer Edmonston-Zagreb vaccine administered at 6 months of age induced antibody concentrations greater than or equal to 200 mIU/ml in 83% of infants by plaque reduction neutralization and 93% of infants by enzyme-linked immunosorbent assay with high rates of antibody persistence at 12 to 24 months of age. The World Health Organization recommends high titer Edmonston-Zagreb measles vaccines for routine use at 6 months of age in areas where measles is an important cause of mortality in young infants.

Cytological differences between normal and malignant human cell populations in culture

Cells from early-passage cultures of normal and malignant human tissues were analyzed for the presence of multiple nucleoli and tri- or multipolar mitoses; these properties are characteristic of malignant cell populations in tissue sections. For the cell types examined the presence of tri- or multipolar mitoses was characteristic of cells of malignant origin. Within epithelial cell populations, cells containing more than 4 nucleoli were found in populations of malignant but not of normal origin; this distinction did not apply to fibroblast populations. Large numbers of cells must be analyzed quantitatively to establish the distinctions described here, since they are properties characteristic of populations, not of individual cells. This approach may facilitate identification of normal and malignant cell populations in primary and early-passage culture.

On speaking of oneself by name

Speaking of oneself by name is studied. Such behavior occurred with unusual frequency in the case of a patient with predominantly narcissistic character pathology who underwent brief psychotherapy for a stress response syndrome following his wife's suicide. A content and context analysis of this phenomenon showed that the patient would refer to himself by name as a characteristic defense in response to severe threats to his self-esteem. An object-relations perspective proved useful in clarifying dynamic aspects of this defensive maneuver, which depended for its effectiveness on the evocation of self-images negating guilt and shame. In addition to the patient's character style and the nature of the stress event, the framework of the therapy and the therapist's countertransference responses to the patient were other factors influencing the appearance of this behavior. It is concluded that referring to oneself by name reflects at least momentary disturbance in the sense of self and may be unusually prominent and frequent in narcissistic pathology. A study of the phenomenon appears to elucidate an important step in the building of self-representation from the self-object representations of the symbiotic phase: the concept of "I" becomes possible through the reconciling of a sense of physical and psychic separateness with the need for emotional relatedness to others. Where problems of this early developmental phase are reactivated in the treatment situation, the patient's relationship with the therapist is the vital bridge toward a more coherent sense of self.

DNA polymerases in mouse spermatogenic cells separated by sedimentation velocity

Activity levels of DNA polymerase alpha and DNA polymerase beta have been measured in mouse spermatogenic cells separated by sedimentation velocity. Testes from prepuberal (17 day old) and sexually mature mice were dissociated and separated by unit gravity sedimentation into 6 populations of cells. Phase contrast microscopy and [3H]thymidine labeling kinetics revealed that at least 85% of the cells in fraction A were pachytene-stage primary spermatocytes, fraction B was enriched for primary spermatocytes and round spermatids, fraction C contained spermatogonia and/or pre-leptotene primary spermatocytes and later stages of spermatids (no spermatids were present in fraction C from the testes of 17 day old mice) and fractions D to F contained mixed populations of cells, many in later stages of spermiogenesis. When expressed as activity in 10(6) cells or as a specific activity, fractions A, B, and C from mature animals population initially loaded onto the gradient while fractions D, E and F had activity levels similar to or below the population of dissociated cells. The ratio of activity between the DNA polymerases was constant in fractions A, B, and C, but in fractions D, E, and F, the ratio decreased due to a more rapid decline of activity of polymerase alpha. A comparison of activity levels in fraction C from prepuberal and sexually mature mice revealed an increase in DNA polymerase alpha activity and a decrease in the activity of DNA polymerase beta in the cells from the 17 day old animals.

RNA polymerase activity in bovine spermatozoa

Washed mature spermatozoa from bulls incorporate ribonucleoside triphosphates into RNA using an endogenous template. Maximum incorporation was observed at 31 degrees C in the presence of MgCl2, all four ribonucleoside triphosphates, beta-mercaptoethanol, and glycine sodium hydroxide buffer at pH 9.0. The amount of synthesis was linearly dependent upon the concentration of spermatozoa and continued for at least 4 h. Digestion studies revealed the RNA to be present in a protected (intracellular?) location in the spermatozoa. The RNA synthesis was inhibited by ethidium bromide, rifampicin, acriflavine, actinomycin D, and caffeine, but not by alpha-amanitine or rifamycin SV. Fractionation of the spermatozoa by sonication and separation of the heads and tails by centrifugation through a discontinuous gradient revealed that more than half of the total RNA polymerase activity was associated with the tail fraction.