What is action research and can it promote change in primary care?

Improving the quality of health care is an international priority. However, research has shown that methods of altering clinician's behaviour or implementing organizational change are often ineffective. Action research has been used successfully to facilitate change and improve service provision in industry, education and more recently in health care. In this paper, action research methodology and why it should be successful in promoting change are outlined. Recently published studies using action research in the primary health care team setting in the UK are discussed. They demonstrate that action research improves clinical care, teamwork, communication and administration. It also encourages practice teams to audit their work and identify their educational needs. The main problems encountered were the amount of time and effort required to maintain collaboration with participants, staff turnover and completing the research process in a short time scale. Action research should be a useful means of improving quality in health care and could be used more widely. In the UK, government strategy has called for individual- and team-based development plans based on individual learning needs. Action research could be a useful method of transforming these from theory to practice.     

Is there a difference between women and men in characteristics and outcome after in hospital cardiac arrest?

AIM: To describe the characteristics and outcome among patients suffering from an in-hospital cardiac arrest in women and men. METHODS: All patients who suffered an in-hospital cardiac arrest during a 4 year period in Sahlgrenska Hospital G?teborg, Sweden, where the cardiopulmonary resuscitation (CPR) team was called, were recorded and described prospectively in terms of characteristics and outcome. RESULTS: There were 557 patients suffering in-hospital cardiac arrest in whom the CPR-team was alerted. Among them, 217 (39%) were women. Women differed from men having a lower prevalence of earlier myocardial infarction, angina pectoris, renal disease and a higher prevalence of rheumatic disease. In terms of aetiology of the cardiac arrest, 47% men and 48% women were judged to have had a confirmed or possible AMI. More men than women were found in ventricular fibrillation/ventricular tachycardia (VF/VT) (57 vs. 41%; P<0.001), whereas more women were found in pulseless electrical activity (30 vs. 15%; P<0.0001). Cerebral performance categories (CPC)-score at discharge did not differ between men and women. Among women, 36.4% survived to discharge as compared with 38.0% among men (NS). Survival from VF/VT was 64.3% in women and 52.7% in men (NS). When correcting for dissimilarities at baseline, the adjusted odd ratio for being discharged alive from hospital among women as compared with men was 1.66 (95% confidence limit 1.06-2.62; P=0.028). CONCLUSION: Thirty nine percent of patients suffering in-hospital cardiac arrest for whom the CPR-team was alerted, were women. Women were less frequently found in VF/VT than men. After correcting for dissimilarities at baseline, female gender was associated with a small improvement in survival.     

Is pelvic floor muscle strength and thickness associated with pelvic organ prolapse in Nepali women? – A cross-sectional study

BackgroundPelvic floor muscle function has been shown to be inversely associated with pelvic organ prolapse in Western women, however differences have been documented between ethnic groups.ObjectiveTo determine if pelvic floor muscle strength and thickness and hiatal area are associated with pelvic organ prolapse in Nepali women.MethodsThis cross-sectional study included non-pregnant Nepali women ≥18 years attending an outpatient gynecology clinic in Kathmandu, Nepal. A clinical examination included the pelvic organ prolapse quantification (POP-Q)- system examination and Modified Oxford Scale. Puborectalis muscle thickness and hiatal area were assessed using 3D/4D translabial ultrasound. Statistical analysis included Pearson's correlation and multiple regression (p < 0.05).ResultsOf the 123 women; 14 (11%) had POP-Q stage 0 prolapse, 29 (24%) stage I, 69 (56%) stage II, 8 (7%) stage III, and 3 (2%) stage IV. Mean ± SD Modified Oxford Scale was 3.37 ± 0.48 and muscle thickness was 1.14 ± 0.21 cm, hiatal area at rest was 14.67 ± 3.11 cm² and on contraction was 11.29 ± 2.51 cm². No associations were found between pelvic floor muscle strength or thickness and POP-Q stages 0–IV. There was a positive correlation found between hiatal area at rest and pelvic organ prolapse stage (r = 0.34, p < 0.001)and hiatal area on contraction and prolapse stage (r = 0.30, p < 0.001) and a negative correlation between pelvic floor muscle strength and hiatal area on contraction (r = ?0.36, p < 0.001).ConclusionIn contrast to previous findings, pelvic floor muscle strength and thickness are not associated with pelvic organ prolapse in this sample of Nepali women. It is important to consider these findings when developing pelvic organ prolapse treatment and management strategies in this population.     

Higher pain sensitivity and lower muscle strength in postmenonpausal women with early rheumatoid arthritis compared with age-matched healthy women – a pilot study

Purpose: The purpose of the study was to examine muscle strength and pain sensitivity in postmenopausal women with and without RA. Methods: Ten women with and ten without early RA were recruited. All were postmenopausal, and did not use hormone replacement therapy. Measurements of isokinetic muscle strength in knee flexors/extensors, hand grip strength, timed standing, pressure pain thresholds (PPT), suprathreshold pressure pain, and segmental and plurisegmental endogenous pain inhibitory mechanisms during muscle contraction were assessed. Results: Participants with early RA were weaker in knee flexors, in hand grip strength and they needed more time for the timed standing. Women with early RA had higher sensitivity to threshold pain and suprathreshold pressure pain compared to women without RA. PPTs increased in the contracting muscle as well as in a distant resting muscle during static contractions in both groups. Conclusions: Our results indicate differences in muscular strength between postmenopausal women with and without RA. Furthermore, women with RA had decreased PPT and hyperalgesia, but no dysfunction of segmental or plurisegmental pain inhibitory mechanisms during static exercise compared to healthy controls. The normal function of endogenous pain inhibitory mechanisms despite chronic pain in women with RA might contribute to the good effects of physical activity previously reported.

Implications for Rehabilitation

• Difference in muscular strength between postmenopausal women with and without (rheumatoid arthritis) RA is present in early disease despite low disease activity.

• Women with RA have decreased pressure pain thresholds and hyperalgesia, but no dysfunction of segmental and plurisegmental pain inhibitory mechanisms.

• The normal function of endogenous pain inhibitory mechanisms despite chronic pain in women with RA might contribute to the good effects of physical activity in this group of patients.

     

Inequalities in the early treatment of women and men with acute chest pain?

Purpose

The aim of this study was to identify sex differences in the early chain of care for patients with chest pain.

Design

This is a retrospective study performed at 3 centers including all patients admitted to the emergency department because of chest pain, during a 3-month period in 2008, in the municipality of Göteborg. Chest pain or discomfort in the chest was the only inclusion criterion. There were no exclusion criteria.

Data Sources

Data were retrospectively collected from ambulance and medical records and electrocardiogram (ECG), echocardiography, and laboratory databases.

Main Findings

A total of 2588 visits (1248 women and 1340 men) made by 2393 patients were included.When adjusting for baseline variables, female sex was significantly associated with a prolonged delay time (defined as above median) between (a) admission to hospital and admission to a hospital ward (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.25-2.03), (b) first physical contact and first dose of aspirin (OR, 2.22; 95% CI, 1.30-3.82), and (c) admission to hospital and coronary angiography (OR, 2.50; 95% CI, 1.29-5.13).Delay time to the first ECG recording did not differ significantly between women and men.

Principal Conclusions

Among patients hospitalized due to chest pain, when adjusting for differences at baseline, female sex was associated with a prolonged delay time until admission to a hospital ward, to administration of aspirin, and to performing a coronary angiography. There was no difference in delay to the first ECG recording.     

What is empathy, and can empathy be taught?

Empathy is a commonly used, but poorly understood, concept. It is often confused with related concepts such as sympathy, pity, identification, and self-transposal. The purposes of this article are to clearly distinguish empathy from related terms and to suggest that the act of empathizing cannot be taught. According to Edith Stein, a German phenomenologist, empathy can be facilitated. It also can be interrupted and blocked, but it cannot be forced to occur. What makes empathy unique, according to Stein, is that it happens to us; it is indirectly given to us, "nonprimordially." When empathy occurs, we find ourselves experiencing it, rather than directly causing it to happen. This is the characteristic that makes the act of empathy unteachable. Instead, promoting attitudes and behaviors such as self-awareness, nonjudgmental positive regard for others, good listening skills, and self-confidence are suggested as important in the development of clinicians who will demonstrate an empathic willingness.     

Perceived impaired physical and cognitive functions after stroke in men and women between 18 and 55 years of age – a national survey

Purpose.?We describe self-reported consequences for physical and cognitive functions, detect possible gender differences, and find factors that were associated with deteriorated physical function in younger stroke patients, independent in their personal activities of daily life.

Methods.?This study involved all first ever stroke patients, aged 18–55 years, registered in the Swedish national quality register for stroke. A questionnaire was answered by 1068 patients 8–36 months after the stroke. Changes were sought in physical and cognitive functions as compared with the pre-stroke condition.

Results.?Eight hundred and sixty-seven patients (83%) were independent in personal activities of daily life. Significant differences between men and women were found: deteriorated physical ability was reported by 56–71% of the men and 65–79% of the women; deteriorated cognitive function was reported by 48–57% of the men and 57–68% of the women. Many patients (70% men, 77% women) reported that they had received insufficient information about physical exertion. Significant associations were found between deteriorated physical function and deteriorated cognitive function as well as fear of physical exertion.

Conclusions.?Deterioration was found in physical and cognitive functions greater in women then in men. Insecurity regarding physical exertion existed indicating that younger stroke patients might need information directly aimed at physical functioning and more gender specific than today. This study has raised the awareness that there also might be gender differences in other fields, which needs further studies.     

Electrical stimulation: can it increase muscle strength and reverse osteopenia in spinal cord injured individuals?

OBJECTIVE: To study the extent to which atrophy of muscle and progressive weakening of the long bones after spinal cord injury (SCI) can be reversed by functional electrical stimulation (FES) and resistance training. DESIGN: A within-subject, contralateral limb, and matching design. SETTING: Research laboratories in university settings. PARTICIPANTS: Fourteen patients with SCI (C5 to T5) and 14 control subjects volunteered for this study. INTERVENTIONS: The left quadriceps were stimulated to contract against an isokinetic load (resisted) while the right quadriceps contracted against gravity (unresisted) for 1 hour a day, 5 days a week, for 24 weeks. MAIN OUTCOME MEASURES: Bone mineral density (BMD) of the distal femur, proximal tibia, and mid-tibia obtained by dual energy x-ray absorptiometry, and torque (strength). RESULTS: Initially, the BMD of SCI subjects was lower than that of controls. After training, the distal femur and proximal tibia had recovered nearly 30% of the bone lost, compared with the controls. There was no difference in the mid-tibia or between the sides at any level. There was a large strength gain, with the rate of increase being substantially greater on the resisted side. CONCLUSION: Osteopenia of the distal femur and proximal tibia and the loss of strength of the quadriceps can be partly reversed by regular FES-assisted training.     

Heart failure in women is different than in men; should treatment be different?

Women with heart failure differ from their male counterparts in a number of ways, including etiology, pattern of cardiac remodeling, and prognosis. They may even respond differently to medical therapy. But until prospective, sex-specific studies show that we should do otherwise, we recommend that women with heart failure be treated the same as men, according to established guidelines.     

Is fatigue after stroke associated with physical deconditioning? A cross-sectional study in ambulatory stroke survivors

Lewis SJ, Barugh AJ, Greig CA, Saunders DH, Fitzsimons C, Dinan-Young S, Young A, Mead GE. Is fatigue after stroke associated with physical deconditioning? A cross-sectional study in ambulatory stroke survivors.

Objective

To determine the relationship between a measure of fatigue and 2 indices of physical fitness, lower limb extensor power (LLEP) and walking economy.

Design

This was a cross-sectional study of patients with stroke. Fatigue was assessed by vitality (VIT) score of the Medical Outcomes Study 36-Item Short-Form Health Survey version 2 (SF-36v2). LLEP of the unaffected limb was measured using a lower leg extensor power rig. Walking economy was calculated by measuring oxygen consumption (mL·kg^–1·m^–1) during walking at a comfortable speed. Bivariate analyses were performed relating VIT to indices of fitness. Multiple regression analyses were also performed and included age, sex, and either SF-36v2 emotional role function or SF-36v2 mental health, as predictors of VIT.

Setting

Community setting.

Participants

Participants (N=66; 36 men; mean age ± SD, 71.0±9.9y) were all community dwelling, had survived a stroke, were able to walk independently, and had completed their stroke rehabilitation.

Interventions

Not applicable

Main Outcome Measures

The main outcome measure is SF-36v2 (VIT), with walking economy and LLEP of the limb unaffected by the stroke being independent variables.

Results

Walking economy was not significantly related to VIT (R=–.024, P=.86, n=60). LLEP was positively related to VIT in bivariate analysis (R=.38, P=.003, n=58). After controlling for age, sex, and SF-36 emotional role function (or SF-36v2 mental health if the extreme outlier was excluded), LLEP remained a significant predictor of VIT.

Conclusions

We found an association between fatigue and reduced LLEP. If a larger study confirms these findings, it would support the need to develop and test interventions to increase LLEP as a treatment for fatigue after stroke.     

Sex differences in knee strength deficit 1?year after anterior cruciate ligament reconstruction

[Purpose] Little is known about the outcome differences between men and women after anterior cruciate ligament (ACL) reconstruction. Therefore, the present study aimed to compare knee muscle strength between men and women 1 year after ACL reconstruction. [Subjects and Methods] Retrospective and outcome study. Between 2012 and 2015, 35 males (mean age, 29.7 ± 010.7 years) and 35 females (mean age, 28.2 ± 11.3 years) who had undergone primary ACL reconstruction were recruited from Samsung medical centers. We assessed the strength deficit in the quadriceps (extensor) and hamstrings (flexor) at 60°/sec and 180°/sec with isokinetic testing equipment. Statistical analysis was conducted with a t-test to determine if sex differences existed in knee strength deficit. [Results] Significant differences were noted between men and women with respect to extensor muscle strength deficit. Women reported less extensor muscle strength than men did, at the angular velocities 60°/sec and 180°/sec. However, no significant sex differences were found at either velocity with respect to the strength deficit of the knee flexor muscles. [Conclusion] Compared to male patients, female patients reported significantly less extensor muscle strength and less improvement 1 year after reconstruction.Key words: Anterior cruciate ligament, Sex, Female     

Do I really want to be going on a bloody diet? Gendered narratives in older men with painful knee osteoarthritis

Purpose: Small reductions in body weight can decrease osteoarthritic knee pain. Intuitively this should provide a strong incentive for weight-loss. However many people undergoing knee joint replacement (KJR) are categorised as obese. Gender theories can help us to understand differential responses to illness and therefore make an important contribution to rehabilitation. We aimed to explore barriers to weight loss in a group of older men with osteoarthritis.

Materials and methods: We conducted 12 in-depth interviews, before and 1 year after surgery, with six obese men listed for KJR. Analysis was influenced by constructivist grounded theory. We abstracted conceptual themes from the data through constant comparison.

Results: We identified the following themes: (1) I am big and healthy and don’t need to lose weight; (2) being this size isn’t good for me; (3) men don’t have to worry about that sort of thing; (4) I am not as active as I used to be; (5) I have worked hard all my life; (6) what is the point in trying anyway?

Conclusions: Gendered narratives can make it challenging for men to lose weight. Healthcare professionals cannot ignore the influence of gender on rehabilitation and should consider gender specific strategies.

• Implications for rehabilitation

• Men may not associate being overweight with being unhealthy.

• Men may take pride in being in good shape and may respond better to weight loss strategies that focus on fitness not body size.

• Men may link weight gain with decrease in activity levels rather than overeating.

• Health care professionals should challenge the assumption that weight loss will follow surgery.

• Health care professionals cannot ignore the influence of gender on the success of rehabilitation.

     

Child-to-Child Unintentional Injury and Death from Firearms in the United States: What can be Done?

Children are unintentionally killing and injuring other children at an alarming rate in the United States owing to the accessibility of firearms. Firearms are found in 33-40% of American households with children. Many of those firearms are stored in an unsafe manner, loaded and unlocked, leaving children vulnerable to injury. Health care professionals dedicated to the well-being of the pediatric population must take an active role in protecting our nation's children from unnecessary injury and death owing to the unsafe storage of firearms.     

Does primary stroke center certification change ED diagnosis,utilization, and disposition of patients with acute stroke?

Background and Purpose

We examined the impact of primary stroke center (PSC) certification on emergency department (ED) use and outcomes within an integrated delivery system in which EDs underwent staggered certification.

Methods

A retrospective cohort study of 30?461 patients seen in 17 integrated delivery system EDs with a primary diagnosis of transient ischemic attack (TIA), intracranial hemorrhage, or ischemic stroke between 2005 and 2008 was conducted. We compared ED stroke patient visits across hospitals for (1) temporal trends and (2) pre- and post-PSC certification—using logistic and linear regression models to adjust for comorbidities, patient characteristics, and calendar time, to examine major outcomes (ED throughput time, hospital admission, radiographic imaging utilization and throughput, and mortality) across certification stages.

Results

There were 15?687 precertification ED visits and 11?040 postcertification visits. Primary stroke center certification was associated with significant changes in care processes associated with PSC certification process, including (1) ED throughput for patients with intracranial hemorrhage (55 minutes faster), (2) increased utilization of cranial magnetic resonance imaging for patients with ischemic stroke (odds ratio, 1.88; 95% confidence interval, 1.36-2.60), and (3) decrease in time to radiographic imaging for most modalities, including cranial computed tomography done within 6 hours of ED arrival (TIA: 12 minutes faster, ischemic stroke: 11 minutes faster), magnetic resonance imaging for patients with ischemic stroke (197 minutes faster), and carotid Doppler sonography for TIA patients (138 minutes faster). There were no significant changes in survival.

Conclusions

Stroke center certification was associated with significant changes in ED admission and radiographic utilization patterns, without measurable improvements in survival.