Effects of using videotaped vignettes on enhancing students' critical thinking ability in a baccalaureate nursing programme

AIM: The aim of this study was to determine the effects of using videotaped vignettes in promoting nursing students' critical thinking abilities in managing different clinical situations. BACKGROUND: The impetus for undertaking this study came from recognition of the need to develop the level of students' critical thinking within clinical nursing practice. Eight videotaped vignettes that simulated clinical situations were developed to promote baccalaureate nursing students' critical thinking abilities in managing clinical situations. Guidelines were also developed to stimulate students' discussion. DESIGN/METHODS: A pre-test/post-test design was employed to determine the effectiveness of videotaped vignettes in promoting critical thinking skills among these students. A final sample of 83 students completed all the pre-test and post-test questionnaires on critical thinking skills and nursing knowledge test specific to a vignette. RESULTS/FINDINGS: The findings indicate that students' post-test knowledge scores were significantly higher than the pre-test knowledge scores. While the post-test critical thinking skill test scores were slightly higher than those of the pre-test for the students, the difference was not significant. One reason for such findings may be the limited exposure students had to these new types of videotaped vignettes. After the course had been completed both students and teachers were asked to reflect and to indicate their level of satisfaction with the new approach. There was overall satisfaction with the new approach to teaching clinical skills as reflected in the interview data from both teachers and students. CONCLUSIONS: While there were positive outcomes in terms of helping students to relate nursing principles to clinical situations, more time for students to learn using videotaped vignette in tutorial hours remains a challenge for teachers in planning the lectures.     

Clinical decision support increases diagnostic yield of computed tomography for suspected pulmonary embolism

Objective

Determine effects of evidence-based clinical decision support (CDS) on the use and yield of computed tomographic pulmonary angiography for suspected pulmonary embolism (CTPE) in Emergency Department (ED) patients.

Binding of the glucocorticoid receptor complex to the nucleosomal core in the P1798 mouse lymphosarcoma

Binding of the glucocorticoid receptor complex to nucleosomes has been studied using the mouse P1798 lymphosarcoma. Cells were incubated with [3H]triamcinolone acetonide (TA), and nuclei prepared and digested with 3 different concentrations of micrococcal nuclease. After fractionation with EDTA and NaCl, it was observed that [3H]TA bound with similar specific radioactivity to mononucleosomes containing both core and linker DNA, of 183 +/- 5, and 168 +/- 4 base pair lengths, respectively, as well as to core size DNA, of 148 +/- 3 base pair length, suggesting that the glucocorticoid receptor bound to the core portion of the nucleosome. Steroid binding was found to be associated with regions of the nucleosome that were depleted in histone H1 and enriched in high mobility group (HMG) proteins 1 and 2; only negligible binding was noted in nucleosomes enriched in histone H1 and depleted in HMG proteins. In addition to binding to core nucleosomes, the glucocorticoid receptor complex was also shown to bind to a fraction sedimenting at 5-6 S on sucrose gradients characterized by subnucleosome and mononucleosome size DNA, as well as by core histones. While binding of the steroid receptor complex to linker regions of the nucleosome cannot be ruled out, this data would appear to present the first concrete evidence that glucocorticoid binding, at least in the P1798 lymphosarcoma, is to core nucleosomes. Some caution in interpretation of the results is indicated, however, on 2 points: (1) receptor redistribution during nuclease digestion cannot be ruled out; (2) only the binding of a small proportion of the steroid receptor complex may be physiologically relevant.     

Surveillance programme for hepatocellular carcinoma improves the survival of patients with chronic viral hepatitis

Background: The survival benefit of surveillance for hepatocellular carcinoma (HCC) is controversial. Aim: We aimed to examine the survival benefit of HCC surveillance in chronic viral hepatitis. Methods: Survivals of HCC patients related to chronic viral hepatitis from the Hepatology Clinic (surveillance group) were compared with those referred from other hospitals/clinics (no‐surveillance group). Lead‐time and length‐time biases were adjusted based on tumour volume doubling times. Results: Among 579 patients (91% hepatitis B), 472 (82%) patients had HCC and 79 (17%) of these patients were referred from the surveillance programme. HCC was smaller (4.2 vs. 7.7 cm; P<0.001) and fewer in numbers (2.6 vs. 3.8, P=0.03) in the surveillance group vs. the no‐surveillance group. Treatment by surgery (20 vs. 10%, P=0.007) and local ablative therapy (46 vs. 19%, P<0.001) were more frequent in the surveillance group than that in the no‐surveillance group. The median survival of the surveillance group (88 weeks) was significantly longer than that of the no‐surveillance group (26 weeks) (P<0.001). The adjusted cumulative survival at 2 years was significantly longer in the surveillance group if the tumour volume doubling time was <90 days (P=0.0352). Conclusions: HCC surveillance can improve the survival of patients with chronic viral hepatitis B.     

Increased serum CD8 antigen level in childhood Hodgkin's disease relates to advanced stage and poor treatment outcome

Measurement of the soluble form of CD8 antigen, a surface membrane component of suppressor/cytotoxic T cells, has yielded useful information relevant to prognosis in the lymphoid malignancies of childhood. We therefore determined pretreatment levels of serum CD8 antigen in 90 children with newly diagnosed Hodgkin's disease. The findings ranged widely, from 220 to 2,585 U/mL (median, 556 U/mL). In patients with advanced disease (stage III or IV), the median serum CD8 level was significantly higher than in those with less disease extension (stage I or II): 675 v 477 U/mL, P = .003. It was also higher in children with B symptoms compared with all others: 622 v 494 U/mL, P = .005. Cases with a histologic classification of mixed cellularity had a significantly higher median level of the antigen than did those classified as nodular sclerosis: 847 v 509 U/mL, P = .005. Finally, higher serum CD8 levels (greater than 430 U/mL) were significantly associated with an increased probability of treatment failure (P = .02). In a multivariate analysis, serum CD8 level retained its impact on treatment outcome after adjustment for other potentially useful prognostic factors, including disease stage, presence of B symptoms, histology, erythrocyte sedimentation rate, sex, age, and race. The prognostic strength shown by soluble CD8 in this analysis suggests that the antigen has clinical value. We postulate that increased CD8 levels in serum indicate enhanced suppressor T-cell activity, which may compromise the host's antitumor immunity, leading to unusually aggressive disease.     

A community study of sleep-disordered breathing in middle-aged Chinese women in Hong Kong: prevalence and gender differences

STUDY OBJECTIVES: To investigate the prevalence of sleep-disordered breathing (SDB) and obstructive sleep apnea syndrome (OSAS) in community-based, middle-aged Chinese women, and to compare the differences between gender with a similar study in men. DESIGN: A cross-sectional study conducted in Hong Kong from 1998 to 2000. SETTING: Sleep questionnaires were distributed to women (30 to 60 years old) in three offices and two community centers. All were invited to undergo full polysomnography in a sleep laboratory. PARTICIPANTS: Questionnaires were distributed to 1,532 women, and 854 questionnaires were returned. Polysomnography was conducted in 106 respondents. Measurements and results: Conservative estimated prevalence of SDB (apnea-hypopnea index [AHI] > = 5) and OSAS (AHI > or = 5 plus excessive daytime sleepiness [EDS]) were 3.7% and 2.1%, respectively. Age-specific prevalence of OSAS was 0.5%, 2.2%, and 6.1% in the 30- to 39-year-old, 40- to 49-year-old, and 50- to 60-year-old age groups, respectively. Stepwise multiple logistic regression analysis identified body mass index (BMI) and age as predictors of SDB. Compared to Chinese men, the prevalence of SDB and OSAS in women was lower, but the gender difference decreased with age. The AHI of affected women was also significantly lower despite comparable BMI. Compared to men, women with SDB had same degree of self-reported snoring and a similar degree of EDS despite the lower AHI. CONCLUSIONS: This study demonstrated an estimated prevalence of OSAS at 2.1% among middle-aged Chinese women in Hong Kong, with a 12-fold rise from the fourth to the sixth decade of life. BMI and age were significant independent predictors of SDB. Compared to men, women with SDB had lower AHIs, despite similar BMIs.     

Administration of the potent PPARalpha agonist, Wy-14,643, reverses nutritional fibrosis and steatohepatitis in mice

Administration of a methionine and choline deficient (MCD) diet to rodents causes progressive fibrosing steatohepatitis pathologically similar to human metabolic steatohepatitis. We have previously shown that the peroxisome proliferator-activated receptor-alpha (PPARalpha) agonist, Wy-14,643, prevented the development of MCD diet-induced steatohepatitis. We have now tested whether Wy-14,643 ameliorates established steatohepatitis and fibrosis. Male C57BL6 mice were fed the MCD diet for 51 days to induce severe steatohepatitis. They were then treated with Wy-14,643 together with the MCD diet for 5 or 12 days; positive controls continued on the MCD diet for 5 or 12 days. After 5 days of Wy-14,643 treatment, alanine aminotransferase (ALT) levels were significantly decreased, steatohepatitis less severe, and hepatic lipoperoxides significantly reduced. After 12 days, hepatic triglycerides were normalized and there was near resolution of histological changes. MCD dietary feeding was associated with increased expression of vascular cell adhesion molecule (VCAM)-1, and increased numbers of activated macrophages in the liver. Treatment with Wy-14,643 reduced VCAM-1 expression and macrophage numbers. MCD diet-fed mice developed hepatic fibrosis with increased hepatic collagen alpha1(I), tissue inhibitor of metalloproteinases (TIMP)-1, TIMP-2, and matrix metalloproteinase (MMP)-13 mRNA levels. After treatment with Wy-14,643, expression of these genes was reduced in a manner that paralleled the reduction in activated hepatic stellate cells and near resolution of liver fibrosis. In conclusion, the present study shows that MCD diet-induced fibrosing steatohepatitis can be reversed by treatment with Wy-14,643. It is likely that activation of PPARalpha reverses fibrosis indirectly by reducing stimuli, such as lipid peroxides, and activation of cells responsible for promoting hepatic fibrosis.     

Obstructive sleep apnea and metabolic syndrome: alterations in glucose metabolism and inflammation

Metabolic syndrome (MS), the commonly used term for the clustering of obesity, insulin resistance, hypertension, and dyslipidemia, affects millions of people worldwide, and is associated with an increased risk of cardiovascular disease and type 2 diabetes. Recently, it has been suggested that obstructive sleep apnea (OSA), an increasingly prevalent condition, may contribute to the development of MS and diabetes. Despite substantial evidence from both clinical and population studies to suggest an independent link between OSA and metabolic abnormalities, the issue still remains controversial. Obesity, particularly visceral obesity, is an important factor in the assessment of adverse metabolic outcome in OSA. Further prospective and interventional studies, with adequate sample sizes and longer follow-up, rigorous control for adiposity, and, ideally, randomization and control for any therapeutic intervention, are clearly needed to address the direction of causality. There are multiple mechanistic pathways involved in the interaction between OSA, obesity, and metabolic derangements. Chronic intermittent hypoxia and sleep fragmentation with sleep loss in OSA are likely key triggers that initiate or contribute to the sustenance of inflammation as a prominent phenomenon, but their complex interplay remains to be elucidated. In summary, OSA may represent a novel risk factor for MS and diabetes, and thus clinicians should be encouraged to systematically evaluate the presence of metabolic abnormalities in OSA and vice versa.     

Laparoscopic-assistedvs. open surgery for colorectal cancer

PURPOSE: Our aim was to test the hypothesis that laparoscopic-assisted resection for colorectal cancer has an immunologic advantage over traditional open surgery. METHODS: Sixteen patients with colorectal cancer were randomized to undergo laparoscopic-assisted resection or open surgery. Basic patient data were recorded, and serum interleukin-6 levels, relative proportions of lymphocytes, and human leukocyte antigen-DR expression on monocytes were determined at specific time intervals. RESULTS: Operating time was longer for laparoscopic-assisted resection (P=0.02), but analgesic requirements were less (P=0.04). All patients exhibited the following: interleukin-6 levels increased to a maximum at 4 hours and returned to preoperative levels within 48 hours. This response appeared greater for open resection (mean peak level, 313vs. 173 pg/ml;P=0.25). Relative granulocytosis (P<0.001) was seen within 48 hours, which was offset by a decrease in percentage of lymphocytes (P<0.001). Changes in lymphocyte subfractions were most significant seven days post-surgery: natural killer cells decreased (P=0.003); T cells increased (P=0.008), with elevation in the CD4/CD8 ratio (P=0.003). B cells were largely unchanged at all time periods. Human leukocyte antigen-DR expression on monocytes was significantly less at 48 hours postsurgery (P<0.001). All changes were reversed within three weeks of surgery. There were no differences when comparing laparoscopic-assisted resection with open surgery. CONCLUSIONS: Both laparoscopic-assisted resection and open surgery affect the immune response. It would appear that laparoscopic-assisted resection does not have an immunologic advantage over open surgery in patients with colorectal cancer.