Heart transplantation: current practice and outlook to the future.

QUESTIONS UNDER STUDY: The field of heart transplantation has seen substantial progress in the last 40 years. The breakthroughs in long-term survival were followed by a period of stagnation in the last decade. This review summarises current recommendations for the identification of candidates for heart transplantation and their immunological and non-immunological postoperative follow-up. RESULTS: The progress made in the treatment of patients with advanced heart failure has considerably changed the profile of candidates for heart transplantation. Patients are older, and the load of co-morbidities is more important requiring careful evaluation for candidacy. Long-standing research in the field of immunosuppression made available various drugs, which decrease the risk of acute allograft rejection and prolong survival after heart transplantation. Powerful new molecules are entering early phase clinical studies, suggesting further improvement in the near future. As a consequence, treatment of non-immunological co-morbidity after heart transplantation will gain in importance, however, the base of evidence guiding current recommendations is poor. CONCLUSIONS: The substantial progress in heart failure treatment and immunosuppression after heart transplantation has changed the profile of heart transplant recipients. The arrival of new molecules will provide additional alternatives for immunosuppressive treatment while studies have to address non-immunological treatment in order to improve long-term survival after heart transplantation.

Patients who attend a private practice vs a university outpatient clinic: how do they differ?

Although interpersonal continuity is commonly assumed to be essential for care, some patients prefer to attend a university outpatient clinic where physicians change regularly and interpersonal continuity of care is not ensured. The aim of this exploratory study was to evaluate the differences between patients attending a university outpatient clinic and patients frequenting a private practice, explore their patterns of care-seeking and their understanding of continued care. We conducted a cross-sectional study of patients attending the university medical outpatient clinic (OC) in Lausanne, Switzerland and ten randomly selected private general practices (PP). Eligible patients were >30 years, Swiss nationals or long term residents, with one or more chronic conditions and attending the same practice for >3 years. They were asked to complete a questionnaire on sociodemographic data, use of medical resources and reasons for choosing and remaining at the same practice. Semi-structured interviews were conducted with a randomly selected subset of 26 patients to further explore their preferences. 329 patient questionnaires were completed, 219 by PP and 110 by OC patients. OC patients tended to be of lower socioeconomic status than PP patients. The main reason for choosing a PP were personal recommendation, while a higher percentage of patients chose the OC because they could obtain a first appointment quickly. A higher percentage of PP patients accorded importance to physician communication skills and trust, whereas a higher percentage of OC patients favoured investigation facilities. Qualitative data suggested that although OC and PP patients reported different reasons for consulting, their expectations on the medical and relationship level were similar. Our study suggests that the two groups of patients belong to different social backgrounds, have different patterns of care-seeking and attach importance to different aspects of care continuity. However, patients' expectations and perceptions of the physician-patient relationship are similar.

Authorship in scientific publications: analysis and recommendations.

In 2008, a Swiss Academies of Arts and Sciences working group chaired by Professor Emilio Bossi issued a "Memorandum on scientific integrity and the handling of misconduct in the scientific context", together with a paper setting out principles and procedures concerning integrity in scientific research. In the Memorandum, unjustified claims of authorship in scientific publications are referred to as a form of scientific misconduct - a view widely shared in other countries. In the Principles and Procedures, the main criteria for legitimate authorship are specified, as well as the associated responsibilities. It is in fact not uncommon for disputes about authorship to arise with regard to publications in fields where research is generally conducted by teams rather than individuals. Such disputes may concern not only the question who is or is not to be listed as an author but also, frequently, the precise sequence of names, if the list is to reflect the various authors' roles and contributions. Subjective assessments of the contributions made by the individual members of a research group may differ substantially. As scientific collaboration - often across national boundaries - is now increasingly common, ensuring appropriate recognition of all parties is a complex matter and, where disagreements arise, it may not be easy to reach a consensus. In addition, customs have changed over the past few decades; for example, the practice of granting "honorary" authorship to an eminent researcher - formerly not unusual - is no longer considered acceptable. It should be borne in mind that the publications list has become by far the most important indicator of a researcher's scientific performance; for this reason, appropriate authorship credit has become a decisive factor in the careers of young researchers, and it needs to be managed and protected accordingly. At the international and national level, certain practices have therefore developed concerning the listing of authors and the obligations of authorship. The Scientific Integrity Committee of the Swiss Academies of Arts and Sciences has collated the relevant principles and regulations and formulated recommendations for authorship in scientific publications. These should help to prevent authorship disputes and offer guidance in the event of conflicts.

Helping medical students to acquire a deeper understanding of truth-telling.

PROBLEM: Truth-telling is an important component of respect for patients' self-determination, but in the context of breaking bad news, it is also a distressing and difficult task. INTERVENTION: We investigated the long-term influence of a simulated patient-based teaching intervention, integrating learning objectives in communication skills and ethics into students' attitudes and concerns regarding truth-telling. We followed two cohorts of medical students from the preclinical third year to their clinical rotations (fifth year). Open-ended responses were analysed to explore medical students' reported difficulties in breaking bad news. CONTEXT: This intervention was implemented during the last preclinical year of a problem-based medical curriculum, in collaboration between the doctor-patient communication and ethics programs. OUTCOME: Over time, concerns such as empathy and truthfulness shifted from a personal to a relational focus. Whereas 'truthfulness' was a concern for the content of the message, 'truth-telling' included concerns on how information was communicated and how realistically it was received. Truth-telling required empathy, adaptation to the patient, and appropriate management of emotions, both for the patient's welfare and for a realistic understanding of the situation. LESSONS LEARNED: Our study confirms that an intervention confronting students with a realistic situation succeeds in making them more aware of the real issues of truth-telling. Medical students deepened their reflection over time, acquiring a deeper understanding of the relational dimension of values such as truth-telling, and honing their view of empathy.

Making it "click": collaborative perceptions of creative practice in art education /

Making it "Click": Collaborative Perceptions ofCreative Practice in Art Education examined the teaching practice of 6 art educators who conducted their work through the Niagara Falls Art Gallery's (NFAG) in-schools and Children's Museum programmes. These community resources service the elementary levels of participatory Public, Catholic and French schools in the Niagara Peninsula. The goal of this research was to find ways in which these teachers could explore their creative potential as art educators. The "click," a term introduced by participants indicating the coming together of all positive factors towards creativity, became the central theme behind this study. Research revealed that the effective creative process was not merely a singular phase, but rather a series of 4 processes: 1 , gathering knowledge; 2, intuitive and experiential; 3, the informal presentation of information in which creativity as a process was explored; and 4, formal presentation that took the analysis of information to a deeper, holistic level. To examine the ways in which experience and knowledge could be shared and brought together through a collaborative process, this study employed data collection that used literature research, interviews, focus group discussions, and personal journal entries. Follow-up discussions that assessed the effectiveness of action research, took place VA months after the initial meetings. It is hoped that this study might assist in creative educational practices, for myself as a member of the NFAG teaching team, for colleagues in the art programmes, art educators, and other teachers in the broader disciplines of education.

Completing the picture: the effects of video game practice on verbal and performance I.Q. scores in high functioning children

The strength and nature of the video game practice effect on tests of visual and perceptual skills were examined using high functioning Grades Four and Five students who had been tested with the WISC-R .for the purpose of gifted identification and placement. The control group, who did not own and .play video games on a sustained basis, and the experimental group, who did own a video game system and had some mastery of video games, including the -Nintendo game, "Tetris", were each composed of 18 juniorg:r;-ade students and were chosen from pre-existing conditions. The experimental group corresponded to the control group in terms of age, sex, and community. Data on the Verbal and Performance I.Q. Scores were· collected for both groups and the author was interested in the difference between the Verbal and Performance Scores within each group, anticipating a P > V outcome for the experimental group. The results showed a significant P > V difference in the experimental, video game playing group, as expected, but no significant difference between the Performance $cores of the control and experimental groups. The results, thus, indicated lower Verbal I.Q. Scores in the experimental group relat'ive to 'the control group.' The study conclu~ed that information about a sUbject's video game experience and "learhing style pref~rence is important for a clear interpretation of the Verbal and Performance I.Q. Scores of the WISC-R. Although the time spent on video game play may, 'indeed, increase P~rformance Scores relative to Verbal Scores for an individual, the possibilities exist that the time borrowed and spent away from language based activities may retard verbal growth and/or that the cognitive style associated with some Performance I.Q.subtests may have a negative effect on the approach to the tasks on the Verbal I.Q. Scale. The study also discussed the possibility that exposure to ,the video game experience, in pre-puberty, can provide spatial instruction which will result in improved spatial skills. strong spatial skills have been linked to improved performance and preference in mathematics, science, and engineering and it was suggested that appropriate video game play might be a way to involve girls more in the fields of mathematics and science.

The examination of assumptions in clinical nursing practice

This was a study designed to identify and explore the assumptions that Registered Nurses have about their current nursing role and practice. A qualitative case study approach was used to gather descriptive data. Thirteen study participants completed the indicators of critical thinking exercise and participated in a group session in which they identified positive and negative critical incidents in their clinical practice. The analysis of the anecdotes that were generated from the critical incident exercises revealed ten assumptions held by the Registered Nurses about their nursing practice. The ten assumptions were reflected back to the study participants to determine their level of agreement with each assumption. The ten assumptions were supported by the majority of the respondents. The Registered Nurses in this study appraised themselves affirmatively on eight out of nine indicators of critical thinking.

Verbal ability, previous practice and load on short-term memory as determiners of differences in a complex learning task: an experimental study

Traditional psychometric theory and practice classify people according to broad ability dimensions but do not examine how these mental processes occur. Hunt and Lansman (1975) proposed a 'distributed memory' model of cognitive processes with emphasis on how to describe individual differences based on the assumption that each individual possesses the same components. It is in the quality of these components ~hat individual differences arise. Carroll (1974) expands Hunt's model to include a production system (after Newell and Simon, 1973) and a response system. He developed a framework of factor analytic (FA) factors for : the purpose of describing how individual differences may arise from them. This scheme is to be used in the analysis of psychometric tes ts . Recent advances in the field of information processing are examined and include. 1) Hunt's development of differences between subjects designated as high or low verbal , 2) Miller's pursuit of the magic number seven, plus or minus two, 3) Ferguson's examination of transfer and abilities and, 4) Brown's discoveries concerning strategy teaching and retardates . In order to examine possible sources of individual differences arising from cognitive tasks, traditional psychometric tests were searched for a suitable perceptual task which could be varied slightly and administered to gauge learning effects produced by controlling independent variables. It also had to be suitable for analysis using Carroll's f ramework . The Coding Task (a symbol substitution test) found i n the Performance Scale of the WISe was chosen. Two experiments were devised to test the following hypotheses. 1) High verbals should be able to complete significantly more items on the Symbol Substitution Task than low verbals (Hunt, Lansman, 1975). 2) Having previous practice on a task, where strategies involved in the task may be identified, increases the amount of output on a similar task (Carroll, 1974). J) There should be a sUbstantial decrease in the amount of output as the load on STM is increased (Miller, 1956) . 4) Repeated measures should produce an increase in output over trials and where individual differences in previously acquired abilities are involved, these should differentiate individuals over trials (Ferguson, 1956). S) Teaching slow learners a rehearsal strategy would improve their learning such that their learning would resemble that of normals on the ,:same task. (Brown, 1974). In the first experiment 60 subjects were d.ivided·into high and low verbal, further divided randomly into a practice group and nonpractice group. Five subjects in each group were assigned randomly to work on a five, seven and nine digit code throughout the experiment. The practice group was given three trials of two minutes each on the practice code (designed to eliminate transfer effects due to symbol similarity) and then three trials of two minutes each on the actual SST task . The nonpractice group was given three trials of two minutes each on the same actual SST task . Results were analyzed using a four-way analysis of variance . In the second experiment 18 slow learners were divided randomly into two groups. one group receiving a planned strategy practioe, the other receiving random practice. Both groups worked on the actual code to be used later in the actual task. Within each group subjects were randomly assigned to work on a five, seven or nine digit code throughout. Both practice and actual tests consisted on three trials of two minutes each. Results were analyzed using a three-way analysis of variance . It was found in t he first experiment that 1) high or low verbal ability by itself did not produce significantly different results. However, when in interaction with the other independent variables, a difference in performance was noted . 2) The previous practice variable was significant over all segments of the experiment. Those who received previo.us practice were able to score significantly higher than those without it. J) Increasing the size of the load on STM severely restricts performance. 4) The effect of repeated trials proved to be beneficial. Generally, gains were made on each successive trial within each group. S) In the second experiment, slow learners who were allowed to practice randomly performed better on the actual task than subjeots who were taught the code by means of a planned strategy. Upon analysis using the Carroll scheme, individual differences were noted in the ability to develop strategies of storing, searching and retrieving items from STM, and in adopting necessary rehearsals for retention in STM. While these strategies may benef it some it was found that for others they may be harmful . Temporal aspects and perceptual speed were also found to be sources of variance within individuals . Generally it was found that the largest single factor i nfluencing learning on this task was the repeated measures . What e~ables gains to be made, varies with individuals . There are environmental factors, specific abilities, strategy development, previous learning, amount of load on STM , perceptual and temporal parameters which influence learning and these have serious implications for educational programs .

Job satisfaction among nurses and its relationship to reflective practice /

This study was undertaken to explore job satisfaction among nurses and its relationship to reflective practice. It is a qualitative study that listens to the perspectives of 7 mental health nurses who work In a conmiunity hospital in southern Ontario. A pilot survey was conducted prior to the face-to -face interviews in order to develop meaningful questions to utilize in the interviews. Nurses participating in the study were ensured anonjnnlty and an opportunity to have their own personal perspectives heard. A convenient sample was obtained from the hospital in which the researcher worked as an educator and professional practice consultant. The concept of job satisfaction was found to be driven by the desire to do important work and to make a difference in patients' lives. The nurses articulated that it is directly related to other factors, such as the opportunity to work in one's area, of preference, involvement in decisionmaking processes, better patient/ staff ratios, and affordable, accessible continuing educational opportunities. Those nurses who have embraced reflective practice for many years seem to be able to sort out that which drives them to stay in nursing and that which will influence them to leave. The constraints of the study cO-e that it is a small qualitative study; therefore, the results are not generallzable. Reflection is integral to the practice of mental heallth nursing find a tool that is used extensively in therapy with patients. Future research could involve studing a different group of nurses who may be more task focused than mental health nurses.

Occupational therapist and client experiences of a mental health group

The purpose of this qualitative study was to understand the client and occupational therapist experiences of a mental health group. A secondary aim was to explore the extent to which this group seemed to have reflected a client-centred approach. The topic emerged from personal and professional issues related to the therapist as teacher and to inconsistencies in practice with the profession's client-centred philosophy. This philosophy, the study's frame of reference, was established in terms of themes related to the client-therapist relationship and to client values. Typical practice was illustrated through an extensive literature review. Structured didacticexperiential methods aiming toward skill development were predominant. The interpretive sciences and, to a lesser extent, the critical sciences directed the methodology. An ongoing support group at a community mental health clinic was selected as the focus of the study; the occupational therapist leader and three members became the key participants. A series of conversational interviews, the . core method of data collection, was supplemented by observation, document review, further interviews, and fieldnotes. Transcriptions of conversations were returned to participants for verification and for further reflection. Analysis primarily consisted of coding and organizing data according to emerging themes. The participants' experiences of group, presented as narrative stories within a group session vignette, were also returned to participants. There was a common understanding of the group's structure and the importance of having "air time" within the group; however, differences in perceptions of such things as the importance of the group in members' lives were noted. All members valued the therapeutic aspects of group, the role of group as weekly activity and, to a lesser extent, the learning that came from group. The researcher's perspective provided a critique of the group experience from a client-centred perspective. Some areas of consistency with client-centred practice were noted (e.g., therapist attitudes); however the group seemed to function far from a client-centred ideal. Members held little authority in a relationship dominated by the leaders, and leader agendas rather than member values controlled the session. Possible reasons for this discrepancy ranging from past health care encounters through to co-leader discord emerged. The actual and potential significance of this study was discussed according to many areas of implications: to OT practice, especially client-centred group practice, to theory development, to further areas of research and methodology considerations, to people involved in the group and to my personal growth and development.

Adult Learning in the Transformational Environments of the Digital Revolution: Connecting Theory and Practice

The purpose of this study was to investigate the learning preferences and the post-secondary educational experiences of a group of Net-Gen adult learners, aged between 18 and 35, currently working in the knowledge economy workplace, and their assessment of how adequately they were prepared to meet the requirements of the knowledge economy workplace. This study utilized an explanatory mixed-method research design. Participants completed a questionnaire providing information on their self-reported learning style preferences, their use of digital tools for formal and informal learning, their use of digital technologies in postsecondary educational experiences, and their use of digital technologies in their workplace. Four volunteers from the questionnaire respondents were selected to participate in interviews based on the diversity of their experiences in higher education, including digital environments, and the diversity of their knowledge economy workplaces. Data collected from the questionnaire were analyzed for descriptive and demographic statistics, and categorized so that common patterns could be identified from information gathered from the online questionnaire and interviews. Findings based on this study indicated that these Net-Gen adult learners were fluent with all types of digital technologies in collaborative environments, expecting their educational experiences to provide a similar experience. Participants clearly expressed an understanding that digital/collaborative aptitudes are essential to successful employment in the knowledge economy workplace. The findings of this study indicated that the majority of participants felt that their post-secondary educational experiences did not adequately prepare them to meet the expectations of this type of working environment.

A Narrative Study of Patient Encounter Accounts of Physicians, Nurses, and Medical Receptionists after Two Decades of a Paradigm of Patient-Centered Care

Despite recent well-known advancements in patient care in the medical fields, such as patient-centeredness and evidence-based medicine and practice, there is rather less known about their effects on the particulars of clinician-patient encounters. The emphasis in clinical encounters remains mostly on treatment and diagnosis and less on communicative competency or engagement for medical professionals. The purpose of this narrative study was to explore interactive competencies in diagnostic and therapeutic encounters and intake protocols within the context of the physicians’, nurses’, and medical receptionists’ perspectives and experiences. Literature on narrative medicine, phenomenology and medicine, therapeutic relationships, cultural and communication competency, and non-Western perspectives on human communication provided the guiding theoretical frameworks for the study. Three data sets including 13 participant interviews (5 physicians, 4 nurses, and 4 medical receptionists), policy documents (physicians, nurses, and medical receptionists) and a website (Communication and Cultural Competency) were used. The researcher then engaged in triangulated analyses, including N-Vivo, manifest and latent, Mishler’s (1984, 1995) narrative elements and Charon’s (2005, 2006a, 2006b, 2013) narrative themes, in recursive, overlapping, comparative and intersected analysis strategies. A common factor affecting physicians’ relationships with their clients was limitation of time, including limited time (a) to listen, (b) to come up with a proper diagnosis, and (c) to engage in decision making in critical conditions and limited time for patients’ visits. For almost all nurse participants in the study establishing therapeutic relationships meant being compassionate and empathetic. The goals of intake protocols for the medical receptionists were about being empathetic to patients, being an attentive listener, developing rapport, and being conventionally polite to patients. Participants with the least iv amount of training and preparation (medical receptionists) appeared to be more committed to working narratively in connecting with patients and establishing human relationships as well as in listening to patients’ stories and providing support to narrow down the reason for their visit. The diagnostic and intake “success stories” regarding patient clinical encounters for other study participants were focused on a timely securing of patient information, with some acknowledgement of rapport and emapathy. Patient-centeredness emerged as a discourse practice, with ambiguous or nebulous enactment of its premises in most clinical settings.

Interprofessional Collaboration: The Experience of Nursing and Medical Students’ Interprofessional Education

In this hermeneutic phenomenological study, we examined the experience of interprofessional collaboration from the perspective of nursing and medical students. Seventeen medical and nursing students from two different universities participated in the study. We used guiding questions in face-to-face, conversational interviews to explore students’ experience and expectations of interprofessional collaboration within learning situations. Three themes emerged from the data: the great divide, learning means content, and breaking the ice. The findings suggest that the experience of interprofessional collaboration within learning events is influenced by the natural clustering of shared interests among students. Furthermore, the carry-forward of impressions about physician–nurse relationships prior to the educational programs and during clinical placements dominate the formation of new relationships and acquisition of new knowledge about roles, which might have implications for future practice.

L’acceptation des rôles de l’infirmière praticienne en première ligne selon les caractéristiques socio-démographiques des usagers de CLSC

Le but de cette étude était de mesurer le niveau d’acceptation des rôles de l’infirmière praticienne de première ligne (IPPL) par les usagers de CLSC, selon les caractéristiques socio-démographiques de ceux-ci. La collecte de données pour cette recherche synthétique comparative s’est effectuée dans cinq CLSC de la région montréalaise par des questionnaires auto-administrés. L’échantillon accidentel est composé de 316 personnes de 18 ans et plus, se présentant au CLSC pour un problème de santé. Ces personnes étaient sollicitées par des affiches ou par des suggestions de la réceptionniste dans les salles d’attente. Les résultats révèlent que près de 40% de l’échantillon acceptent tous les rôles de l’IPPL. Des analyses de régression logistique montrent que les personnes ayant un revenu annuel élevé (supérieur à 40000$) sont plus susceptibles d’accepter tous les rôles de l’IPPL. Ces résultats vont permettre aux décideurs de prendre les mesures nécessaires pour implanter ce nouveau groupe professionnel ; ils peuvent également aider les IPPL à concevoir des stratégies pour faire une promotion efficiente de leur rôle en pratique avancée auprès de la population.

Le rôle de l’évaluation économique dans la pratique des médecins de famille = The role of economic evaluation in the practice of family physicians

L’évaluation économique en santé consiste en l’analyse comparative d’alternatives de services en regard à la fois de leurs coûts et de leurs conséquences. Elle est un outil d’aide à la décision. La grande majorité des décisions concernant l’allocation des ressources sont prises en clinique; particulièrement au niveau des soins primaires. Puisque chaque décision est associée à un coût d’opportunité, la non-prise en compte des considérations économiques dans les pratiques des médecins de famille peut avoir un impact important sur l’efficience du système de santé. Il existe peu de connaissances quant à l’influence des évaluations économiques sur la pratique clinique. L’objet de la thèse est de comprendre le rôle de l’évaluation économique dans la pratique des médecins de famille. Ses contributions font l’objet de quatre articles originaux (philosophique, théorique, méthodologique et empirique). L’article philosophique suggère l’importance des questions de complexité et de réflexivité en évaluation économique. La complexité est la perspective philosophique, (approche générale épistémologique) qui sous-tend la thèse. Cette vision du monde met l’attention sur l’explication et la compréhension et sur les relations et les interactions (causalité interactive). Cet accent sur le contexte et le processus de production des données souligne l’importance de la réflexivité dans le processus de recherche. L’article théorique développe une conception nouvelle et différente du problème de recherche. L’originalité de la thèse réside également dans son approche qui s’appuie sur la perspective de la théorie sociologique de Pierre Bourdieu; une approche théorique cohérente avec la complexité. Opposé aux modèles individualistes de l’action rationnelle, Bourdieu préconise une approche sociologique qui s’inscrit dans la recherche d’une compréhension plus complète et plus complexe des phénomènes sociaux en mettant en lumière les influences souvent implicites qui viennent chaque jour exercer des pressions sur les individus et leurs pratiques. L’article méthodologique présente le protocole d’une étude qualitative de cas multiples avec niveaux d’analyse imbriqués : les médecins de famille (niveau micro-individuel) et le champ de la médecine familiale (niveau macro-structurel). Huit études de cas furent réalisées avec le médecin de famille comme unité principale d’analyse. Pour le niveau micro, la collecte des informations fut réalisée à l’aide d’entrevues de type histoire de vie, de documents et d’observation. Pour le niveau macro, la collecte des informations fut réalisée à l’aide de documents, et d’entrevues de type semi-structuré auprès de huit informateurs clés, de neuf organisations médicales. L’induction analytique fut utilisée. L’article empirique présente l’ensemble des résultats empiriques de la thèse. Les résultats montrent une intégration croissante de concepts en économie dans le discours officiel des organisations de médecine familiale. Cependant, au niveau de la pratique, l'économisation de ce discours ne semble pas être une représentation fidèle de la réalité puisque la très grande majorité des participants n'incarnent pas ce discours. Les contributions incluent une compréhension approfondie des processus sociaux qui influencent les schèmes de perception, de pensée, d’appréciation et d’action des médecins de famille quant au rôle de l’évaluation économique dans la pratique clinique et la volonté des médecins de famille à contribuer à une allocation efficiente, équitable et légitime des ressources.