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PubMedDate not supplied

Frequency, reasons, and risk factors of entacapone discontinuation in Parkinson disease.

OBJECTIVES: To determine the rate of and identify reasons for discontinuation of entacapone treatment in Parkinson disease patients. METHODS: A retrospective study design was used, including medical record reviews and telephone call to the patient as needed. RESULTS: Two hundred and twenty-two Parkinson disease patients were started on entacapone over a period of 3 years. One hundred and twenty-two patients (56%) had discontinued the medication by the end of the follow up period. Reasons for discontinuation included lack of efficacy (46%), worsening of parkinsonian symptoms (28%), worsened cognition (20%), dyskinesia (17%), nausea (11%), diarrhea (9%), cost (4%), other side effect (8%), and other, non-medication related reasons (19%). Presence of wearing off at the time of initial treatment and male sex were associated with decreased dropout rates, while the presence of orthostatic hypotension increased the likelihood of discontinuation. Patient age, disease duration, Hoehn and Yahr stage, Unified Parkinson's Disease Rating Scale section II score, presence of dementia, hallucinations, dyskinesias, or depression, number of daily L-dopa doses, and concomitant treatment with dopamine agonists did not affect dropout rate. CONCLUSIONS: Lack of efficacy seems to be the main reason for entacapone discontinuation. Male patients with wearing off and no orthostatic hypotension seem to tolerate the medication better. Advanced disease stage, presence of cognitive dysfunction, and presence of dyskinesia should not necessarily preclude patients from being treated with entacapone, when otherwise indicated.

Aged↗
PubMed2002

Parents' reasons for enrolment of their motor-disabled child in a Dutch therapeutic toddler class.

This article describes and categorizes the reasons why parents enrol their motor-disabled children in the therapeutic toddler class, a special centre-based service in early intervention. The results among a representative Dutch sample of 84 mothers showed that child-related reasons were considered more important than family- and parent-related reasons. Family- and parent-related reasons were influenced by the presence and severity of the child's behaviour problems. The results of this study are discussed within the context of parental expectations in early intervention, and the concept of family centredness.

Adult↗
PubMed2004

Reasons for not intensifying antihypertensive treatment (RIAT): a primary care antihypertensive intervention study.

OBJECTIVE: Hypertension is often poorly controlled, despite its importance and despite the availability of very effective treatments. An under-recognized problem is the failure of consensus guidelines to acknowledge the important difference between efficacy in clinical trials and effectiveness in clinical practice. The present survey was designed to prospectively assess what is the target blood pressure (BP) goal defined by a general practitioner (GP) for an individual patient, and what are the reasons for not modifying an antihypertensive drug regimen, when pre-defined individual BP goals are not achieved. DESIGN: Family practice based, open intervention survey. SUBJECTS: Participating GPs enrolled 2621 hypertensive patients. At the first visit each physician was required to assess the cardiovascular risk profile of each patient and to define individual BP targets. INTERVENTIONS: Treatment was started with irbesartan alone or in fixed combination with hydrochlorothiazide. Follow-up visits were suggested after 1 month, 2 months and 4 months. Physicians were asked to report BP values under the new treatment regimen and to indicate whether in their opinion pre-defined BP targets set at baseline were achieved or not and whether the antihypertensive regimen was modified or maintained in relation to whether target BP was reached or not. MAIN OUTCOME MEASURE: To provide reasons for not changing the treatment even though BP goals were missed. RESULTS: Average target BP values defined by the physicians at baseline were 138 +/- 8 mmHg for systolic and 84 +/- 5 mmHg for diastolic BP. Among GPs, defined target BP values did not depend on individual risk stratification, but rather depended on baseline BP values. At baseline systolic and diastolic BP averaged 165/97 +/- 17/10 mmHg, while at the last visit achieved BP averaged 140/84 +/- 14/8 mmHg. There were three main reasons for not intensifying antihypertensive treatment when BP targets were not achieved. These reasons were: (1). the assumption that the time after starting the new drug was too short to appreciate its full effect (44% at first, 14% at last follow-up), (2). that there was a clear improvement or the target BP was almost reached (24% at first, 34% at last follow-up) or (3). that self-measurements were considered satisfactorily (10% at the last visit). CONCLUSIONS: Failure of physicians to follow guidelines is apparently dependent on the belief that baseline BP dictates the target, that a clear improvement in BP might be sufficient and that the full drug effect may take up to 4 months or more to be attained.

Aged↗
PubMedDate not supplied

Progress in the moral reasoning of baccalaureate nursing students between program entry and exit.

Changes in moral reasoning between entry into and exit from a baccalaureate nursing program and the relationship between student characteristics and moral reasoning at entry and exit were explored in this descriptive study. The moral reasoning of four cohorts of students was measured using the Defining Issues Test (DIT). Admission grade point average, prior college credits, and gender accounted for 10% of the variance in DIT P% scores at entry and 14% of the variance at exit from the program. Female students had significantly higher moral reasoning scores than men. Age did not contribute significantly to explaining DIT score variance. DIT P% scores at entry for all four cohorts were within the range of reported norms for college students. Exit scores for all four cohorts were between the normative means for undergraduate students and graduate students. DIT P% score gains between entry and exit were significant for all four cohorts. Students whose entry scores were in the lowest categories had the greatest mean gains.

Adult↗
PubMed1998

Reasons why women who have mastectomy decide to have or not to have breast reconstruction.

Breast reconstruction after mastectomy is chosen by approximately 10 percent of Australian women. Younger women are more likely to have this surgical procedure. This suggests that there may be many factors determining this choice. Sixty-four women who wore an external postmastectomy breast prosthesis and 31 women who had postmastectomy breast reconstruction participated in the present study. The purpose was to gain a greater understanding through semi-structured interviews of why women who had breast reconstruction chose this alternative and why women who wore the external postmastectomy breast prosthesis elected not to have reconstruction. The study also ascertained how difficult it was for the women in both groups to decide their particular breast restoration alternative. The most frequently endorsed reasons for not having breast reconstruction in the prosthesis group included: (1) not essential for physical well being, (2) not essential for emotional well being, (3) not having enough information about the procedure, and (4) not wanting anything unnatural in the body. When each member of the group was asked to identify a major reason for not having reconstruction, two predominant issues emerged: (1) fearing complications and (2) perceiving themselves as being too old for the procedure. Twelve percent of the prosthesis group experienced difficulty in making the decision not to have reconstruction. Three factors accounted for this difficulty: (1) the lack of family support, (2) the inability to have a specific type of reconstruction, and (3) the perception that friends and acquaintances saw the surgery as cosmetic. The most frequently reported reasons given by the reconstruction group for having reconstruction included: (1) to get rid of the external breast prosthesis, (2) to be able to wear many different types of clothing, (3) to regain femininity, and (4) to feel whole again. The least influential factors were to improve marital and sexual relations. The major reason cited most often by this group was to feel whole again. None of the women in the reconstruction group experienced any difficulty when deciding their method of breast restoration. What factors are taken into consideration by women when they decide either to have or not to have reconstruction need to be understood by physicians. This knowledge will assist them in conveying appropriate information regarding alternatives and will help them deal with the women's concerns and/or misconceptions.

Adult↗
PubMed2006

Medical students' clinical reasoning skills as a function of basic science achievement and clinical competency measures: a structural equation model.

BACKGROUND: The purpose of this study was to investigate the fit of a hypothesized model of medical students' diagnostic or clinical reasoning skills based on their aptitude for medical school, basic science achievement, and clinical competency measures. METHOD: A total of 589 medical students who received their MD from 1994 to 2002 participated in this study. Confirmatory factor analysis was used to evaluate the fit of theoretical models of clinical reasoning using measures of basic science and clinical knowledge. RESULTS: The results provided support for a three-factor model of medical student performance (Bentler's Comparative Fit Index = .905, standardized root mean squared residual = .054, root mean squared error of approximation = .105). The clinical reasoning skills of medical students were influenced by an independent relationship between latent variables of basic science achievement and clinical competency. CONCLUSION: The findings support a theoretical model of diagnostic or clinical reasoning that treats the basic science and clinical knowledge of medical students as distinct domains.

Aptitude Tests↗
PubMed2006

Reasons for modification of generic highly active antiretroviral therapeutic regimens among patients in southern India.

OBJECTIVE: To describe reasons for modification and discontinuation of antiretroviral regimens in association with adverse events (AEs), treatment failure, and cost among patients in southern India. METHODS: Secular trends of patients initiating highly active antiretroviral therapy (HAART) between January 1996 and October 2004 at a tertiary HIV referral center in India were analyzed using a previously validated natural history database. RESULTS: All previously antiretroviral therapy-naive patients who initiated HAART (N = 1443) and had at least 1 follow-up visit were evaluated. The median CD4 count at the time of initiating HAART was 108 cells/microL. The most common first-line regimens were stavudine (d4T) plus lamivudine (3TC) plus nevirapine (NVP) (63%), zidovudine (AZT) plus 3TC plus NVP (19%), d4T plus 3TC plus efavirenz (EFV) (9%), and AZT plus 3TC plus EFV (4%). Twenty percent of patients modified their first-line regimen. The most common reason for modifying therapy was the development of an AE (64%), followed by cost (19%) and treatment failure (14%), with median times to modify therapy being 40, 151, and 406 days, respectively. Common AEs were itching and/or skin rash (66%), hepatotoxicity (27%), and anemia (23%). Nine percent of patients discontinued therapy entirely after a median duration of 124 days, primarily because of cost (64%). CONCLUSION: The most common reason for modifying therapy was the occurrence of AEs, whereas cost was the most common reason for discontinuing therapy. Despite increasing access to lower cost generic HAART in India, even less expensive and more tolerable first-line regimens and cost-effective treatment monitoring tools need to be introduced to achieve better treatment outcomes and access in resource-constrained settings.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

Analytic and heuristic processing influences on adolescent reasoning and decision-making.

The normative/descriptive gap is the discrepancy between actual reasoning and traditional standards for reasoning. The relationship between age and the normative/descriptive gap was examined by presenting adolescents with a battery of reasoning and decision-making tasks. Middle adolescents (N = 76) performed closer to normative ideals than early adolescents (N = 66), although the normative/descriptive gap was large for both groups. Correlational analyses revealed that (1) normative responses correlated positively with each other, (2) nonnormative responses were positively interrelated, and (3) normative and nonnormative responses were largely independent. Factor analyses suggested that performance was based on two processing systems. The "analytic" system operates on "decontextualized" task representations and underlies conscious, computational reasoning. The "heuristic" system operates on "contextualized," content-laden representations and produces "cognitively cheap" responses that sometimes conflict with traditional norms. Analytic processing was more clearly linked to age and to intelligence than heuristic processing. Implications for cognitive development, the competence/performance issue, and rationality are discussed.

Adolescent↗
PubMed2004

Mechanisms of belief-desire reasoning. Inhibition and bias.

Biases in reasoning can provide insight into underlying processing mechanisms. We demonstrate a new bias in children's belief-desire reasoning. Children between 4 and 8 years of age were told a story in which a character was mistaken about which of three boxes contained some object. The character wanted to go to one of the boxes, but only if it did not contain the object. In this scenario, the character would be expected to avoid the box where she falsely believed the object to be, but might go to either of the remaining boxes. Though the character was equally likely to go to either box, children were biased to predict that the character would go to the box that contained the object. In a control task, the character had the same desire but did not have a false belief; in this case, children showed no bias, choosing the two correct answers equally often. The observed pattern of bias was predicted by a developmental model of belief-desire reasoning. Competent belief-desire reasoning depends on a process of selection by inhibition in which the best belief content emerges from a set of candidates.

Bias↗
PubMed2004

A framework for understanding clinical reasoning in community nursing.

BACKGROUND: Clinical reasoning is employed to develop solutions to health needs. The impact of the clinical environment on the organization of knowledge-guiding practice has received limited attention. This gap in the clinical landscape restricts the sharing of decision-making processes. AIMS: Focusing on the community, and specifically the patient's home as a context for nursing, this paper describes the creation of a collective conceptual map for a group of community nurses. There is a twofold aim of exploring the process of exposing and articulating the clinical framework and enhancing and sharing understanding of the clinical paradigm in this context. DESIGN: An interpretive research approach was utilized. Hermeneutic phenomenology guided the level of meaning accessed and constructivism was used to build an educational picture. METHODS: Multiple methods including focus groups, observation and narrative recordings were utilized to collect and analyse research data. RESULTS: All nurses may engage with the same concepts--health, need, care and partnerships--but organized into particular frames by the guiding practice philosophy and service organization. A four-stage framework for understanding clinical reasoning in the community setting is presented. This acknowledges the multi-faceted nature of health, the lived experience of health deficits, and is located in a participation and negotiated model of care. Practice examples are presented to expose the construction of need and response which often occurs in a triadic decision-making process. CONCLUSIONS: Environment of care has significant implications on need identification and response. RELEVANCE TO CLINICAL PRACTICE: Mechanisms to enhance the sharing of clinical reasoning and decision-making transparency are essential to aid inter- and intra-professional communication. Presentation of a clinical reasoning framework exposes the breath of 'signals' encountered in practice and the range of knowledge employed in understanding and responding to patient need.

Community Health Nursing↗
PubMed1997

Measuring knowledge and clinical reasoning skills in a problem-based curriculum.

The purpose of this study was to investigate the validity of the Progress Test that was specially designed for measuring the growth of knowledge and clinical reasoning skills in a problem-based medical curriculum. Scores and subscores of students from the different categories of the Progress Test were compared with their scores on a Clinical Reasoning Tests. Both the Progress Test and the Clinical Reasoning Test revealed the same pattern of increasing scores over the years, and had a high intercorrelation. Further analyses revealed that the clinical sciences subscore in the progress test explained the variations in the clinical reasoning test scores. The knowledge of the behavioural sciences subscore made a small but independent contribution. The knowledge of the biomedical sciences subscore did not have this independent effect. These outcomes are discussed in this paper from the perspective of development of medical expertise research and theory. Some educational consequences are also discussed.

Curriculum↗
PubMed1996

Rider training, reasons for riding, and the social context of riding among young on-road motorcyclists in New Zealand.

Serious injuries to young motorcyclists represent an important public health problem. Little is known about the opinions and behaviours of the young riders at risk. We document the training experiences of young motorcyclists, and their reasons for riding or discontinuing riding, and identify the role models and sources of disapproval of motorcycling. The research was part of a longitudinal study of health, development, attitudes and behaviours of a birth cohort. At age 18 years, cohort members who had ridden a motorcycle during the past year completed a comprehensive questionnaire. Initial riding instruction was rarely received from a qualified instructor but was usually informal, from a male friend or father, and occurred off the road, usually on a farm. The most commonly given reasons for riding were excitement and economy. Most motorcyclists who had ceased riding attributed this to the lack of access to a motorcycle, and few mentioned safety. Mothers were the main source of disapproval. The young riders were not a homogeneous group. More licensed than unlicensed riders said manoeuvrability in traffic and ease of parking were reasons for riding. Licensed motorcyclists had more friends who rode and were more likely than unlicensed riders to have received paternal instruction. Early informal training off the road may establish attitudes and behaviours inappropriate in a traffic context. The main reasons for motorcycling (excitement, economical and manoeuvrable transport, freedom from supervision) and for discontinuing riding (lack of access) indicate motivations that should be considered before implementation of injury prevention interventions.

Accidents, Traffic↗
PubMed2006

A reasoning bias revealed by electrodermal activity.

The sufficiency of behavioral data supporting reasoning biases was challenged. Our objective was to test if physiological data could significantly support reasoning biases. Experiment 1: When performing a rule discovery task with feedback, participants systematically gave the same response. This was not compatible with norms referring to a formal logic system, but was insufficient to conclude there was a reasoning bias. Only the knowledge of participants' expectations of feedback would merit this conclusion. Experiment 2: Participants' expectations were indexed by electrodermal activity. The results showed that when participants displayed the behavioral bias, they considered their responses to be correct and hence committed an error of logic. However, this error of logic did not prevent them from solving the task. This argues for a theory according to which human reasoning uses more economical strategies than the simple application of formal logical rules.

Adult↗
PubMedDate not supplied

Patterns of use of triptans and reasons for switching them in a tertiary care migraine population.

OBJECTIVE: To assess the reasons for switching triptans within migraine patients presenting to a specialty clinic. DESIGN AND METHODS: We reviewed data of migraineurs who (1) were currently using a triptan as acute treatment medication for migraine, and (2) had previously used at least one other triptan, or a different triptan formulation. All subjects were followed for at least 1 year. For every triptan/formulation used, the reasons for discontinuation were obtained. RESULTS: Our sample consisted of 386 patients, 339 of whom (87.8%) were females. Sumatriptan was first used by 349 (90.4%); zolmitriptan, by 238 (61.5%); rizatriptan, by 195 (50.5%); naratriptan, by 137 (35.4%); and almotriptan, by 31 (8.0%). Almotriptan was excluded from this analysis because of our small sample. We found significant differences among those who wanted to try another triptan to see if it would be better in those who first used sumatriptan 25 mg, compared to those first using sumatriptan 50 mg (P = .01), sumatriptan 100 mg (P < .001), sumatriptan nasal spray (NS) (P < .001), sumatriptan subcutaneous (SC) (P < .001), zolmitriptan 5 mg (P < .001), rizatriptan 10 mg (P < .001), and naratriptan (P = .001). Patients using rizatriptan, sumatriptan NS, and sumatriptan SC had significantly lower rates of reporting this answer. Subjects first using naratriptan were less likely to report recurrence than those using sumatriptan 25 mg (P = .004), sumatriptan 50 mg (P = .0005), sumatriptan 100 mg (P = .003), zolmitriptan (P = .02), and rizatriptan (P = .006). Incomplete relief was more frequently reported by those first using sumatriptan 25 mg and naratriptan. Inconsistency was a reason for switching in those initially using sumatriptan NS, sumatriptan 25 mg, and naratriptan and less frequently reported in those using zolmitriptan and sumatriptan SC. Side effects were major factors for those first using sumatriptan 100 mg, NS, and SC, and less for those using naratriptan and sumatriptan 25 mg. From those subjects that initially used sumatriptan SC and were switched to a different triptan or formulation, 19.5% returned to sumatriptan SC; for the other triptans/formulations, the percentages were: sumatriptan 25 mg, 7.8%; sumatriptan 50 mg or 100 mg, 42.3%; sumatriptan NS, 17.7%; zolmitriptan, 17.6%; rizatriptan, 16.5%; naratriptan, 9.4%. For those who used more than three triptans/formulations, the last triptan used was: sumatriptan, 29.5%; zolmitriptan, 31.8%; rizatriptan, 25.0%; naratriptan, 12.5%. CONCLUSIONS: A variety of treatment attributes are important in determining the reasons involved in switching a triptan. To assess this attributes can provide additional information to supplement the traditional tests of efficacy provided by randomized clinical trials.

Adolescent↗
PubMed1994

Alcohol norms, expectancies, and reasons for drinking and alcohol use in a U.S. versus a Japanese college sample.

Two hundred eighty-two students at Arizona State University in the U.S. and 339 students at Okayama University in Japan completed a questionnaire on their alcohol use, expectancies of the effects of alcohol on their own and others' moods and behaviors, the desirability of these effects, norms of significant others for levels of alcohol use and the subject's desire to comply with these norms, and reasons for drinking and not drinking alcohol. Although frequencies of current drinkers versus abstainers did not differ between the two samples, the U.S. students began regular alcohol use at a significantly earlier age, currently drank more alcohol, had higher alcohol expectancies for emotional responses, and endorsed more celebratory reasons for drinking than their Japanese counterparts. U.S. students, however, had lower expectancies for flushing and lower perceived norms for drinking. Hierarchical multiple regressions performed using data from the current drinkers indicated that expectancies of disinhibition and especially aggressiveness after alcohol use, alcohol norms, celebratory (but not pathological) reasons for drinking, and reasons for not drinking were more predictive of reported levels of alcohol use among the U.S. students as compared with the Japanese students.

Adolescent↗
PubMed1989

Rethinking moral reasoning theory.

Many nursing studies on moral reasoning and ethics have used Kohlberg's theory of moral development. The body of knowledge that resulted from these studies indicated that nurses and nursing students had consistently lower than expected levels of moral reasoning. Educational offerings were developed to assist nurses to improve their moral reasoning. This article explores the cognitive-developmental theory of moral development as one way of determining the moral development of nurses. Since this theory of moral reasoning focuses on the rational thought of the individual and does not consider the impact of the environment, it is of limited applicability in nursing. A new theory of morality needs to be developed--a more holistic one that will include both universal principles and contextual tissues.

Cognition↗
PubMed2003

Physician-reported reasons for limited follow-up of patients with a positive fecal occult blood test screening result.

OBJECTIVE: Fecal occult blood testing (FOBT) screening can reduce colorectal cancer (CRC) mortality when patients with an abnormal result [FOBT(+)] undergo a complete diagnostic evaluation (colonoscopy or double-contrast barium enema with or without flexible sigmoidoscopy). The aim of this study was to determine common reasons for nonperformance of a complete diagnostic evaluation. METHODS: We identified 544 FOBT(+) patients, aged 50 yr or older, who had participated in a managed care organization-sponsored CRC screening program. The performance of a complete diagnostic evaluation was determined from a patient-specific follow-up form and managed care organization claims data. Physicians were asked to report whether patients submitted to a complete diagnostic evaluation. When an evaluation was not done, the physicians were also asked to state the reasons for nonperformance. RESULTS: A total of 248 (46%) patients did not undergo a complete diagnostic evaluation. Physicians provided reasons for nonperformance for 50% (123/248). Factors accounting for nonperformance of a complete diagnostic evaluation were classified as follows: primary care physician decision (50%); specialist decision (28%); patient decision (17%); and other (practice-related) (5%). Many failures to complete an appropriate diagnostic evaluation were due to providers deciding to repeat the FOBT, perform a sigmoidoscopy, or not to proceed with any further testing. CONCLUSION: Many patients with a positive FOBT do not receive a complete diagnostic evaluation. The reasons for nonperformance most frequently have to do with physician decision making. Many physician-related explanations do not conform to expert recommendations for appropriate follow-up.

Aged↗
PubMed2006

Reasons for choosing dentistry as a career: a study involving male and female first-year students in Peru.

The aim of this study was to compare the reported reasons to choose dentistry as a career between Peruvian male and female first-year students. A self-completion questionnaire was administered to 75 first-year students registered at the Faculty of Dentistry of the Universidad Peruana Cayetano Heredia, Lima, Peru. The questionnaire comprised 16 items grouped into four categories (economic, professional, vocational and personal background). Students rated the importance of each item for selecting dentistry as a career on a Likert-type scale of five points. The Mann-Whitney test was used to compare groups and item scores by gender. A male/female proportion of 1/2.1 was found in the pool of participating students. When group and item scores were compared between genders, statistically significant differences were only found for vocational and personal background reasons (P < 0.05); however, the three reasons that obtained higher scores for each gender were found to be different. It is recommended that further studies be conducted to increase the sample, by extending the study and evaluating not only reasons for choosing dentistry, but also other factors that may influence the decision.

Adolescent↗