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PubMed1999

Integrating the creative arts into a midwifery curriculum: a teaching innovation report.

The practice of midwifery has long been recognized as both art and science. However, educational programmes for midwifery are most often undertaken within an academic health sciences environment, and tend to be based on knowledge derived from the sciences (e.g. life sciences, biomedical sciences, behavioural sciences and social sciences). These scientific perspectives, while essential to the preparatory and on-going education of midwives, do not necessarily fully prepare midwives to fulfil their practice roles. This paper reports a teaching innovation aimed at facilitating student exploration of fundamental, complex and ethereal concepts which are essential to the effective and skillful practice of midwifery. Through the exploration of the arts and humanities, students were encouraged to engage with concepts such as 'caring', 'empathy', 'suffering', 'motherhood', 'pain', 'love', 'attachment', 'health' and 'illness'. Students were also encouraged to explore cultural and social symbols pertaining to parenthood and family life. Evaluation revealed that students valued the course, and that they gained insights which assisted them to develop understanding of key concepts. Implications for practice and education are drawn from this paper.

Art↗
PubMed2005

Engaging rural youth in physical activity promotion research in an after-school setting.

BACKGROUND: West Virginia, the second most rural state in the nation, has a higher than average prevalence of chronic diseases, especially those related to physical inactivity and obesity. Innovative educational approaches are needed to increase physical activity among adults and youth in rural areas and reduce rural health disparities. This paper describes West Virginia's Health Sciences and Technology Academy (HSTA) Education and Outreach on Healthy Weight and Physical Activity. The project involved teachers and underserved high school students in social science research aimed at increasing physical activity among student and community participants. CONTEXT: The HSTA is an ongoing initiative of university-school-community partnerships in West Virginia that offers academic enrichment to high-school students in after-school clubs. For this project, six HSTA clubs were awarded grants to conduct research on physical activity promotion during the 2003-2004 school year. The project was funded by the Centers for Disease Control and Prevention. METHODS: Focus groups, workshops, and targeted technical assistance were used to assist teachers and students with developing, implementing, and evaluating their research projects. Each club completed one project, and students reported on their research at the annual HSTA symposium held in the spring. Teachers documented their experience with the projects in process journals before and during implementation. CONSEQUENCES: Data from the teachers' process journals revealed that they believed this research experience increased their students' interest in health and health science careers and increased their students' understanding of social science research methods. Challenges included lack of time after school to complete all activities, competing student activities, limited social science research experience of both teachers and students, and delays that resulted from a lengthy human subjects approval process. INTERPRETATION: The entire process was too ambitious to be achieved in one school year. Recommendations for future implementation include offering training modules on social science research methods for both teachers and students. These modules could be offered as a graduate course for teachers and as an in-school elective within the curriculum or as a summer institute for students. This preparatory training might alleviate some of the time management issues experienced by all the projects and could result in more skilled teacher and student researchers.

Age Factors↗
PubMed2006

Acupuncture and related interventions for smoking cessation.

BACKGROUND: Acupuncture and related techniques are promoted as a treatment for smoking cessation in the belief that they may reduce nicotine withdrawal symptoms. OBJECTIVES: The objectives of this review are to determine the effectiveness of acupuncture and the related interventions of acupressure, laser therapy and electrostimulation, in smoking cessation in comparison with no intervention, sham treatment, or other interventions. SEARCH STRATEGY: We searched the Cochrane Tobacco Addiction Group specialized register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, BIOSIS Previews, PsycINFO, Science and Social Sciences Citation Index, AMED and CISCOM. Date of last search January 2005. SELECTION CRITERIA: Randomized trials comparing a form of acupuncture, acupressure, laser therapy or electrostimulation with either no intervention, sham treatment or another intervention for smoking cessation. DATA COLLECTION AND ANALYSIS: We extracted data in duplicate on the type of smokers recruited, the nature of the acupuncture and control procedures, the outcome measures, method of randomization, and completeness of follow up. We assessed abstinence from smoking at the earliest time-point (before six weeks), and at the last measurement point between six months and one year. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. Those lost to follow up were counted as continuing smokers. Where appropriate, we performed meta-analysis using a fixed-effect model. MAIN RESULTS: We identified 24 reports of studies. The only comparison for which there were sufficient studies to combine meaningfully was acupuncture compared with sham acupuncture. The fixed-effect odds ratio (OR) for the short-term effect was 1.36 (95% confidence interval 1.07 to 1.72), but the studies are heterogeneous and the result is strongly influenced by one individual positive study. The significant short-term effect was lost with the random-effects model for pooling, or by removing the outlying study that led to heterogeneity. The long-term result shows no effect of acupuncture compared with sham acupuncture. There was no consistent evidence that acupuncture is superior to no treatment, and no evidence that the effect of acupuncture was different from that of other anti-smoking interventions, or that any particular acupuncture technique is superior to other techniques. AUTHORS' CONCLUSIONS: There is no consistent evidence that acupuncture, acupressure, laser therapy or electrostimulation are effective for smoking cessation, but methodological problems mean that no firm conclusions can be drawn. Further research using frequent or continuous stimulation is justified.

Acupressure↗
PubMed2001

Information provision for stroke patients and their caregivers.

BACKGROUND: The provision of information has been recommended as a key component of service provision after stroke. However, research suggests that patients' understanding of stroke and associated issues remains poor. We determined to undertake a systematic review of information provision strategies for patients and their carers after stroke. OBJECTIVES: To examine the effectiveness of an information and/or education strategy to improve the outcome of stroke patients and/or their identified caregivers. SEARCH STRATEGY: Relevant trials were identified in the Cochrane Stroke Group Specialised Trials Register (last searched: June 2000). Additional intervention-based search strategies were developed for: The Cochrane Controlled Trials Register (CENTRAL/CCTR) Medline; Embase; CINAHL; ISI citation index; Science and Social Science Citation Indexes; ISI Web of Science Service; Aslib Index to UK theses; Dissertation Abstracts International, ASSIA and Psychlit/PsycINFO. We also searched the Journal of Advanced Nursing, bibliographies of retrieved papers, relevant articles and books. SELECTION CRITERIA: Two or three investigators independently assessed trials and abstracts identified for eligibility, methodological quality and other participant characteristics. DATA COLLECTION AND ANALYSIS: Data were extracted independently using piloted data extraction forms. The primary outcomes were knowledge about stroke and stroke services, and impact on health, specifically mood. MAIN RESULTS: We identified 152 abstracts, of which 36 studies were potentially relevant to this review. The current analysis includes nine completed trials, a further eight studies are ongoing. Of the nine trials, three evaluated a programme of lectures and the remaining trials evaluated the provision of information. There is some evidence that information combined with educational sessions improved knowledge and was more effective than providing information only. Information provision only had no effect on mood, perceived health status or quality of life for patients or carers. Two trials used an objective measure of satisfaction and no significant differences were found between groups. One trial reported that information and education sessions for carers improved 'family functioning'. REVIEWER'S CONCLUSIONS: The results of the review are limited by the variable quality of the trials and the wide range of outcome measures used. The general effectiveness of information provision has not been conclusively demonstrated. Future work should address the expressed needs of patients and carers and seek to identify appropriate teaching strategies which can be successfully implemented within clinical practice.

Caregivers↗
PubMed2004

Effectiveness of intermediate care in nursing-led in-patient units.

BACKGROUND: The Nursing led inpatient Unit (NLU) is one of a range of services that have been considered in order to manage more successfully the transition between hospital and home for patients with extended recovery times. OBJECTIVES: To determine whether nursing-led inpatient units are effective in preparing patients for discharge from hospital compared to usual inpatient care. SEARCH STRATEGY: We searched The Cochrane Library, the Specialized Register of the Cochrane Effective Practice and Organisation of Care (EPOC) group, MEDLINE, CINAHL, EMBASE, BNI and HMIC databases. Citation searches were undertaken on the science and social science citation indices. Authors were contacted to identify additional data. SELECTION CRITERIA: Controlled trials and interrupted time series designs that compared the NLU to usual inpatient care managed by doctors. Patients over 18 years of age following an acute hospital admission for a physical health condition. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed study quality. MAIN RESULTS: Ten random or quasi-random controlled trials reported on a total of 1896 patients. There was no statistically significant effect on inpatient mortality ( OR 1.10, 95% CI 0.56 to 2.16) or mortality to longest follow up (OR 0.92, 95% CI 0.65 to 1.29) but higher qaulity studies showed a larger non-significant increase in inpatient mortality (OR 1.52, 95% CI 0.86 to 2.68). Discharge to institutional care was reduced for the NLU (OR 0.44 95% CI 0.22 to 0.89) and functional status at discharge increased (SMD 0.37, 95% CI 0.20 to 0.54) but there was a near significant increase in inpatient stay (WMD 5.13 days 95% CI -0.5 days to 10.76 days). Early readmissions were reduced (OR 0.52 95% CI 0.34 to 0.80). One study compared a NLU for the chronically critically ill with ICU care. Mortality (OR 0.62 95% CI 0.35 to 1.10) and length of inpatient stay differ did not differ (WMD 2 days, 95% CI 10.96 to -6.96 days). Early readmissions were reduced (OR 0.33 95% CI 0.12 to 0.94). Costs of care on the NLU were higher for UK studies but lower for US based studies. REVIEWERS' CONCLUSIONS: There is some evidence that patients discharged from a NLU are better prepared for discharge but it is unclear if this is simply a product of an increased length of inpatient stay. No statistically significant adverse effects were noted but the possibility of increased early mortality cannot be discounted. More research is needed.

Health Care Costs↗
PubMed2003

Therapy-based rehabilitation services for stroke patients at home.

BACKGROUND: Stroke Unit care is now accepted as an effective service model for hospital care, but the effectiveness of outpatient care is less certain. This review focuses on therapy-based rehabilitation services targeted at stroke patients living at home. OBJECTIVES: To assess the effects of therapy-based rehabilitation services targeted towards stroke patient resident in the community within one year of stroke onset/ discharge from hospital following stroke. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (last searched November 2001). In addition we searched the following electronic databases: the Cochrane Controlled Trials Register (Cochrane Library Issue 4, 2001), MEDLINE (1996 - Nov 2001), EMBASE (1980 - Nov 2001), CINAHL (1983 - Nov 2001), PsycINFO (1967 - Nov 2001), AMED (1985 - Nov 2001), Wilson Social Sciences Abstracts (1984-Nov 2001), Science Citation Index and Social Sciences Citation Index (1981-Nov 2001). Other strategies to ensure identification of all potentially relevant trials included scanning reference lists of relevant articles and original papers, personal communication and hand searching journals. SELECTION CRITERIA: All unconfounded, truly randomised controlled trials of stroke patients resident in the community receiving a therapy service intervention, which was compared to conventional or no care. Therapy services were those provided by physiotherapy, occupational therapy, or multidisciplinary staff working with patients primarily to improve task-orientated behaviour (e.g. walking, dressing) and hence increase activity and participation. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials and extracted data on a number of prespecified outcomes. The primary outcomes were the proportion of patients who had deteriorated or were dependent in personal activities of daily living and performance in personal activities of daily living at the end of follow-up. MAIN RESULTS: We identified a heterogeneous group of 14 trials including 1617 patients. Therapy-based rehabilitation services reduced the odds of a poor outcome (Peto odds ratio 0.72 (95% CI 0.57 to 0.92; P = 0.009) and increased personal activity of daily living scores (standardised mean difference 0.14 (95% CI 0.02 to 0.25; P = 0.02). For every 100 stroke patients resident in the community receiving therapy-based rehabilitation services, 7 (95% CI 2 to 11) patients would be spared a poor outcome, assuming 37.5% would have had a poor outcome with no treatment. REVIEWER'S CONCLUSIONS: Therapy-based rehabilitation services targeted towards stroke patients living at home appear to improve independence in personal activities of daily living. However, the evidence is derived from a review of heterogeneous interventions and therefore further exploration of the interventions is justifiable.

Activities of Daily Living↗
PubMed2003

Modification of the home environment for the reduction of injuries.

BACKGROUND: Injury in the home is extremely common, accounting for around a third of all injuries. The majority of injuries of children under five and people aged 75 and over occur at home. Multi-factorial injury prevention interventions have been shown to reduce injuries in the home. However, few studies have focussed specifically on the impact of physical adaptations to the home environment and the effectiveness of such intervention needs to be ascertained. OBJECTIVES: To review the evidence for the effect on injuries of modification of the home environment with a primary focus on interventions to reduce physical hazards. SEARCH STRATEGY: We searched the following databases: APId, ASSIA, British Nursing Index, CINAHL, Cochrane Library databases, Dissertation Abstracts, EMBASE, HealthSTAR, ICONDA, ISI Science (and Social Science) Citation Index, MEDLINE, National Research Register, PREMEDLINE, SIGLE and Urbadisk. Conference proceedings and reference lists were scanned. Experts in the field and trialists were contacted. Searches were not restricted to English language. Handsearching of relevant journals was not conducted. SELECTION CRITERIA: Randomised controlled trials, non-randomised controlled trials, controlled before-and-after studies and interrupted time series studies. DATA COLLECTION AND ANALYSIS: All abstracts were screened by two reviewers for relevance, outcome and design. Two reviewers independently evaluated methodological quality and extracted data from each eligible study. MAIN RESULTS: We found 28 published trials and one unpublished study. Trials were not sufficiently similar to allow for the combination of data by statistical analyses, so this review takes a narrative form. Studies were divided into three groups based on the primary population sample: children, older people and the general population. None of the 11 childhood studies demonstrated a reduction in injuries that might have been due to environmental adaptation in the home. One study reported a reduction in injuries and in hazards but the two could not be linked. The majority of studies used hazard reduction as the outcome. Of the 15 studies in older people, none demonstrated a reduction in injuries due to hazard reduction, although two demonstrated a reduction in falls that could be due to hazard reduction. In the mixed age group there were two trials; neither demonstrated an effect on injuries. REVIEWER'S CONCLUSIONS: There is insufficient evidence to determine the effects of interventions to modify environmental home hazards. Further interventions to reduce hazards in the home should be evaluated by adequately designed randomised controlled trials measuring injury outcomes. Recruitment of large study samples to measure effect may be a major consideration for future trials.

Accidents, Home↗
PubMed2003

Surgery for morbid obesity.

BACKGROUND: Obesity is associated with increased morbidity and mortality. Surgery for morbid obesity may be considered when other conventional measures have failed, and a number of procedures are available. However, the effects of these surgical procedures compared with medical management and with each other are uncertain. OBJECTIVES: To assess the effects of surgery for morbid obesity on weight, comorbidities and quality of life. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (issue 4, 2001), Medline (SilverPlatter) up to 2001, PubMed (Internet) 01/01/01-19/10/01, Embase (SilverPlatter) up to 09/2001, PsychINFO up to 10/2001, CINAHL (SilverPlatter) up to 07/2001, Science and Social Sciences Citation Index up to 10/12001, British Nursing Index up to 07/2001, Web of Science Proceedings up to 06/2001, BIOSIS up to10/2001, AMED up to 07/2001, National Research Register (issue 2, 2001), reference lists of relevant articles, and handsearched relevant journals. We also contacted experts in the field. Date of the most recent searches: October 2001. SELECTION CRITERIA: Randomised controlled trials comparing different surgical procedures, and randomised controlled trials and non-randomised controlled trials comparing surgery with non-surgical management for morbid obesity. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer and checked independently by two reviewers. Two reviewers independently assessed trial quality. MAIN RESULTS: 18 trials involving 1891 people were included. One randomised controlled trial and one non-randomised controlled trial compared surgery with non-surgical management, and 11 randomised controlled trials compared different surgical procedures. The overall quality of the trials was variable, with just one trial having adequate allocation concealment. A meta-analysis was not possible due to differences in the surgical procedures performed, measures of weight change and length of follow-up. Compared with conventional management, surgery resulted in greater weight loss (23-28 kg more weight loss at two years), with improvements in quality of life and comorbidities. Some complications of surgery occurred, such as wound infection. Gastric bypass was associated with greater weight loss and fewer revisions, reoperations and/or conversions than gastroplasty, but had more side-effects. Greater weight loss and fewer side-effects and reoperations occurred with adjustable gastric banding than vertical banded gastroplasty, while vertical banded gastroplasty was associated with greater weight loss but more vomiting than horizontal gastroplasty. Some postoperative deaths occurred in the studies. Weight loss was similar between open and laparoscopic procedures. Fewer serious complications occurred with laparoscopic surgery. Laparoscopic surgery had a longer operative time, but resulted in reduced blood loss, reduced proportion of patients requiring intensive care unit stay, reduced length of hospital stay, reduced days to return to activities of daily living and reduced days to return to work. REVIEWER'S CONCLUSIONS: The limited evidence suggests that surgery is more effective than conventional management for weight loss in morbid obesity. The comparative safety and effectiveness of different surgical procedures is unclear.

Gastric Bypass↗
PubMed2003

Post-licence driver education for the prevention of road traffic crashes.

BACKGROUND: Worldwide, each year over a million people are killed and some ten million people are permanently disabled in road traffic crashes. Post-licence driver education is used by many as a strategy to reduce traffic crashes. However, the effectiveness of post-licence driver education has yet to be ascertained. OBJECTIVES: To quantify the effectiveness of post-licence driver education in reducing road traffic crashes. SEARCH STRATEGY: We searched the following electronic databases: the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, TRANSPORT (NTIS, TRIS, TRANSDOC, IRRD), Road Res (ARRB), ATRI, National Research Register, PsycInfo, ERIC, SPECTR, Zetoc, SIGLE, Science (and Social Science) Citation Index. We searched the Internet, checked reference lists of relevant papers and contacted appropriate organisations. The search was not restricted by language or publication status. SELECTION CRITERIA: Randomised controlled trials comparing post-licence driver education versus no education, or one form of post-licence driver education versus another. DATA COLLECTION AND ANALYSIS: Two reviewers independently screened search results, extracted data and assessed methodological trial quality. MAIN RESULTS: We found 24 trials of driver education, 23 conducted in the USA and one in Sweden. Twenty trials studied remedial driver education. The methodological quality of the trials was poor and three reported data unsuitable for meta-analysis. Nineteen trials reported traffic offences: pooled relative risk (RR) = 0.96, 95% confidence interval (95% CI) = 0.94, 0.98); trial heterogeneity was significant (p=<0.00001). Fifteen trials reported traffic crashes: pooled RR = 0.98 (95% CI 0.96, 1.01), trial heterogeneity was not significant (p=0.75). Four trials reported injury crashes: pooled RR = 1.12 (95% CI 0.88, 1.41), trial heterogeneity was significant (p=<0.00001). No one form of education (correspondence, group or individual) was found to be substantially more effective than another, nor was a significant difference found between advanced driver education and remedial driver education. Funnel plots indicated the presence of publication bias affecting the traffic offence and crash outcomes. REVIEWER'S CONCLUSIONS: This systematic review provides no evidence that post-licence driver education is effective in preventing road traffic injuries or crashes. Although the results are compatible with a small reduction in the occurrence of traffic offences, this may be due to selection biases or bias in the included trials. Because of the large number of participants included in the meta-analysis (close to 300,000 for some outcomes) we can exclude, with reasonable precision, the possibility of even modest benefits.

Accidents, Traffic↗
PubMed2006

Speed enforcement detection devices for preventing road traffic injuries.

BACKGROUND: It is estimated that by 2020, road traffic crashes will have moved from ninth to third in the world ranking of burden of disease, as measured in disability adjusted life years. The identification of effective strategies for the prevention of road traffic injuries is of global public health importance. Measures aimed at reducing traffic speed are considered essential to preventing road injuries; the use of speed enforcement detection devices (including speed cameras and radar and laser devices) is one such measure. OBJECTIVES: To assess whether the use of speed enforcement detection devices (SEDs) reduces the incidence of speeding, road traffic crashes, injuries and deaths. SEARCH STRATEGY: We searched the Cochrane Injuries Group's Specialised Register, CENTRAL, MEDLINE, EMBASE, Science (and Social Science) Citation Index, TRANSPORT, PsycINFO, CINAHL, EconLit. We searched the websites of road safety and motoring associations, as well as general internet searches. We handsearched selected journals and conference proceedings, and contacted experts in the field. The searches were conducted during May to November 2004. SELECTION CRITERIA: Randomised controlled trials and controlled before-after studies that assessed the impact of speed enforcement detection devices on speeding, road crashes, injuries and deaths were eligible for inclusion. For studies involving co-interventions, SEDs had to be the major intervention focus of the study to be eligible. DATA COLLECTION AND ANALYSIS: We independently screened search results, assessed studies for inclusion, extracted data and assessed methodological quality. Due to variability between and within included studies, a pooled analysis was not appropriate. MAIN RESULTS: No randomised controlled trials were identified. Twenty-six studies met the inclusion criteria, of which 22 were controlled before-after trials incorporating a distinct control or comparison group(s) and four were interrupted time series designs with a comparison group(s). Fourteen studies reported speed and crash outcomes, seven reported crash outcomes only and five reported speed outcomes only. All but one study reported an absolute reduction in pre/post average speeds. A pre/post reduction in the proportion of speeding vehicles ranged across studies from 5% to 70% depending on the speed threshold set. Pre/post reductions of 50% to 65% were reported in the proportion of speeding vehicles travelling >15 km/h over the speed limit. Compared with controls, the relative improvement was from 1% to 15% for average speed and from 14% to 65% for percent speeding. All studies reporting crash outcomes reported an absolute pre/post reduction in all crashes and injury related crashes. In the vicinity of camera sites these pre/post reductions ranged from 14% to 72% for all crashes, 8% to 46% for injury crashes, and 40% to 45% for crashes resulting in fatalities or serious injuries. More generalised effects over wider areas showed an absolute pre/post crash reduction ranging from 9% to 35%, 7% to 30% for all injury crashes and 13% to 58% for crashes resulting in fatalities alone, or in combination with serious injuries. The studies of longer duration showed that these positive trends were either maintained or improved with time. Compared with controls, the relative improvement in pre/post crash numbers resulting in any type of injury ranged from 5% to 36%. AUTHORS' CONCLUSIONS: Despite the methodological limitations of the studies reviewed, the consistency of reported positive reductions in speed and crash outcomes across all studies suggest that SEDs are a promising intervention for reducing the number of road traffic injuries and deaths. More studies of a scientifically rigorous nature are necessary to provide a stronger evidence base that these interventions are worthwhile. There is a need for international harmonisation of data collection methods, including standards on how best to measure speeds and collect crash data, over lengthy intervention and follow-up periods, as well as some consensus as to the expression of outcomes in studies, so that studies can be compared.

Accident Prevention↗
PubMed2005

Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm.

BACKGROUND: Conventional management of abdominal aortic aneurysm (AAA) is by open repair and is associated with a mortality rate of 2-6 per cent. Endovascular aneurysm repair (EVAR) is an alternative technique first introduced in 1991. A systematic review was undertaken of the evidence for the safety and efficacy of elective EVAR in the management of asymptomatic infrarenal AAA. METHODS: Thirteen electronic bibliographical databases were searched, covering biomedical, health-related, science and social science literature. Outcomes were assessed with respect to efficacy (successful deployment, technical success, conversion rates and secondary intervention rates) and safety (30-day mortality rate, procedure morbidity rates and technical issues-endoleaks, graft thrombosis, stenosis and migration). RESULTS: Of 606 reports identified, 61 met the inclusion criteria (three randomized and 15 non-randomized controlled trials, and 43 uncontrolled studies). There were 29 059 participants in total; 19,804 underwent EVAR. Deployment was successful in 97.6 per cent of cases. Technical success (complete aneurysm exclusion) was 81.9 per cent at discharge and 88.8 per cent at 30 days. Secondary intervention to treat endoleak or maintain graft patency was required in 16.2 per cent of patients. Mean stay in the intensive care unit and mean hospital stay were significantly shorter following EVAR. The 30-day mortality rate for EVAR was 1.6 per cent (randomized controlled trials) and 2.0 per cent in nonrandomized trials and case series. Technical complications comprised stent migration (4.0 per cent), graft limb thrombosis (3.9 per cent), endoleak (type I, 6.8 per cent; type II, 10.3 per cent; type III, 4.2 per cent) and access artery injury (4.8 per cent). DISCUSSION: EVAR is technically effective and safe, with lower short-term morbidity and mortality rates than open surgery. However, there is a need for extended follow-up as the long-term success of EVAR in preventing aneurysm-related deaths is not yet known.

Angioplasty↗
PubMed2002

Randomized controlled trials of continuing medical education: what makes them most effective?

INTRODUCTION: It is essential that professional standards of excellence are demonstrated in the continuing medical education (CME) curriculum and research. METHODS: This review examines 20 randomized controlled trial (RCT) studies in CME and their effect on physician performance and/or patient health care outcomes. A systematic evaluation of the 20 RCT articles was performed. The investigators of the trials were interviewed using a standardized interview schedule. Citations from science and social science publications were compiled to obtain an unobtrusive measure of the influence of the trials. RESULTS: Investigators were most often motivated to build on earlier research of others, their own earlier research, or a combination of others' earlier research and their own. The most effective educational strategies used multiple interventions, two-way communications, printed and graphic materials in person, and locally respected health personnel as educators. Statistically significant findings more often related to physician performance than to patient health care outcomes. The most effective studies were the ones in which the educational methods were cost effective, findings could be generalized to other physician groups, the studies were implemented elsewhere in multisite health care and health-related programs and had the most citations. Investigators interviewed about their RCTs provided advice for future directions of CME curriculum development and research. DISCUSSION: CME program directors should determine what physicians need to learn, should reach out to nonparticipating physicians, and should focus on relevant problem areas. These problem areas should be ones in which it is possible to make changes, particularly in patient health care outcomes.

Curriculum↗
PubMed2005

A team effort: reply to Snyder and Elliott.

This response to C.R. Snyder and T.R. Elliott's innovative proposals for training (this issue, pp. 1033-1054) highlights areas of agreement with the authors as well as encourages greater attention to several issues. These include counseling psychology and its historical emphasis on wellness, mentoring training for current faculty as well as graduate students, and appreciation for the diverse areas within psychology as well as within the broader social sciences (e.g., social work, marriage and family therapy) as contributors to such training.

Clinical Competence↗
PubMed2006

[Methods in health services research. The example of the evaluation of the German disease management programmes].

According to the established definition of Pfaff, health services research analyses patients' path through the institutions of the health care system. The focus is on development, evaluation and implementation of innovative measures of health care. By increasing its quality health services research strives for an improvement of efficacy and efficiency of the health care system. In order to allow for an appropriate evaluation it is essential to differentiate between structure, process and outcome quality referring to (1) the health care system in its entirety, (2) specific health care units as well as (3) processes of communication in different settings. Health services research comprises a large array of scientific disciplines like public health, medicine, social sciences and social care. For the purpose of managing its tasks adequately a special combination of instruments and methodological procedures is needed. Thus, diverse techniques of evaluation research as well as special requirements for study designs and assessment procedures are of vital importance. The example of the German disease management programmes illustrates the methodical requirements for a scientific evaluation.

Disease Management↗
PubMed2005

Post-acute intermediate care in nursing-led units: a systematic review of effectiveness.

OBJECTIVE: In order to determine whether post-acute intermediate care in nursing-led inpatient units (NLUs) is effective in preparing patients for discharge from hospital we conducted a systematic review of the evidence. REVIEW METHODS: The Cochrane Library, Effective Practice and Organisation of Care specialist register, Medline, Cinahl, Embase, British Nursing Index and the HMIC databases were searched for all available dates up to mid-2003. The science and social science citation indices were searched for papers that cited key works. Authors of papers were asked to identify additional research. Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time-series designs that compared the NLU to usual post-acute inpatient care for adults were included in the review. Studies were assessed for quality. Statistical meta-analysis on the results of controlled trials was performed. Sensitivity analyses were conducted to determine the impact of methodological quality on conclusions. OUTCOMES: Outcomes considered were mortality, institutionalisation after discharge, functional status early readmission, length of inpatient stay and cost. RESULTS: Nine random or quasi-random controlled trials involving 1669 patients were reviewed. Quality was variable. The mean age of patients in all studies was over 70 years. There was no statistically significant difference in inpatient mortality between NLU and usual inpatient care (OR 1.10, 95% CI 0.56-2.16). The NLU was associated with reduced odds of discharge to institutional care (OR 0.44 95% CI 0.22-0.89), better functional status at discharge (SMD 0.37, 95% CI 0.20-0.54) and reduced odds of early readmission (OR 0.52 95% CI 0.34-0.80). Length of stay until discharge home was increased by 5.13 days (WMD) (95% CI-0.5-10.76 days). At longest follow up (3-6 months) there was no statistically significant difference in the proportion of patients in institutional care (OR 0.97, 95% CI 0.60-1.58). The results were not generally sensitive to study quality. CONCLUSIONS: The NLU successfully functions as a form of intermediate care, so far there is no evidence of adverse outcome from the lower level of routine medical care. However, more research is required to confirm safety. Patients discharged from NLUs have higher levels of function although it is unclear if the benefit is simply a product of an increased stay. There is no evidence of benefit over the longer term.

Aged↗
PubMed2006

The prevalence of lisping in young adults.

UNLABELLED: This paper reports the results of a pilot study that investigated the prevalence of lisping in a cohort of young adults. The motivation for the study was the observation that a substantial number of incoming students in speech language pathology at the Ghent University (Belgium), still presented with frontal lisping of the /s/, /z/ and sometimes other alveolar sounds too. Seven hundred and forty eight students (374 females, 374 males), native speakers of Dutch, were video-recorded while reading aloud the Dutch version of the text "The north wind and the sun..." from the International Phonetic Association (1974). Analysis of the samples yielded an overall prevalence of lisping of 23.3%. Significantly less participants presented with lisping among students of humanities than among students of natural sciences or social sciences. No significant difference was found between males and females. It remains to be determined if this high prevalence of lisping in adults represents a recent trend or if the persistence of the pattern of lisping into adulthood in some individuals is perhaps quite normal. LEARNING OUTCOMES: As a result of this activity, the participant will be able to (1) discuss the nature and prevalence of residual phonological errors in general and (2) to discuss the prevalence of lisping in young adult native speakers of Dutch in particular.

Adolescent↗
PubMed1998

Informed consent for clinical trials: in search of the "best" method.

OBJECTIVE: To review the literature on comparisons between different methods of obtaining informed consent for clinical trials. DESIGN: Eight hundred and twelve articles were traced, in the process of conducting a systematic review of the ethics of clinical trials, by searching a number of sources: bibliographic databases (Medline, Psychlit and BIDS science and social science indices), hand searches, personal contacts, an original collection and a systematic follow-up of reference lists. Fourteen research reports were found which provided comparative data on different methods of obtaining informed consent. Eleven of these used a randomised design. Studies were classified according to three outcome measures (anxiety, consent rate and understanding). RESULTS: The results of the various studies suggest that giving people more information and more time to reflect tends to be associated with a lower consent rate. There seems to be an optimal level of information about side-effects such that patients are not overburdened by detail, while grasping the most important risks. More information in general is associated with greater awareness of the research nature of the trial, voluntariness of participation, right to withdraw and (available) alternative treatments. This result does not, however, extend to explanations of the concept of randomisation on which the literature is contradictory--sometimes more information is associated with increased understanding of the concept and sometimes it is not. Although divulging less information seems to be associated with less anxiety, there is evidence of an interaction with knowledge--high levels of knowledge are significantly associated with less anxiety, irrespective of consent method. The more that patients know before they are invited to participate in a trial, the better equipped they are to cope with the informed consent procedure. CONCLUSION: There is some evidence to suggest that there is an optimal amount of information which enhances patient understanding and which might, in turn, reduce anxiety. However. the studies were not altogether conclusive. More work needs to be carried out, especially on public understanding of science and on how different ways of explaining scientific concepts affect that understanding.

Clinical Trials as Topic↗
PubMed1996

The gender difference in orienting liquid surfaces and plumb-lines: its robustness, its correlates, and the associated knowledge of simple physics.

In comparison between male and female psychology students, a greater proportion of female students fail to represent liquid surfaces and plumb-line objects as invariably horizontal and vertical, respectively. However, the occurrence of this perplexing gender difference has not been ascertained among young adults enrolled in science programs, who should ostensibly be more fully equipped in terms of academic competence, irrespective of their gender. The present large sample of undergraduates (N = 1412), majoring in natural and applied sciences, and social sciences or humanities and arts, completed water-level and plumb-line items, along with other simple physics problems, indicating how and in reference to which principle they had solved these tasks. They also answered questions pertaining to possible personal proficiency correlates of a biological, experiential, perceptual, and sociocognitive nature. The data revealed not only that women's achievement was consistently poorer than men's across discipline categories, but surprisingly that this was so even within specific fields requiring and providing the most visuo-spatial skills as well as physical knowledge and training. Especially for women, mastery was predicted by success in simple physics problems, and to a lesser degree by perceptual, sociocognitive, and experiential variables. Biological variables did not contribute to proficiency for either gender, though the data fitted a recessive gene model. Responses based on relevant physics principles were more accurate, but men and women generally adopted the same procedural strategies. The present compelling demonstration of a gender gap in achievement that is not compensated by formal science education, extending thus even to future physical scientists, invites further investigation into its perceptual and cognitive determinants, as well as into those more distally connected with early aptitudes, interests, and experiences.

Adolescent↗