Doing the right thing or doing the thing right:implications of participant withdrawal

This article discusses implications of participant withdrawal for inductive research. I describe and analyze how a third of my participants withdrew from a grounded theory study. I position my example, ensuing issues, and potential solutions as reflective of inductive methodologies as a whole. The crux of the problem is the disruption inflicted by withdrawal on inductive processes of generating knowledge. I examine the subsequent methodological and ethical issues in trying to determine the best course of action following withdrawal. I suggest three potential options for researchers: Continuing the study with partial data, continuing the study with all data, and discontinuing the study. Motivated by my experience, and wider theoretical considerations, I present several suggestions and questions, with the aim of supporting researchers in determining the best course of action for their individual field circumstances.

A case study of the assignment of withdrawal codes for reporting dropout in two disciplinary alternative schools

Dropout rates are major issues facing any nation's continued economic and social progress. The seriousness of this issue in the United States is evidenced by the recent legislation of the 2001 No Child Left Behind Act. The purpose of this study was to use the richness of qualitative methodology to analyze inaccuracies in the assignment of withdrawal codes by school administrators in two different disciplinary alternative schools. The primary codes examined were Code 05, any students over the age of 16 who leaves school voluntarily with no intention of returning; Code 15, any PK–12 student who is withdrawn from school due to nonattendance; Code 22, whereabouts unknown; Code 23, no other code can be used to identify the student's reason for leaving school, and Code 26, entering an adult program. ^ The cross-case method was used for this study. The participants were comprised of 19 school personnel and 25 students from two disciplinary alternative schools, designated X and Y, in the Miami-Dade County Public School system, Miami, FL. Data collection procedures included semi-structured interview, observations, field notes, and district documents. With a matrix, these data were analyzed to compare patterns and themes that emerged within both schools. ^ Results indicated that withdrawal codes were assigned inaccurately for two distinct reasons. At School Y, withdrawal codes were inaccurately assigned intentionally to keep the students from returning to a regular school without notification. At School X, withdrawal codes were inaccurately assigned due to lack of ability to properly track students and ascertain the real circumstances for their departure from school. The end result in both cases was that the school systems were not accurately identifying the whereabouts of students. It was recommended that further investigation be conducted to compare the accuracy of reporting dropouts among traditional/regular high schools and disciplinary alternative schools. ^

A Case Study of the Assignment of Withdrawal Codes for Reporting Dropouts in Two Disciplinary Alternative Schools

This study examined assignment of withdrawal codes by school administrators in two disciplinary alternative schools. Findings revealed: (a) codes were inaccurately assigned intentionally to keep students from returning to a regular school without notification, and (b) administrators improperly tracked students and failed to ascertain students’ reasons for dropping out.

Interactive Effects of Morphine on HIV Infection: Role in HIV-Associated Neurocognitive Disorder

HIV epidemic continues to be a severe public health problem and concern within USA and across the globe with about 33 million people infected with HIV. The frequency of drug abuse among HIV infected patients is rapidly increasing and is another major issue since injection drug users are at a greater risk of developing HIV associated neurocognitive dysfunctions compared to non-drug users infected with HIV. Brain is a major target for many of the recreational drugs and HIV. Evidences suggest that opiate drug abuse is a risk factor in HIV infection, neural dysfunction and progression to AIDS. The information available on the role of morphine as a cofactor in the neuropathogenesis of HIV is scanty. This review summarizes the results that help in understanding the role of morphine use in HIV infection and neural dysfunction. Studies show that morphine enhances HIV-1 infection by suppressing IL-8, downregulating chemokines with reciprocal upregulation of HIV coreceptors. Morphine also activates MAPK signaling and downregulates cAMP response element-binding protein (CREB). Better understanding on the role of morphine in HIV infection and mechanisms through which morphine mediates its effects may help in devising novel therapeutic strategies against HIV-1 infection in opiate using HIV-infected population.

Rôle de la neurotensine dans le phénomène de sensibilisation à la morphine

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal.

Use of analgesics in intentional drug overdose presentations to hospital before and after the withdrawal of distalgesic from the Irish market

BACKGROUND: Distalgesic, the prescription-only analgesic compound of paracetamol (325 mg) and dextropropoxyphene (32.5 mg) known as co-proxamol in the UK, was withdrawn from the Irish market as of January 2006. This study aimed to evaluate the impact of the withdrawal of distalgesic in terms of intentional drug overdose (IDO) presentations to hospital emergency departments (EDs) nationally. METHODS: A total of 42,849 IDO presentations to 37 of the 40 hospitals EDs operating in Ireland in 2003-2008 were recorded according to standardised procedures. Data on sales of paracetamol-containing drugs to retail pharmacies for the period 1998-2008 were obtained from IMS Health. RESULTS: The withdrawal of distalgesic from the Irish market resulted in an immediate reduction in sales to retail pharmacies from 40 million tablets in 2005 to 500,000 tablets in 2006 while there was a 48% increase in sales of other prescription compound analgesics. The rate of IDO presentations to hospital involving distalgesic in 2006- 2008 was 84% lower than in the three years before it was withdrawn (10.0 per 100,000). There was a 44% increase in the rate of IDO presentations involving other prescription compound analgesics but the magnitude of this rate increase was five times smaller than the magnitude of the decrease in distalgesic-related IDO presentations. There was a decreasing trend in the rate of presentations involving any paracetamol-containing drug that began in the years before the distalgesic withdrawal. CONCLUSIONS: The withdrawal of distalgesic has had positive benefits in terms of IDO presentations to hospital in Ireland and provides evidence supporting the restriction of availability of means as a prevention strategy for suicidal behaviour.

Rôle de la neurotensine dans le phénomène de sensibilisation à la morphine

Mémoire numérisé par la Direction des bibliothèques de l'Université de Montréal.

Withdrawal of Antidementia Drugs in Older People: Who, When and How?

The evidence base to guide withdrawal of antidementia medications in older people with dementia is limited; while some randomised controlled studies have considered discontinuation of cholinesterase inhibitors, no such studies examining discontinuation of the N-Methyl-D-aspartate receptor antagonist memantine have been conducted to date. The purpose of this opinion article was to summarise the existing evidence on withdrawal of cholinesterase inhibitors and memantine, to highlight the key considerations for clinicians when making these prescribing decisions and to offer guidance as to when and how treatment might be discontinued. Until the evidence-base is enhanced by the findings of large scale randomised controlled discontinuation trials of ChEIs and memantine which use multiple, clinically relevant cognitive, functional and behavioural outcome measures, clinicians’ prescribing decisions involve balancing the risks of discontinuation with side-effects and costs of continued treatment. Such decisions must be highly individualised and patient-centred.

Statin withdrawal in people with dementia

Background: There are approximately 24 million people worldwide with dementia; this is likely to increase to 81 million by 2040. Dementia is a progressive condition, and usually leads to death eight to ten years after first symptoms. End-of-life care should emphasise treatments that optimise quality of life and physicians should minimise unnecessary or non-beneficial interventions. Statins are 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors; they have become the cornerstone of pharmacotherapy for the management of hypercholesterolaemia but their ability to provide benefit is unclear in the last weeks or months of life. Withdrawal of statins may improve quality of life in people with advanced dementia, as they will not be subjected to unnecessary polypharmacy or side effects. However, they may help to prevent further vascular events in people of advanced age who are at high risk of such events.

Objectives: To evaluate the effects of withdrawal or continuation of statins in people with dementia on: cognitive outcomes, adverse events, behavioural and functional outcomes, mortality, quality of life, vascular morbidity, and healthcare costs.

Search methods: We searched ALOIS (medicine.ox.ac.uk/alois/), the Cochrane Dementia and Cognitive Improvement Group Specialised Register on 11 February 2016. We also ran additional searches in MEDLINE, EMBASE, PsycINFO, CINAHL, Clinical.Trials.gov and the WHO Portal/ICTRP on 11 February 2016, to ensure that the searches were as comprehensive and as up-to-date as possible.

Selection criteria: We included all randomised, controlled clinical trials with either a placebo or 'no treatment' control group. We applied no language restrictions.

Data collection and analysis: Two review authors independently assessed whether potentially relevant studies met the inclusion criteria, using standard methodological procedures expected by Cochrane. We found no studies suitable for inclusion therefore analysed no data.

Main results: The search strategy identified 28 unique references, all of which were excluded.

Authors' conclusions: We found no evidence to enable us to make an informed decision about statin withdrawal in dementia. Randomised controlled studies need to be conducted to assess cognitive and other effects of statins in participants with dementia, especially when the disease is advanced.

Spontaneous Cirrhosis Regression in an IFN-beta-induced AIH-like Syndrome Following Drug Withdrawal: Art of Facts or Artifacts?

Autoimmune hepatitis (AIH) is a disease of unknown aetiology with drug-induced AIH being the most complex and not fully understood type. We present the case of a 57-year-old female patient with acute icteric hepatitis after interferon-beta-1b (IFNβ-1b) administration for multiple sclerosis (MS). Based on liver autoimmune serology, histology and appropriate exclusion of other liver diseases, a diagnosis of AIH-related cirrhosis was established. Following discontinuation of IFNβ-1b, a complete resolution of biochemical activity indices was observed and the patient remained untreated on her own decision. However, 3 years later, after a course of intravenous methylprednisolone for MS, a new acute transaminase flare was recorded which subsided again spontaneously after 3 weeks. Liver biopsy and elastography showed significant fibrosis regression (F2 fibrosis). To our knowledge, this is the first report showing spontaneous cirrhosis regression in an IFNβ-1b-induced AIH-like syndrome following drug withdrawal, suggesting that cirrhosis might be reversible if the offending fibrogenic stimulus is withdrawn.

Complications of pneumococcal bacteremia after 13-valent conjugate vaccine withdrawal

In the Region of Madrid, universal immunization with the 13-serotypes pneumococcal conjugate vaccine (PCV13) started in May 2010. In July 2012, public funding ceased. Vaccination coverage decreased from >95% to 82% in 2013 and to 67% in 2014. Our aim was to investigate the impact of PCV13 withdrawal from Madrid Region's universal immunization program on the incidence of complicated pneumococcal bacteremia. We performed a multi-center retrospective cohort study, from 2009 to 2014. Participants were children aged <14 years with Streptococcus pneumoniae bacteremia. Complications were defined as any condition requiring intensive care or surgery. Sequelae were conditions lasting ≥90 days. A total of 168 patients were recruited. One-fourth of both immunized and non-immunized patients had complications. Global complications increased after PCV13 withdrawal. A total of 28% of PCV13 serotypes presented complications. Complications due to PCV13 serotypes did not increase after July 2012. No-PCV13 serotypes increased progressively from 2009 on, and 23% presented complications. A significant risk of complications was found for patients with meningitis, empyema, C-reactive protein >100 mg/L, and serotype 1. A multivariate analysis indicated that complications were associated with meningitis and hospital admission after July 2012. Sequelae were significantly associated with children <2 years of age, meningitis and no-PCV13 serotypes. The incidence of complications due to PCV13 serotypes did not increase two years after PCV13 withdrawal. Nevertheless, all-serotypes complications increased. The likely cause was that no-PCV13 serotypes (associated with meningitis) are on the rise.

Ketamina para el tratamiento de la hiperalgesia causada por remifentanil en cirugía: revisión sistemática de literatura

La hiperalgesia secundaria a la administración de remifentanil se ha documentado tanto en estudios animales como en estudios experimentales en humanos y ha aumentado su incidencia dado su uso cada vez más frecuente para el mantenimiento durante diferentes procedimientos anestésicos, anestesia general balanceada, anestesia total intravenosa y sedaciones. La hiperalgesia secundaria al uso de remifentanil es un proceso pro-nociceptivo relacionado pero que difiere de la tolerancia aguda, en el que los neurotransmisores excitatorios de N- metil D aspartato (NMDA) juegan un rol central. Por tanto la ketamina se ha utilizado en diferentes dosis para la prevención de dicha hiperalgesia sin que se haya establecido su efectividad para la prevención y tratamiento de esta condición. Se encontraron 8 estudios publicados en los últimos 10 años que proponen a la ketamina como una estrategia útil y efectiva el tratamiento de la hiperalgesia inducida por el uso de remifentanil. Los resultados demuestran que la ketamina es un tratamiento costo efectivo para el tratamiento de la hiperalgesia en diferentes poblaciones sometidas a diversos procedimientos quirúrgicos y anestésicos que incluyan la administración de remifentanil tanto en la inducción como en el mantenimiento anestésico sin generar efectos secundarios adicionales, así como que logra disminuir el consumo de opioides y la EVA en el posoperatorio.