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PubMed2003

Access and effectiveness in psychological therapies: self-help as a routine health technology.

The ability of psychological treatment services to deliver effective and accessible mental healthcare, as demanded by the National Service Framework for mental health, is compromised by the traditional configuration of psychological therapy services, powerful gatekeeping by these services and the difficulties which exist in engaging primary care in mental healthcare. Although a number of service models have been suggested, most address access from the perspective of secondary care service providers. In particular, self-help, a powerful ideology and a clinically effective health technology, is given insufficient prominence in psychological therapy services. Self-help is often only considered for mild problems or as an adjunct to therapy, and it is assumed that mental health professionals with traditional therapeutic skills are needed to support self-help. Following a review of access and self-help in psychological therapies, the present authors propose criteria against which services could be designed in order to fully utilise self-help as a powerful health technology in psychological therapies. Accompanying these criteria is a research framework drawn from recent work on access and illness self-management that can be used to evaluate the performance of services attempting to improve access to psychological therapies.

Adaptation, Psychological↗

PubMed1999

Protective steering: a grounded theory study of the processes by which midwives facilitate informed choices during pregnancy.

Helping women to make informed choices during pregnancy is an important and complex part of a midwife's role that does not appear as yet to have been investigated in depth. The purpose of this study was to use a grounded theory approach to investigate the processes involved when midwives engage in facilitating the making of informed choices for women in the United Kingdom. Interactions between midwives and pregnant women were observed and recorded and focused interviews were conducted with the midwives. Data were analysed according to the grounded theory method. The core category was identified as protective steering, whereby midwives were concerned to protect the women in their care, as well as themselves, when choices were made. Substantive categories were orienting, protective gatekeeping and raising awareness.

Decision Making↗

PubMed2001

The importance of conducting and reporting pilot studies: the example of the Scottish Births Survey.

BACKGROUND: In many research papers, pilot studies are only reported as a means of justifying the methods. This justification might refer to the overall research design, or simply to the validity and reliability of the research tools. It is unusual for reports of pilot studies to include practical problems faced by the researcher(s). Pilot studies are relevant to best practice in research, but their potential for other researchers appears to be ignored. OBJECTIVE: The primary aim of this study was to identify the most appropriate method for conducting a national survey of maternity care. METHODS: Pilot studies were conducted in five hospitals to establish the best of four possible methods of approaching women, distributing questionnaires and encouraging the return of these questionnaires. Variations in the pilot studies included (a) whether or not the questionnaires were anonymous, (b) the staff involved in distributing the questionnaires and (c) whether questionnaires were distributed via central or local processes. For this purpose, five maternity hospitals of different sizes in Scotland were included. RESULTS: Problems in contacting women as a result of changes in the Data Protection Act (1998) required us to rely heavily on service providers. However, this resulted in a number of difficulties. These included poor distribution rates in areas where distribution relied upon service providers, unauthorized changes to the study protocol and limited or inaccurate information regarding the numbers of questionnaires distributed. CONCLUSIONS: The pilot raised a number of fundamental issues related to the process of conducting a large-scale survey, including the method of distributing the questionnaire, gaining access to patients, and reliance on 'gatekeepers'. This paper highlights the lessons learned as well as the balancing act of using research methods in the most optimal way under the combined pressure of time, ethical considerations and the influences of stakeholders. Reporting the kinds of practical issues that occur during pilot studies might help others avoid similar pitfalls and mistakes.

Attitude to Health↗

PubMed2001

From tall poppies to squashed weeds*: why don't nurses pull together more?

AIMS: To develop a conceptual framework to account for interpersonal conflict in nursing. To extend the boundaries of debate on the causes of interpersonal conflict in nursing. BACKGROUND/RATIONALE: In nursing, attempts to offer an explanation for staff conflict or, as it is traditionally referred to, horizontal violence, have, nearly always, been influenced by oppression and feminist theories. Such macrolevel analyses avoid discussing the details of individual acts of aggression in favour of considering nurses' alleged disempowerment in relation to other perceived dominant groups, especially male doctors, and the violence these groups inflict in terms of the denial of power, control, and access to rewards - material or otherwise. METHODOLOGY: A critical analysis of an extended literature review adapted from a doctoral dissertation. DISCUSSION: While the oppression and feminist perspectives can be insightful they are also limiting in that they omit the finer grained-analysis necessary for a fuller understanding of staff conflict. At least three levels of explanation can be offered to account for poor staff relationships - a macrolevel, which focuses on nurses' relationships vis-à-vis dominant groups, a mesolevel analysis, which concentrates on organizational structures, including workplace practices - many of which are controlled by nurses themselves, and a microlevel analysis, which emphasizes the interactional nature of interpersonal conflict. CONCLUSIONS: It is contented that it is not only the alleged misogyny intrinsic to oppression theory that shackles and impedes nurses, but nurses themselves, who in their everyday work and interpersonal interactions, act as insidious gatekeepers to an iniquitous status quo.

Conflict, Psychological↗

PubMed2002

Nurses' experience with vancomycin-resistant enterococci (VRE).

The emergence and spread of resistant organisms, in particular vancomycin-resistant enterococci (VRE), is an issue facing all staff in acute hospitals. This study explored how nurses coped with the responsibility of halting further spread of this organism during an outbreak. VRE-positive patients were cohorted with nurses who cared for them in an endeavour to contain the spread of VRE. The majority of nurses found the situation extremely stressful because of the need to act as 'gatekeepers' responsible for educating and monitoring the practices of staff and visitors. The nurses reported that they felt they were inadequately supported, were blamed for the outbreak, and that they had an increased workload as they took on duties of other staff. The results reinforce the need for a multidisciplinary team approach to education and control of VRE, more support for nursing staff cohorted with VRE-positive patients, and stringent adherence to infection control measures by all hospital staff.

Communicable Disease Control↗

PubMed2003

Barriers to physicians' decisions to discuss hospice: insights gained from the United States hospice model.

Due to its comprehensive and cost-saving design, hospice has become a critical component of health care. Physicians have become the primary gatekeepers to information on hospice and sources of referral to hospice. However, many physicians do not discuss hospice options until late in the disease course, when patients and their families are no longer able to benefit from hospice services. Although physicians, as well as patients and hospice personnel, cite patient and hospice structure factors as barriers, the present article will focus on barriers physicians have more control over, such as their discomfort discussing terminality and fear of losing contact with patients. Focusing on the American hospice model, the present article will review past findings, examine gaps in the research, and propose systematic ways to discern whether the factors physicians claim are barriers actually affect their decision making about hospice referral.

Attitude of Health Personnel↗

PubMed1996

High-technology medicine and the old: the dialysis example.

High-technology medicine, which is often expensive, and most often very useful for old people, whose numbers are rapidly increasing, is presenting huge moral problems for physicians. There are now pressures to make physicians salaried employees rather than professionals, and this will decrease or obliterate their efficiency as advocates for patients. Advocacy is a previously non-described duty, which is an important ethical principle for physicians, in addition to the four universally recognized principles: beneficence, non-maleficence, respect for autonomy, and justice. Not-so-subtle economic pressure by managed care, government, administrators, and politicians, is already in force. If physicians, by advocating expensive treatment for many, irritate those with economic power, they may violently retaliate. Chronic dialysis illustrates well the dilemma of high-technology medicine because acceptance numbers are accurate and widely known, most patients are old, the treatment is rationed everywhere by age, and, as patients die if excluded, it can be used to analyse reactions to an ongoing age rationing. Post-modern bioethics and moral philosophy appears helpless and, in some regards, irrelevant in elucidating and solving the concrete moral conflict posed by high-technology medicine and the old. Administrators and politicians wish physicians to be society's economic gatekeepers; however, this is incompatible with classical ethical concepts of the profession of physicians. Physicians and their professional organizations had better realize this in order to map out defensive strategies so that physicians, as a profession, do not disappear.

Adult↗

PubMed1998

Identification of an additional member of the secretin superfamily of proteins in Pseudomonas aeruginosa that is able to function in type II protein secretion.

Pseudomonas aeruginosa is a prolific exporter of virulence factors and contains three of the four protein secretion systems that have been described in gram-negative bacteria. The P. aeruginosa type II general secretory pathway (GSP) is used to export the largest number of proteins from this organism, including lipase, phospholipase C, alkaline phosphatase, exotoxin A, elastase and LasA. Although these exoproteins contain no sequence similarity, they are specifically and efficiently transported by the secretion apparatus. Bacterial homologues of XcpQ (GspD), the only outer membrane component of this system, have been proposed to play the role of gatekeeper, by presumably interacting and recognizing the exported substrates to allow their passage through the outer membrane. While determining the phenotype of nonpolar deletions in each of the xcp genes, we have shown that a deletion of the P. aeruginosa strain K xcpQ does not completely abolish protein secretion. As the proposed function of XcpQ should be requisite for secretion, we searched for additional factors that could carry out this role. A cosmid DNA library from a PAK strain deleted for xcpP-Z was tested for its ability to increase protein secretion by screening for enhanced growth on lipid agar, a medium that selects for the secretion of lipase. In this manner, we have identified an XcpQ homologue, XqhA, that is solely responsible for the residual export observed in a deltaxcpQ strain, although it is not required for efficient secretion in wild-type P. aeruginosa. We have also demonstrated that this protein is capable of recognizing all of the exoproteins of P. aeruginosa, arguing against the proposed role of members of the secretin family as determinants of specificity.

Agar↗

PubMed1997

Developmental regulation of the gibberellin biosynthetic gene GA1 in Arabidopsis thaliana.

The GA1 gene of Arabidopsis thaliana encodes ent-kaurene synthase A (KSA), which catalyzes the first committed step in the biosynthetic pathway of the plant hormone gibberellin (GA). Its location in the GA biosynthetic pathway has led to speculation that KSA regulation is one of the controlling steps. However, because KSA activity is so low that it is only measurable in Arabidopsis siliques, GA1 promoter-GUS reporter gene fusions and quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) were used to examine the expression pattern of GA1. The results from this study indicate that GA1 gene expression is highly regulated during growth and development, and it is restricted to specific cell types at the sites of expression. GA1 promoter activity is highest in rapidly growing tissues, e.g. shoot apicas, root tips, developing flowers and seeds. It is also active in the vascular tissue of some non-growing organs, such as expanded leaves, suggesting that these leaves may be a site of GA synthesis for transport to other organs. It was also found that the first one or two introns in the GA1 gene are required for proper expression. Because of the high degree of regulation, GA1 may act as a gatekeeper, controlling the flow of metabolites into the GA biosynthetic pathway, while the levels of specific bioactive GAs are controlled by other downstream steps.

Alkyl and Aryl Transferases↗

PubMed1998

Dual role of Ras and Rho proteins: at the cutting edge of life and death.

Small GTP-binding proteins of the Ras superfamily are master controllers of the cell physiology. The range of processes in which these proteins are involved include cell cycle progression, cell division, regulation of cell morphology and motility and intracellular trafficking of molecules and organelles. The study of apoptosis, the physiological form of cell suicide, is progressively linking the functions of small G proteins to the control of the mechanisms that trigger the genetic programmes of cell death. To date, isoforms of the Ras and Rho groups have been related to both promotion and suppression of apoptosis. Further, signalling pathways driven by these proteins have been associated with the function and/or expression of molecules that regulate apoptotic responses. Thus, all available evidence points to a critical role for Ras and Rho proteins as major gatekeepers of the decision between cellular life and death.

Apoptosis↗

PubMed2003

Gastroenterologists' views of symptoms following laparoscopic fundoplication: anecdotally based medicine?

BACKGROUND: Currently gastro-oesophageal reflux disease (GORD) can be managed either medically or surgically. The management decision is often based on the referring doctor's perception of the pros and cons of surgical management versus the medical alternative. A large group of gastroenterologists was surveyed to determine their understanding of the common outcomes of surgical management of GORD. METHODS: A 15-question survey was sent to all gastroenterologists in Australia who were members of the Gastroenterology Society of Australia. Questions centred on management decisions and postoperative symptoms in fundoplication patients. The findings were compared to current published outcome data. RESULTS: One hundred and thirty-four gastroenterologists responded anonymously to the survey. More than 75% described fundoplication as a safe and established procedure, and 80% had referred patients who were well controlled on medication for surgical management. The gastroenterologists' perceptions of the problems of postoperative dysphagia and bloating differed from published outcomes. CONCLUSIONS: Gastroenterologists are often the gatekeepers for the management of patients with GORD. The understanding that this group has about surgical outcomes is important so that patients can make well-informed management decisions. The present study found that gastroenterologists are likely to convey to their patients higher degrees of postoperative dysphagia and bloating following fundoplication than is actually reported. This may deter some patients who would benefit from fundoplication from consulting a surgeon.

Adult↗

PubMed2001

Negotiating the informed-consent process in developing countries: a comparison of Swaziland and Pakistan.

Protecting the rights of research participants when conducting studies within an international context presents many challenges. The purpose of this article was to compare and contrast the process of obtaining informed consent in two very different countries - Swaziland and Pakistan. Major aspects of the informed-consent process presented included identification of gatekeepers, seeking permission from officials, negotiating with these officials and Institutional Review Board (IRB) committees in regard to the type of data to be collected, and explaining informed consent to participants in the field. Data for this article is based upon qualitative research of collaboration between nurses and healers in Swaziland and from a variety of studies completed in Pakistan. These studies demonstrate the inadequacy and complexity of applying western-based concepts of informed consent to developing countries.

Cross-Cultural Comparison↗

PubMed1998

Oxidative activity of the type 2 isozyme of 17beta-hydroxysteroid dehydrogenase (17beta-HSD) predominates in human sebaceous glands.

Sebum production is regulated by the opposing effects of androgens and estrogens. The intracrine activity of steroid metabolizing enzymes is important in regulating sebum production because these enzymes can convert weak steroids from the serum into potent androgens and estrogens within the sebaceous gland (SG). 17Beta-hydroxysteroid dehydrogenase (17beta-HSD) interconverts weak and potent sex steroids via redox reactions. In this regard, it may function as a gatekeeping enzyme regulating the hormonal milieu of the SG. Six isozymes of 17beta-HSD have been identified that differ in their substrate preference and their preference to produce weak or potent sex steroids via oxidation or reduction, respectively. The goals of this study are: (i) to identify which isozyme (s) of 17beta-HSD is active in SG; (ii) to determine if its activity differs in facial skin compared with nonacne-prone skin that may account for the regional differences in sebum production; (iii) to compare the activity of 17beta-HSD in intact glands and in SG homogenates; and (iv) to determine if 13-cis retinoic acid inhibits 17beta-HSD activity. Human SG were assayed for 17beta-HSD activity using estrogens, androgens, and progestins as substrates. Oxidative activity of the type 2 isozyme predominated in all samples tested. Although transcripts for the types 1, 2, 3, and 4 isozymes were detected using reverse transcriptase-polymerase chain reaction, only mRNA for the predominant type 2 isozyme and the type 4 isozyme were detected in northern analysis. Greater reductive activity of 17beta-HSD was noted in SG from facial areas compared with nonacne-prone areas, suggesting an increased net production of potent androgens in facial areas. Oxidation was more predominant over reduction in intact SG compared with homogenized SG, thus supporting the hypothesis that 17beta-HSD protects against the effects of potent androgens in vivo. Activity of the type 2 17beta-HSD was not inhibited by 13-cis retinoic acid. In conclusion, SG possess the cellular machinery needed to transcribe the genes for the type 1-4 isozymes of 17beta-HSD. At the protein level, however, oxidative activity of the type 2 isozyme predominates, suggesting that 17beta-HSD isozyme activity may be translationally regulated.

17-Hydroxysteroid Dehydrogenases↗

PubMed2001

Blood pumps: technologies and markets in transformation.

The heart failure industry or sector of blood pump technologies comprised of scientists, medicine, and business has inadequate attention from the financial community due to the perception of unmet market potential and regulatory hurdles. There are more than 20 mechanical circulatory support technologies currently in some stage of development. The application is defined initially for emerging technologies as bridge-to-transplant whereas more mature devices have focused on bridge-to-recovery and alternative-to-transplant. Regulatory hurdles and financing resources have dictated this initial application strategy. Whether a technology has valves, bearings, is magnetically suspended, acts as a pressure cuff, and so on, the future will belong in large part to those technologies that are less expensive, have improved ergonomics, are simpler in surgical application, and can demonstrate efficacy levels that are an improvement over today's approved devices. Today's devices have provided a valuable platform for the emerging technologies. However, there has been little market expansion over these past years, relative to the potential market. The cardiologist is the patient's gatekeeper, and drugs appear to be the therapy of choice as options are considered. Technologies without a business model will have a difficult time attracting much needed funding, the result being protracted development times or project termination. MicroMed has modified its ventricular assist device (VAD) focus, with a broader look at treating the heart failure patient. MicroMed recently entered into an agreement with Chrysalis Biotechnology, Inc., Galveston, TX, covering a synthetic peptide technology (Chrysalin) that when injected into tissue has demonstrated an angiogenic effect without the concerns inherent in recombinant angiogenic/growth factors. We believe a combination therapy of the DeBakey VAD-synthetic peptide could provide sufficient revascularization for bridge-to-recovery or as an alternative-to-transplant in certain patients.

Angiogenesis Inducing Agents↗

PubMed2001

End-stage renal disease: factors affecting referral decisions by family physicians in Canada, the United States, and Britain.

The objective of this study is to determine how patient age, sex, creatinine level, and comorbidity affect referral decisions for the treatment of end-stage renal disease (ESRD) and whether these decisions are affected by physician characteristics in three countries: Canada, the United States, and Britain. A vignette-based questionnaire was mailed to a random sample of family physicians in Ontario, Canada (1,818 physicians); all family physicians in the state of New York (1,814 physicians); and a sample of general practitioners from the south of England (2,228 physicians) in 1996. Physicians were presented with clinical scenarios involving a patient with varying degrees of renal insufficiency and a complicating comorbidity, including angina, diabetes, cancer, mental illness, or socioeconomic circumstances. They were asked to indicate the likelihood of referral. Half the physicians received a questionnaire describing a male patient, and half, a female patient. Mean creatinine levels at which physicians would refer were 260 micromol/L for British physicians, 297 micromol/L for Canadian physicians, and 340 micromol/L for American physicians. No difference in referral rates was found based on the sex of the patient or physician. Sixty-five percent of American and Canadian physicians would refer regardless of patient age, but only 49% of British physicians would do so. Family physicians in the United States, Canada, and Britain function as gatekeepers for patients with ESRD. They are less likely to refer based on increasing severity of comorbid conditions. They also discriminate based on age, but not sex.

Adult↗

PubMed2002

Targeted expression of oncogenic K-ras in intestinal epithelium causes spontaneous tumorigenesis in mice.

BACKGROUND & AIMS: Ras oncoproteins are mutated in about 50% of human colorectal cancers, but their precise role in tumor initiation or progression is still unclear. METHODS: This study presents transgenic mice that express K-ras(V12G), the most frequent oncogenic mutation in human tumors, under control of the murine villin promoter in epithelial cells of the large and small intestine. RESULTS: More than 80% of the transgenic animals displayed single or multiple intestinal lesions, ranging from aberrant crypt foci (ACF) to invasive adenocarcinomas. Expression of K-ras(V12G) caused activation of the MAP kinase cascade, and the tumors were frequently characterized by deregulated cellular proliferation. Unexpectedly, we obtained no evidence of inactivating mutations of the tumor suppressor gene Apc, the "gatekeeper" in colonic epithelial proliferation. However, spontaneous mutation of the tumor-suppressor gene p53, a frequent feature in the human disease, was found in 3 of 7 tumors that were tested. CONCLUSIONS: This animal model recapitulates the stages of tumor progression as well as a part of the genetic alterations found in human colorectal cancer. Furthermore, it indicates that activation of K-ras in concert with mutations in p53 may constitute a route to digestive tumor formation and growth, underlining the fact that the pathway to intestinal cancer is not necessarily a single road.

Animals↗

PubMed2006

Epithelial Ca2+ and Mg2+ channels in kidney disease.

Many physiological functions rely on the precise maintenance of body calcium (Ca2+) and magnesium (Mg2+) balance, which is tightly regulated by the concerted actions of intestinal absorption, renal reabsorption, and exchange with bone. The kidney plays an important role in the homeostasis of divalent ions. Most Ca2+ and Mg2+ reabsorption occurs in the proximal tubules and the thick ascending limb of Henle's loop via a passive paracellular pathway. At the level of the distal convoluted tubule (DCT) and the connecting tubule (CNT), Ca2+ and Mg2+ are reabsorbed via an active transcellular route. Reabsorption of divalents in these latter segments is regulated in a Ca2+ and Mg2+-specific manner and determines the final excretion in the urine. Importantly, genetic studies, as well as molecular cloning strategies, recently identified epithelial ion channels as the gatekeepers of active Ca2+ and Mg2+ reabsorption. These channels are members of the transient receptor potential (TRP) superfamily. TRP vanilloid 5 (TRPV5) is responsible for the rate-limiting Ca2+ entry, and TRP melastatin 6 (TRPM6) constitutes the apical entry step in Mg2+ reabsorption. Dysregulation or malfunction of these influx pathways has been associated with renal Ca2+ and Mg2+ wasting. This review updates the current knowledge and the recent advances of Ca2+ and Mg2+ reabsorption and related disorders.

Animals↗

PubMedDate not supplied

Recruiting vulnerable populations for research: revisiting the ethical issues.

The successful recruitment of participants is essential to the research process. To increase the rate of subject participation, investigators have to rely on help from health care providers who often serve as gatekeepers to potential research study subjects. These well-meaning professionals may limit subject participation in a study involving vulnerable populations under the guise of protecting these individuals from harm. We describe some of the characteristics of vulnerable populations affecting their recruitment into research studies. We examine the ethical conflicts that occur when health care professionals control access to these subjects during recruitment for research studies. Finally, we discuss the implications for practice and research designed to protect the rights of vulnerable populations participating in research. We identify collaboration and dialogue between researchers, health care providers, and members of the potential subject populations as most important in recruiting sufficient numbers of subjects to ensure the scientific merit of the study.

Ethics, Research↗