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PubMed1997

["To be used as directed by your physician"--reasons why patients do not use prescribed medicines].

Research and practice indicate that a substantial amount of drugs prescribed for patients are never used. However, we do not know much as to why around 10% of the drugs paid for by the National Insurance are not used. The object of our survey was to identify and illustrate different reasons for this waste. On a questionnaire, 462 persons, who returned unused medication to 14 Norwegian pharmacies during a three-month period in 1994, indicated their reasons for not using the drugs. About half of these persons were also willing to participate in an in-depth interview. Using qualitative methodology, we grouped the reasons for having surplus medication into four main categories: Altered drug requirements--because of changes in the state of the patient's health or because of a new treatment regime. How the patients handled the prescribed drugs--influenced by the patient's knowledge, attitude and physical ability. Illness, social network and the complexity of the treatment were also contributing factors in this category. Coordination of the health services--related to how closely the various sections within the health care service worked together. Prescribing and distribution of drugs--related to rules and regulations, politics, technology, availability and the degree of economic consciousness among doctors and pharmacists. Both the professional and the socioeconomic aspects cited in this study call for reflection and may be used as a basis for further general discussion on the prescribing and handling of drugs, as well as the economic aspect of drug issue. They may also serve as an inspiration for local quality assurance measures and collaboration, especially between the various groups involved in the primary health care service.

Drug Costs↗
PubMed1997

[Reasons for chronic expectoration in patients with pulmonary tuberculosis registered in the Central Tuberculosis Registry].

The aim of the retrospective population-based study was to identify reasons for failure of sputum culture negativity from the 12th month on since the start of chemotherapy of pulmonary tuberculosis (PTB). Medical records of 97 patients with PTB (85 men and 12 women) remaining sputum culture positive for over 12 months, reported to the Central TB Registry (1988-1990), were reviewed. The mean age was 46.7 years. There were 39.2% blue collar workers, 18.6% peasants, 21.6% unemployed, 14.4% pensioners. Only 4.1% constituted persons with education above elementary level. 44 patients abused alcohol, 13 of them had severe alcohol related health problems. Initial susceptibility tests were done in 79 subjects, showing resistance to at least one drug in 15. In 21 subjects the new resistance occurred during observation. The mean period until conversion of sputum culture was 23.5 months. Sputum culture conversion was finally achieved in 63 (64.9%) subjects. The reasons for delayed sputum culture conversion were identified in 86 persons. The main reason for long duration of positive sputum culture in 75 (87.2%) subjects was poor compliance. In 7 (8.1%) cases evident treatment error was relevant. Serious adverse reactions to drugs were responsible in 4 (4.6%).

Adult↗
PubMed1997

[Reasons for chronic expectoration--case reports].

To illustrate reasons for chronic culture positive pulmonary tuberculosis 4 patients are presented. In two cases the reasons for treatment failure were on the doctors' side. In one case a doctor used an insufficient number of drugs, in the second case the treatment was too short. In the third case there were more than one reason for treatment failure: the patients' poor compliance, and the doctors' fault: an inadequate choice of drugs. In the last case adverse reactions to drugs caused the treatment failure.

Adult↗
PubMed1998

The effectiveness of guided design on ethical decision making and moral reasoning among community nursing students.

This study evaluated the effectiveness of guided design as an instructional method in ethical decision making and moral reasoning among 145 community health nursing students. Changes in the process of ethical decision making and moral reasoning were measured using Ketefian's judgment About Nursing Decisions (JAND) one week after the intervention. Results indicated a significant difference in ethical decision-making scores after instruction, but no difference in moral reasoning. The one specific component--Taking professional initiatives--increased on both subscales.

Community Health Nursing↗
PubMed1998

The development of conditional reasoning and the structure of semantic memory.

The present article examines 2 predictions concerning conditional reasoning in children derived from a revised version of Markovits's model of conditional reasoning. The first study examined the prediction that younger children (8 years of age) would have greater difficulty in responding correctly to premises where the antecedent was strongly associated with the consequent than to premises where the association was weaker; for example, "If something is a car, then it has a motor" should be more difficult than "If something is a refrigerator, then it has a motor." A total of 55 children in grades 2 and 3 (average age: 8 years) and 49 children in grades 5 and 6 (average age: 11 years) were given either 2 strongly associated problems or weakly associated counterparts. Results indicated that 8-year-olds did better on the weakly associated problems than on the strongly associated problems, but there was no difference among the 11-year-olds. The second study examined the prediction that younger children (8 years of age) would have greater difficulty in responding correctly to causal premises ("If a rock is thrown at a window, the window will break") than to corresponding ad hoc premises ("A rock is something that can be used to break a window"). A total of 53 children in grades 2 and 3 (average age: 8 years) and 49 children in grades 5 and 6 (average age: 11 years) were given either 2 causal problems or ad hoc counterparts. Results indicated that 8-year-old did better on the ad hoc problems than on the causal problems, but there was no difference among the 11-year-olds. These studies are interpreted as consistent with the idea that 1 major factor in the development of reasoning in this age level is the development of children's ability to explore their own knowledge base.

Aptitude↗
PubMed1998

Loss to follow-up of patients with abnormal Pap smear: magnitude and reasons.

We studied the magnitude and reasons for loss to follow-up in cases of abnormal Pap smears. We studied 162 women whose Pap smear results were abnormal. The lost follow-up rate was 41.1 per cent (95% CI: 33.1 to 49.3). Reasons for not coming to receive treatment was mostly related to communication such as not receiving informed letters from the hospital (35.6%), not understanding the messages in the informed letters (10.2%), were informed from the hospital's letters that their results were normal (5.1%), and perceiving that the test result was not serious (13.6%). One third of them had traveling-related reasons. There were 25.4 per cent of patients who sought treatment at other hospitals and 8.5 per cent went to see a traditional healer for treatment. The results provide information to prevent such unnecessary loss after having a Pap smear screening test for cervical carcinoma.

Adult↗
PubMed1998

Selection of restorative materials, reasons for replacement, and longevity of restorations in Florida.

The purpose of the present study was to obtain information relating to the types of restorative materials used, the main reason for replacement of restorations, and the age of failed restorations. Dentists in general dental practice in Florida were invited to record details from their own work pertaining to restorations. The diagnostic criteria were described and coded. The clinicians were not calibrated in the use of the criteria but they could call in for further explanation if needed. The 27 clinicians involved placed 2,035 restorations of which 53% were replacements of failed restorations. The increased use of resin based restorative material was clearly evident including posterior composites. The clinical diagnosis secondary caries was the most common reason for replacement of amalgam (56%) and composite (59%) restorations. Only discoloration showed a statistically significant difference in the reason for replacement of the two types of materials. The median age of the replaced amalgam restoration was 15 years and that of composite restoration was 8 years.

Adolescent↗
PubMed1998

Maternal infant-feeding decisions: reasons and influences.

The purpose of this prospective longitudinal study was to determine the reasons for and influences on mothers' infant-feeding decisions over the 6 months post-birth. The breastfeeding initiation rate of 41.7% had declined to 11.4% at 6 months. The major reasons for not choosing breastfeeding were embarrassment and discomfort with the idea. Younger, less-educated mothers with lower incomes were less likely to start breastfeeding, more likely to discontinue breastfeeding early, and more likely to feed their babies cheaper evaporated milks. Mothers gave up breastfeeding early because it was too difficult or because they were returning to work. Reasons given by both breastfeeding and bottle-feeding mothers for switching milks were that the baby was "not satisfied" on the milk or that it was "not agreeing with" the baby. Generally, the social network, rather then health professionals, had greater influence on mothers' decisions.

Adult↗
PubMed2006

Reasons why few patients with acute stroke receive tissue plasminogen activator.

Despite the US Food and Drug Administration's approval in 1996, tissue plasminogen activator (tPA) therapy for acute ischemic stroke remains substantially underused. We reviewed 3 potential reasons for low rates of tPA use: poor patient education, physicians' perceived risk of legal liability from negative patient outcomes, and insufficient reimbursement. The recent addition of diagnosis-related grouping code 559 will provide higher payment for stroke patients treated with tPA, creating a natural experiment to examine our third reason.

Drug Utilization↗
PubMed1999

Should victim impact influence sentences? Understanding the community's justice reasoning.

Victim impact statements have been introduced in response to growing community concern about apparent neglect of victims in the criminal justice system. Their use in sentencing is a contentious issue, because victim characteristics such as resilience or fragility can contribute to impacts. Is it appropriate for sentences to be influenced by consequences arising from chance victim circumstances unforeseeable by the offender? In the interest of achieving an optimal fit between the justice system and community expectations, this research examined a neglected question: how does the public reason about the issue? Using offense vignettes presented to 260 people in Western Australia, sentencing decisions were found to vary according to consequences arising from victim characteristics. There was little to indicate participants fully appreciated the issue; thus, further research is needed to clarify how justice reasoning principles are used, and to ascertain whether different decisions are taken when people are informed about the problem.

Adolescent↗
PubMed1997

Initial treatment choices, second-line therapy, and reasons for stopping medication in the treatment of hypertension by general practitioners in England, Scotland and Wales: 1990-1995.

Information on general practitioners' choices of initial and second-line antihypertensive treatment, and reasons for stopping therapy, are limited. We analysed data on the use of the four main classes of antihypertensive drugs (diuretics, beta-blockers, calcium antagonists and angiotensin-converting enzyme inhibitors) between 1990 and 1995 from an ongoing cross-sectional postal survey of general practitioners' prescribing activity (the New and Change Therapy Enquiry). There were 18,092 new courses and 9424 discontinuations between 1990 and 1995. Diuretics were the commonest first-line choice. Use of beta-blockers first-line decreased significantly in comparison with diuretics during the study period. Switches to calcium antagonists and angiotensin-converting enzyme inhibitors increased. The increased use of newer agents was not explained by increased use for concomitant conditions (diabetes or cardiovascular disease). Diuretics were most often discontinued because of poor efficacy (44% of diuretic stops). In contrast, most beta-blockers (55%), calcium antagonists (64%) and angiotensin-converting enzyme inhibitors (60%) were stopped because of side-effects. In conclusion, use of beta-blockers first-line decreased. Switches to calcium antagonists and angiotensin-converting enzyme inhibitors increased. The reasons may be due to greater perceived efficacy of newer agents rather than increased use for concomitant conditions.

Journal Article↗
PubMed1990

Client reasons and experiences in treatment that influence termination of psychotherapy.

Thirty-one male and female university counseling center clients completed questionnaires that identified reasons for termination and experiences in psychotherapy. Early terminators responded that they ended therapy because of situational constraints and discomfort with services more often than did late terminators. Late terminators said they stopped treatment because of improvement attributed to therapy more often than did early terminators. Late terminators also reported higher levels of belief that the therapist respected them, therapist warmth, and therapist competency than did early terminators. It was concluded that motivational factors in which volition plays a greater (reasons for termination) and lesser (client experiences) role combine to influence psychotherapy termination.

Adaptation, Psychological↗
PubMed2006

Caesarean section for non-medical reasons at term.

BACKGROUND: Caesarean section rates are progressively rising in many parts of the world. One suggested reason is increasing requests by women for caesarean section in the absence of clear medical indications, such as placenta praevia, HIV infection, contracted pelvis and, arguably, breech presentation or previous caesarean section. The reported benefits of planned caesarean section include greater safety for the baby, less pelvic floor trauma for the mother, avoidance of labour pain and convenience. The potential disadvantages, from observational studies, include increased risk of major morbidity or mortality for the mother, adverse psychological sequelae, and problems in subsequent pregnancies, including uterine scar rupture and greater risk of stillbirth and neonatal morbidity. An unbiased assessment of advantages and disadvantages would assist discussion of what has become a contentious issue in modern obstetrics. OBJECTIVES: To assess, from randomised trials, the effects on perinatal and maternal morbidity and mortality, and on maternal psychological morbidity, of planned caesarean delivery versus planned vaginal birth in women with no clear clinical indication for caesarean section. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2005), MEDLINE (1974 to April 2005), EMBASE (1974 to April 2005), CINAHL (1982 to April 2005) and PsycINFO (1887 to April 2005). We also performed a manual search of the references of all retrieved articles, sought unpublished papers and abstracts submitted to international conferences and contacted expert informants. SELECTION CRITERIA: All comparisons of intention to perform caesarean section and intention for women to give birth vaginally; random allocation to treatment and control groups; adequate allocation concealment; women at term with single fetuses with cephalic presentations and no clear medical indication for caesarean section. DATA COLLECTION AND ANALYSIS: We identified no studies that met the inclusion criteria. MAIN RESULTS: There were no included trials. AUTHORS' CONCLUSIONS: There is no evidence from randomised controlled trials, upon which to base any practice recommendations regarding planned caesarean section for non-medical reasons at term. In the absence of trial data, there is an urgent need for a systematic review of observational studies and a synthesis of qualitative data to better assess the short- and long-term effects of caesarean section and vaginal birth.

Cesarean Section↗
PubMed2002

From college to clinic: reasoning over memorization is key for understanding anatomy.

Anatomy and physiology are taught in community colleges, liberal arts colleges, universities, and medical schools. The goals of the students vary, but educators in these diverse settings agree that success hinges on learning concepts rather than memorizing facts. In this article, educators from across the postsecondary educational spectrum expand on several points: (1) There is a problem with student perception that anatomy is endless memorization, whereas the ability to manage information and use reasoning to solve problems are ways that professionals work. This misperception causes students to approach the subject with the wrong attitude. (2) The process of learning to use information is as important as the concepts themselves. Using understanding to explain and make connections is a more useful long-term lesson than is memorization. Anatomy should be presented and learned as a dynamic basis for problem solving and for application in the practice and delivery of quality health care. (3) Integration of form and function must be explicit and universal across all systems. (4) Using only models, images, audiovisuals, or computers cannot lead students to the requisite reasoning that comes from investigative dissection of real tissue. (5) Some undergraduate courses require students to memorize excessive musculoskeletal detail. (6) Learning tissue biology is a particular struggle for medical students who have no background from an undergraduate course. (7) Medical professors and students see benefits when students have taken undergraduate courses in anatomy, histology, and physiology. If medical schools suggest these electives to applicants, medical students might arrive better prepared and, thus, be able to learn clinical correlations more efficiently in the limited allocated time of medical school curricula.

Anatomy↗
PubMed2006

Anatomical reasoning in the informatics age: Principles, ontologies, and agendas.

Reasoning about anatomy shares historical scientific roots with formal logic and artificial intelligence. With advances in computer-based intelligent programming, high-level biological structural knowledge may be exploited directly for biomedical research, clinical tasks, and educational applications. We consider the special nature of anatomical domain knowledge, emphasizing the complex concepts and semantics that must be represented in the development of ontologies, formally structured databases of biological information. We review the evolution of the fundamental scientific principles of logic and artificial intelligence needed for building machines that can make use of anatomical knowledge. We look at methods for compiling ontologies and compare the structural designs of the Foundational Model of Anatomy and Open GALEN ontologies. We further consider issues related to mapping developing anatomy resources with other biological ontologies in genomics, proteomics, and physiology. Although early results are promising, considerable resources and continuing effort must be committed to completing and extending anatomical ontologies for the ultimate success of computer-based anatomical reasoning. Anat Rec (Part B: New Anat) 289B:72-84, 2006. (c) 2006 Wiley-Liss, Inc.

Artificial Intelligence↗
PubMed2003

The competency of criminal defendants to refuse, for delusional reasons, a viable insanity defense recommended by counsel.

This article addresses the issues of whether mentally ill defendants charged with serious crimes who refuse to plead a viable and counsel-recommended insanity defense for delusional reasons (but who are otherwise competent to stand trial) should be considered to be competent, or incompetent, to stand trial; whether such defendants should be allowed to represent themselves with a delusional defense; and whether an insanity defense may properly be imposed upon such defendants. Based on an analysis of relevant Supreme Court decisions and other relevant cases, it is concluded that such defendants should not be allowed to go forward with a delusional defense (at least until reasonable efforts to treat the defendants' delusions are made). It is also argued, however, that unless an insanity defense would be viable (as well as recommended by counsel) delusional defendants who are otherwise competent to stand trial should be permitted to go forward, and represent themselves, with the defense of their choosing.

Decision Making↗
PubMed1997

Is computer interpretation of the exercise electrocardiogram a reasonable surrogate for visual reading? Veterans Affairs ACME Investigators.

BACKGROUND: Interpretation of exercise tests as positive or negative is primarily based upon exercise-induced ST segment changes. Consistently accurate measurements are difficult to obtain during exercise. HYPOTHESIS: This study compared on-line computer-generated electrocardiographic (ECG) analysis with visual interpretation. The goals were to document the extent of agreement, establish reasons for disagreements, characterize ST-segment depression (extent, onset, duration), and determine the sensitivity and ability to localize coronary artery disease for each method. METHODS: Comparisons were made in 120 patients at eight Veterans Affairs Medical Centers. An exercise test was considered positive if > 1.0 mm horizontal or downsloping ST-segment depression was detected 0.08 s after the J point during exercise or recovery. The ST-segment depression had to be present on at least two successive ECG recordings 15 s apart. Computer interpretation was based on median averaged beats. RESULTS: There was an 88% agreement of visual and computer interpretations [106/120 (both positive, n = 62; both negative, n = 44)]. The disagreements involved visual negative, computer positive in 10 cases and visual positive, computer negative in 4 cases. Correlation was excellent between methods for characterization of ST-segment depression (p < 0.0001). Sensitivity for detecting and the ability to localize coronary artery disease (> or = 70% stenosis) were similar for both methods. CONCLUSION: This computer algorithm using median averaged beats is a reasonable surrogate for visual interpretation of the exercise ECG, making it a valuable source of confirmation of physician readings in large research trials and in clinical settings.

Algorithms↗
PubMed2004

Reasons of informal caregivers for institutionalizing dementia patients previously living at home: the Pixel study.

CONTEXT: Study of the problems and requirements of the main caregiver providing home care for dementia patients that have resulted in the patient being institutionalised. OBJECTIVES: To determine the reasons for placing the dementia patient in an institution. RESOURCES: Self-administered questionnaire of 48 questions on the patient and caregiver, including a list of complaints, given to the main caregiver. Medical questionnaire on the patient filled in by the geriatrician. RESULTS: Data were collected from 109 questionnaires concerning 75 females with dementia (84.7 +/- 6.7 years) and 34 demented males (80.8 +/- 7.4 years). In two-thirds of cases the main caregiver was a female, aged 61.1 +/- 12.1 years. Cognitive disorders were not the main reasons for institutionalizing patients. The most frequent caregiver complaint at the time of institutionalisation was incontinence, followed by withdrawal. The caregiver's main problem resulting in institutionalisation was dependence, with behavioural disorders in second place. A treatment with anticholinesterase for dementia was associated with a live-in career being provided for 20 months longer than in the case of patients not receiving this treatment. Statistical analysis revealed 6 groups of separate caregiver-patient situations. On the one hand there were those patients who appeared to be easy for the caregiver to cope with: those with no problems, docile patients and passive patients not opposing care. In these cases the caregiver was most often young and male, or not directly related to the patient. On the other hand there were 3 other groups: patients with inappropriate motor behaviours, violent/agitated patients and unmotivated patients who opposed care. These patients lived with an elderly caregiver who had been looking after the patient for several years. DISCUSSION: Caregivers' requirements are for help with coping with and preventing dependence. The caregiver suffers terribly from a lack of relief, particularly when young. CONCLUSION: It is necessary to change the focus of home care for dementia patients towards preventing loss of autonomy and its consequences and to allow for periods of relief for home caregivers.

Adaptation, Psychological↗