Investigating the influence of treatment philosophy on outcome of methadone maintenance

This study is based on a ‘natural experiment’ in which a cohort of heroin users was assessed at one unit, then referred on geographic grounds for treatment to one of two clinics—one orientated to long-term maintenance (Clinic 2, with 61 subjects), the other to time-limited treatment aimed at achieving abstinence from all drugs including methadone (Clinic 1, 141 subjects). The outcome measure was heroin use as measured by urine testing performed regularly at both clinics. Overall, 25% of urine tests from Clinic 1 were positive for heroin compared to 18% in Clinic 2. This difference reflected in part a high rate of heroin use during the period of mandatory withdrawal from treatment in Clinic 1. Statistical models were developed to identify factors associated with heroin use. There was a strong association between methadone dose and heroin use; relative to a daily dose of 40 mg, a dose of 80 mg/day of methadone was less likely to be associated with a heroin-positive urine (OR 0.55, 95% CI [0.45,0.68]). Average doses prescribed in Clinic 1 were lower, reflecting the clinic's orientation to abstinence. Adjusting for dose, and for the fact that certain individuals tend to use heroin heavily while others do not, there was no difference between the clinics in risk of heroin use during maintenance treatment. The higher rates of heroin use in the abstinence-orientated clinic were attributable to time-limited treatment and the use of lower doses of methadone. This finding confirms that in investigating the effects of treatment factors, the powerful influence of methadone dose needs to be taken into account.     

Characteristics of 1986 First Year Occupational Therapy Students at Lincoln Institute of Health Sciences

This paper presents the findings of a survey aimed at determining specific biographical, educational, attitudinal, and aptitudinal characteristics of students at the beginning of the 1986 first year occupational therapy course at Lincoln Institute of Health Sciences. It suggests that these types of data could assist in the identification of factors, in addition to the ones related to gender, which may contribute to the professional attrition of occupational therapists. It also suggests that these additional factors may need to be considered when planning and reviewing undergraduate curricula and in devising criteria for selection of students for occupational therapy. These assumptions, however, need to be further investigated.     

Attitudes towards gamete donation among couples undergoing in vitro fertilization

Summary. The attitudes of 234 anonymous couples undergoing in vitro fertilization toward sperm and oocyte donation were explored by questionnaire. All the questionnaires were returned of which 222 (95%) were complete and analysed. A high proportion of couples found the use of donor sperm acceptable for therapeutic, diagnostic and treatment purposes (77%, 90% and 97% respectively) and 72%, 84% and 90% respectively were willing to donate oocytes for these purposes. Of potential oocyte donors 41% would agree to nonanonymous donation, 12% would wish to meet the recipient couple and although only 4% wanted to choose the recipient, a quarter of the couples would prefer a relative or friend as the recipient. Provision of nonidentifying information about the donor to the recipient couple was acceptable to almost 70% whereas 40% found giving the same information to the child acceptable.     

Leading edge practitioners in community pharmacy: approaches to innovation

Despite the recommendations of the Nuffield (1986) and Pharmaceutical Care (1992) reports, implementation of the “wider role” in pharmacy practice has been piecemeal. While individual pharmacists have successfully introduced innovations in tasks and working methods, others have not. The paper explores the hypothesis that innovation is related to a set of (largely) generic characteristics possessed by those who promote professional change, together with enabling elements in the work environment. The hypothesis is explored by the identification of leading edge practitioners (LEPs) by key stakeholders in pharmaceutical service delivery and tested using critical incident analysis, an extended interview schedule and a psychometric test (KAI). LEPs were found to initiate more actions, to be more patient-centred, to be effective “soft” networkers, more focused on staff development and more effective influencers. There are wide implications for both providers and purchasers of pharmaceutical care, together with those who have a responsibility for training and development.     

Blood pressure during sustained inhibitory breathing in the natural environment

Previous studies reported that breathing frequency of laboratory dogs decreased preceding the onset of an avoidance task and that this decrease was accompanied by increases in blood pressure and decreases in heart rate. Low frequency/normal tidal volume breathing has also been observed in ambulatory humans, but the cardiovascular concomitants of this inhibitory breathing pattern remain to be determined. The present study recorded blood pressure and heart rate in humans during periods of inhibitory breathing in the natural environment. Systolic and mean pressure were higher during inhibitory breathing than at other times, but no differences in diastolic pressure or heart rate were observed. Inhibitory breathing was differentially associated with the workplace and with social situations. Thus, major components of a physiological pattern that predisposes laboratory animals to sodium-sensitive experimental hypertension have now been observed to covary in ambulatory humans. Whether inhibitory breathing in the natural environment is a correlate or a cause of elevated blood pressure remains to be determined.     

Factors Determining Success and Energy Requirements for Cardioversion of Atrial Fibrillation

Factors thought to affect the success of and energy requirementsfor cardioversion of atrial fibrillation were studied in 80(49 male, 31 female) patients aged 21–88 (mean 61.5 years).Transthoracic impedance was measured in advance of the countershockusing a 30 kHz low amplitude AC current passed through self-adhesiveECG/defibrillator pads (diameters 8–12cm) applied to thechest in the antero-posterior (AP) position in 57 patients andthe anteroapical (AA) position in 23 patients. Mean transthoracicimpedance for all patients was 69.3±16 (SD) ohms (range39–131 ohms), but transthoracic impedance was significantlygreater in the AA than the AP position (75.4±13 vs. 66.7±16ohms, p=0.02). Initial energy was 50 J (delivered) and was graduallyincreased to a maximum of 360 J if required. Cardioversion wassuccessful in 73 of 80 (91.2 per cent), and low energy shocks(200 J) were successful in 45 of 80 (56.2 per cent) patients.Using single factor analysis, sex, left atrial enlargement,electrode pad positions, aetiology of atrial fibrillation, presenceof left ventricular failure, and prior treatment with verapamilor ß-adrenergic blockers were not significant determinantsof cardioversion success or success of low energy shocks butprior treatment with digoxin was, both for cardioversion successand success at low energies. In patients with transthoracicimpedance 70 ohms, low energy shocks were more often successful(33 or 50, 66 per cent) than in patients with transthoracicimpedance >70 ohms (12 of 30, 40 per cent), p=0.04. Usingunivariate analysis, cardioversion success with low energy shockswas not only significantly associated with prior treatment withdigoxin but also with the duration of atrial fibrillation (24hours to one month and one month to three years) and for shocksof 100 J, with prior treatment with amiodarone. Multifactorial linear regression analysis selected, in rankorder, only duration of atrial fibrillation of 24 hours to lessthan one month and one month to three years as significant predictorsof both cardioversion success irrespective of shock strength,and success of low energy shocks.     

‘A thorny problem for feminism’: an analysis of the subjective work experiences of enrolled nurses

• ? Feminist methodology has been used in this study to investigate the subjective work experiences of 19 enrolled nurses.
• ? Reflexive conversational techniques enabled participants to relate autobiographical narratives examining their experiences of working in a nursing hierarchy.
• ? Two themes are reported: ‘nursing identity’ and ‘exploitation’. Through an analysis of these themes insight has been gained into the manner in which nurses inter-relate.
• ? The study demonstrates how the correlation between rank, status and expertise within the nursing hierarchy may have negative consequences for patient care.

     

Where are we now? Research-mindedness in the 1990s

Summary

• ? Nurses taking a research course carried out a research project investigating colleagues' knowledge of and attitudes to research.
• ? Only a minority of the nurses studied read nursing journals regularly.
• ? Many reported negative attitudes to research articles.
• ? Observation in wards showed limited application of research in practice.
• ? Course members gained valuable knowledge of and insights into the research process through carrying out the project