Somerset Medical Center

BACKGROUND: Interviews are among the most familiar strategies for collecting qualitative data. The different qualitative interviewing strategies in common use emerged from diverse disciplinary perspectives resulting in a wide variation among interviewing approaches. Unlike the highly structured survey interviews and questionnaires used in epidemiology and most health services research, we examine less structured interview strategies in which the person interviewed is more a participant in meaning making than a conduit from which information is retrieved. PURPOSE: In this article we briefly review the more common qualitative interview methods and then focus on the widely used individual face-to-face in-depth interview, which seeks to foster learning about individual experiences and perspectives on a given set of issues. We discuss methods for conducting in-depth interviews and consider relevant ethical issues with particular regard to the rights and protection of the participants.

PURPOSE: We wanted to review and synthesize published criteria for good qualitative research and develop a cogent set of evaluative criteria. METHODS: We identified published journal articles discussing criteria for rigorous research using standard search strategies then examined reference sections of relevant journal articles to identify books and book chapters on this topic. A cross-publication content analysis allowed us to identify criteria and understand the beliefs that shape them. RESULTS: Seven criteria for good qualitative research emerged: (1) carrying out ethical research; (2) importance of the research; (3) clarity and coherence of the research report; (4) use of appropriate and rigorous methods; (5) importance of reflexivity or attending to researcher bias; (6) importance of establishing validity or credibility; and (7) importance of verification or reliability. General agreement was observed across publications on the first 4 quality dimensions. On the last 3, important divergent perspectives were observed in how these criteria should be applied to qualitative research, with differences based on the paradigm embraced by the authors. CONCLUSION: Qualitative research is not a unified field. Most manuscript and grant reviewers are not qualitative experts and are likely to embrace a generic set of criteria rather than those relevant to the particular qualitative approach proposed or reported. Reviewers and researchers need to be aware of this tendency and educate health care researchers about the criteria appropriate for evaluating qualitative research from within the theoretical and methodological framework from which it emerges.

The synthesis and functionalization of amines are fundamentally important in a vast range of chemical contexts. We present an amine synthesis that repurposes two simple feedstock building blocks: olefins and nitro(hetero)arenes. Using readily available reactants in an operationally simple procedure, the protocol smoothly yields secondary amines in a formal olefin hydroamination. Because of the presumed radical nature of the process, hindered amines can easily be accessed in a highly chemoselective transformation. A screen of more than 100 substrate combinations showcases tolerance of numerous unprotected functional groups such as alcohols, amines, and even boronic acids. This process is orthogonal to other aryl amine syntheses, such as the Buchwald-Hartwig, Ullmann, and classical amine-carbonyl reductive aminations, as it tolerates aryl halides and carbonyl compounds.

The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices' internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare. The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care. The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following: Giving primacy to the core tenets of primary care. Assessing practice and system changes that are hypothesized to provide added value Assessing development of practices' core processes and adaptive reserve. Assessing integration with more functional healthcare system and community resources. Evaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspects. Recognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings. Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

In Brief Study Design. A randomized, controlled, prospective multicenter trial comparing the outcomes of neurogenic intermittent claudication (NIC) patients treated with the interspinous process decompression system (X STOP) with patients treated nonoperatively. Objective. To determine the safety and efficacy of the X STOP interspinous implant. Summary of Background Data. Patients suffering from NIC secondary to lumbar spinal stenosis have been limited to a choice between nonoperative therapies and decompressive surgical procedures, with or without fusion. The X STOP was developed to provide an alternative therapeutic treatment. Methods. 191 patients were treated, 100 in the X STOP group and 91 in the control group. The primary outcomes measure was the Zurich Claudication Questionnaire, a patient-completed, validated instrument for NIC. Results. At every follow-up visit, X STOP patients had significantly better outcomes in each domain of the Zurich Claudication Questionnaire. At 2 years, the X STOP patients improved by 45.4% over the mean baseline Symptom Severity score compared with 7.4% in the control group; the mean improvement in the Physical Function domain was 44.3% in the X STOP group and −0.4% in the control group. In the X STOP group, 73.1% patients were satisfied with their treatment compared with 35.9% of control patients. Conclusions. The X STOP provides a conservative yet effective treatment for patients suffering from lumbar spinal stenosis. In the continuum of treatment options, the X STOP offers an attractive alternative to both conservative care and decompressive surgery. A randomized, controlled, prospective multi-center trial of neurogenic intermittent claudication patients was conducted to compare the safety and efficacy of the interspinous implant with nonoperative therapy. At 2-year follow-up, the interspinous implant treatment was significantly more effective in improving the symptoms and function of neurogenic intermittent claudication patients when compared with nonoperative therapy, and safety was comparable.

OBJECTIVE: The epidemiology of chronic constipation in the elderly remains poorly defined. We aimed to study the prevalence of, and potential risk factors for, constipation in a representative elderly community, using symptom-based diagnostic criteria. METHODS: An age and gender-stratified random sample of 1833 eligible residents of Olmsted County, Minnesota, aged 65 yr and over, was mailed a valid self-report questionnaire; 1375 responded (75%). RESULTS: The overall age- and gender-adjusted prevalence (per 100) of any constipation was 40.1 (95% CI 38.9, 44.4); for functional constipation and outlet difficulty or delay, the prevalence rates were 24.4 (95% CI 22.0-26.9) and 20.5 (95% CI 18.2-22.8), respectively. Self-reported constipation did not reliably identify functional constipation or outlet delay. Outlet delay, but not functional constipation, was more frequent in women; functional constipation, but not outlet delay, was associated with advancing age. Nonsteroidal anti-inflammatory drugs and other medications were significant risk factors in subjects with functional constipation and outlet delay combined. CONCLUSIONS: In independently living, elderly persons, constipation is a common complaint; among these subjects, there appear to be symptom subgroups that can be identified.

OBJECTIVE: Reasons for failing to initiate prescribed insulin (primary nonadherence) are poorly understood. We investigated barriers to insulin initiation following a new prescription. RESEARCH DESIGN AND METHODS: We surveyed insulin-naïve patients with poorly controlled type 2 diabetes, already treated with two or more oral agents who were recently prescribed insulin. We compared responses for respondents prescribed, but never initiating, insulin (n = 69) with those dispensed insulin (n = 100). RESULTS: Subjects failing to initiate prescribed insulin commonly reported misconceptions regarding insulin risk (35% believed that insulin causes blindness, renal failure, amputations, heart attacks, strokes, or early death), plans to instead work harder on behavioral goals, sense of personal failure, low self-efficacy, injection phobia, hypoglycemia concerns, negative impact on social life and job, inadequate health literacy, health care provider inadequately explaining risks/benefits, and limited insulin self-management training. CONCLUSIONS: Primary adherence for insulin may be improved through better provider communication regarding risks, shared decision making, and insulin self-management training.

Nature Communications 5: Article number: 3513 (2014); Published: 29 April 2016; Updated: 31 October 2016 This article was published without any competing financial interests statement. A revised declaration that lists potentially competing financial interests is provided below: A.D.M., M.M. and M.A.are affiliated with Bcs Biotech S.

A statistical theory for crosstalk in multicore fibers is derived from coupled-mode equations including bend-induced perturbations. Bends are shown to play a crucial role in crosstalk, explaining large disagreement between experiments and previous calculations. The average crosstalk of a fiber segment is related to the statistics of the bend radius and orientation, including spinning along the fiber length. This framework allows efficient and accurate estimates of cross-talk for realistic telecommunications links.

One hundred and seventy‐eight (178) Rh‐negative volunteers, distributed into a treated and control series of six groups each, were studied to establish: (i) approximately 70 per cent of Rh‐negative individuals are susceptible to being immunized by a single injection of Rh‐positive blood; (ii) that, for immunologically susceptible individuals, the frequency of immunization increases with the volume of Rh‐positive erythrocytes administered; and (iii) that a possible relationship exists between potency of Rh immune globulin and effectivity. This relationship can be used to calculate an effective dose of Rh immune globulin in the treatment of large feto‐maternal hemorrhages or accidental tranfusions of Rh‐positive blood to Rh‐negative women.

Cervical cancer is the third most common cause of cancer in women in the world. During the past few decades tremendous strides have been made toward decreasing the incidence and mortality of cervical cancer with the implementation of various prevention and screening strategies. The causative agent linked to cervical cancer development and its precursors is the human papillomavirus (HPV). Prevention and screening measures for cervical cancer are paramount because the ability to identify and treat the illness at its premature stage often disrupts the process of neoplasia. Cervical carcinogenesis can be the result of infections from multiple high-risk HPV types that act synergistically. This imposes a level of complexity to identifying and vaccinating against the actual causative agent. Additionally, most HPV infections spontaneously clear. Therefore, screening strategies should optimally weigh the benefits and risks of screening to avoid the discovery and needless treatment of transient HPV infections. This article provides an update of the preventative and screening methods for cervical cancer, mainly HPV vaccination, screening with Pap smear cytology, and HPV testing. It also provides a discussion of the newest United States 2012 guidelines for cervical cancer screening, which changed the age to begin and end screening and lengthened the screening intervals.

This paper describes mathematical and computational methodology for estimating the parameters of the Burr Type XII distribution by the method of maximum likelihood. Expressions for the asymptotic variances and covariances of the parameter estimates are given, and the modality of the log‐likelihood and conditional log‐likelihood functions is analyzed. As a result of this analysis for various a priori known and unknown parameter combinations, conditions are given which guarantee that the parameter estimates obtained will, indeed, be maximum likelihood estimates. An efficient numerical method for maximizing the conditional log‐likelihood function is described, and mathematical expressions are given for the various numerical approximations needed to evaluate the expressions given for the asymptotic variances and covariances of the parameter estimates. The methodology discussed is applied in a numerical example to life test data arising in a clinical setting.

High-power fiber lasers operating at the 1.5 μm wavelength region have attractive features, such as eye safety and atmospheric transparency, and cascaded Raman fiber lasers offer a convenient method to obtain high-power sources at these wavelengths. A limitation to power scaling, however, has been the lower conversion efficiency of these lasers. We recently introduced a high-efficiency architecture for high-power cascaded Raman fiber lasers applicable for 1.5 μm fiber lasers. Here we demonstrate further power scaling using this new architecture. Using numerical simulations, we identify the ideal operating conditions for the new architecture. We demonstrate a high-efficiency 1480 nm cascaded Raman fiber laser with an output power of 301 W, comparable to record power levels achieved with rare-earth-doped fiber lasers in the 1.5 μm wavelength region.

The incidence of Rh immunization of Rh‐negative volunteers given approximately 500 ml of Rh‐positive blood is 18 out of 22. Complete Rh immune suppression was achieved in a treated group given a precalculated dose of Rh immune globulin. Rh immune prophylaxis is safe, effective and practical after transfusion accidents or massive fetomaternal hemorrhages where large volumes of Rh‐positive blood enter the circulation of Rh‐negative individuals. The dose of RhoGAM,* Rho(D) Immune Globulin (Human) found to be effective in suppressing an immune response to the Rh factor was 20 μg/ml of red blood cells (not whole blood). Since each vial contains no less than 300 μg of anti‐Rho(D), the potency for RhoGAM is 15 ml of red blood cells/vial.

Smoking cessation is crucial for reducing cancer risk and premature mortality. The US Preventive Services Task Force (USPSTF) has recommended annual lung cancer screening with low-dose computed tomography (LDCT), and the Center for Medicare and Medicaid Services recently approved lung screening as a benefit for patients ages 55 to 77 years who have a 30 pack-year history. The Society for Research on Nicotine and Tobacco (SRNT) and the Association for the Treatment of Tobacco Use and Dependence (ATTUD) developed the guideline described in this commentary based on an illustrative literature review to present the evidence for smoking-cessation health benefits in this high-risk group and to provide clinical recommendations for integrating evidence-based smoking-cessation treatment with lung cancer screening. Unfortunately, extant data on lung cancer screening participants were scarce at the time this guideline was written. However, in this review, the authors summarize the sufficient evidence on the benefits of smoking cessation and the efficacy of smoking-cessation interventions for smokers ages 55 to 77 years to provide smoking-cessation interventions for smokers who seek lung cancer screening. It is concluded that smokers who present for lung cancer screening should be encouraged to quit smoking at each visit. Access to evidence-based smoking-cessation interventions should be provided to all smokers regardless of scan results, and motivation to quit should not be a necessary precondition for treatment. Follow-up contacts to support smoking-cessation efforts should be arranged for smokers. Evidence-based behavioral strategies should be used at each visit to motivate smokers who are unwilling to try quitting/reducing smoking or to try evidence-based treatments that may lead to eventual cessation.

Abstract Breast cancer risk has traditionally been linked to nulliparity or late first full-term pregnancy, whereas young age at first childbirth, multiparity, and breast-feeding are associated with a reduced risk. Early pregnancy confers protection by inducing breast differentiation, which imprints a specific and permanent genomic signature in experimental rodent models. For testing whether the same phenomenon was detectable in the atrophic breast of postmenopausal parous women, we designed a case-control study for the analysis of the gene expression profile of RNA extracted from epithelial cells microdissected from normal breast tissues obtained from 18 parous and 7 nulliparous women free of breast pathology (controls), and 41 parous and 8 nulliparous women with history of breast cancer (cases). RNA was hybridized to cDNA glass microarrays containing 40,000 genes; arrays were scanned and the images were analyzed using ImaGene software version 4.2. Normalization and statistical analysis were carried out using Linear Models for Microarrays and GeneSight software for hierarchical clustering. The parous control group contained 2,541 gene sequences representing 18 biological processes that were differentially expressed in comparison with the other three groups. Hierarchical clustering of these genes revealed that the combined parity/absence of breast cancer data generated a distinct genomic profile that differed from those of the breast cancer groups, irrespective of parity history, and from the nulliparous cancer-free group, which has been traditionally identified as a high-risk group. The signature that identifies those women in whom parity has been protective will serve as a molecular biomarker of differentiation for evaluating the potential use of preventive agents. (Cancer Epidemiol Biomarkers Prev 2008;17(1):51–66)

Paradoxical tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) was first described almost two decades ago. We undertook this systematic review and meta-analysis to collate findings across studies that have reported the incidence, clinical features, management and outcomes of paradoxical TB-IRIS. Forty studies that cumulatively reported 1048 paradoxical TB-IRIS cases were included. The pooled estimated incidence among patients with HIV-associated TB initiating antiretroviral therapy was 18% (95% CI: 16-21%). Frequent features were pulmonary and lymph node involvement. Hospitalization occurred in 25% (95% CI: 19-30%). In studies that reported treatment, corticosteroids were prescribed more frequently (38%; 95% CI: 27-48%) than nonsteroidal anti-inflammatory drugs (28%; 95% CI: 2-53%). Case fatality was 7% (95% CI: 4-11%), but death attributed to TB-IRIS occurred in 2% of cases (95% CI: 1-3%).

Background Reducing emergency admissions to hospital has been a cornerstone of healthcare policy. Little evidence exists to show that systematic interventions across a population have achieved this aim. The authors report the impact of a complex intervention over a 44-month period in Frome, Somerset, on unplanned admissions to hospital. Aim To evaluate a population health complex intervention of an enhanced model of primary care and compassionate communities on population health improvement and reduction of emergency admissions to hospital. Design and setting A cohort retrospective study of a complex intervention on all emergency admissions in Frome Medical Practice, Somerset, compared with the remainder of Somerset, from April 2013 to December 2017. Method Patients were identified using broad criteria, including anyone giving cause for concern. Patient-centred goal setting and care planning combined with a compassionate community social approach was implemented broadly across the population of Frome. Results There was a progressive reduction, by 7.9 cases per quarter (95% confidence interval [CI] = 2.8 to 13.1, P = 0.006), in unplanned hospital admissions across the whole population of Frome during the study period from April 2013 to December 2017, a decrease of 14.0%. At the same time, there was a 28.5% increase in admissions per quarter within Somerset, with a rise in the number of unplanned admissions of 236 per quarter (95% CI = 152 to 320, P <0.001). Conclusion The complex intervention in Frome was associated with highly significant reductions in unplanned admissions to hospital, with a decrease in healthcare costs across the whole population of Frome.

BACKGROUND: Hidradenitis suppurativa (HS) is a disease associated with significant patient morbidity and less-than-ideal therapies. OBJECTIVES: To determine the long- and short-term benefits of carbon dioxide (CO(2)) laser excision and marsupialization in the management of persisent lesions of HS. METHODS: Patients with long-standing lesions of HS were treated using a CO(2) laser to excise inflammatory and draining masses. RESULTS: One hundred eighty-five areas were treated in 61 patients using the CO(2) laser excision and marsupialization technique in 154 sessions. Local anesthesia was used for all but three sessions. Healing occurred primarily through secondary intention. In follow-up from 1 to 19 years, acceptable to excellent qualities of healing occurred. Recurrence within the treated area occurred in two of 185 sites treated. CONCLUSION: CO(2) laser excision and marsupialization appears to be an effective therapy for management of persisent or late-stage HS. There was good patient comfort during and after treatment, lower costs than with inpatient modalities, good healing, and minimal risk of recurrence within the treated areas.

AIM: To identify and describe gender-related differences in the self-esteem and optimism levels of rural adolescents. BACKGROUND: Self-esteem and optimism have been broadly examined and are associated with health-practices, social interaction, attachment, resiliency, and personal identity. Information describing the relationship of self-esteem and optimism as it relates to gender is limited. METHODS: Using a cross-sectional survey design, students (N = 193) from three high-schools in rural Pennsylvania, USA completed the Rosenberg Self-Esteem Scale and the Optimism Scale-Life Orientation Test-Revised as part of a National Institute of Health, National Institute of Nursing Research funded study. RESULTS: Both instruments' mean scores were in the range of average for this population, with females scoring lower than males in both self-esteem (p < 0.0001) and optimism (p < 0.0001). The results of this study have nursing implications for evidenced based interventions that target self-esteem and optimism. Attention to self-esteem and optimism in female youth is recommended.