Strong Research Evidence Research Articles

The age‐21 minimum legal drinking age: a case study linking past and current debates

The minimum legal drinking age (MLDA) in the United States (U.S.) has raised debate over the past several decades. During the 1970s many states lowered their MLDAs from age 21 to 18, 19, or 20. However, as a result of studies showing that these lower MLDAs were associated with increases in traffic crashes, state-level movements began in the later1970s to return MLDAs to age 21. A new movement has arisen to again lower the MLDA in the U.S. Aim The aim is to discuss this current MLDA debate within the context of the long history of the U.S. MLDA. A search of research articles, websites, and newspaper articles was conducted to identify key messages and influences related to the MLDA movements. The complexity of state movements to change their MLDAs is illustrated by the Michigan experience, where strong political forces on both sides of the issue were involved, resulting in the MLDA returning to 21. Because the 21st Constitutional amendment prevents the federal government from mandating a MLDA for all states, a federal policy was proposed to provide incentives for all states to implement age-21 MLDAs. Due largely to strong research evidence, the National Minimum Legal Drinking Age Act was enacted in 1984, stipulating that states set their MLDA to 21 or face loss of federal highway funds. By 1988, all states had an age-21 MLDA. Any current debate about the MLDA should be informed by the historical context of this policy and the available research.

Community-Based Services for Homeless Adults Experiencing Concurrent Mental Health and Substance Use Disorders: A Realist Approach to Synthesizing Evidence

Consultations with community-based service providers in Toronto identified a lack of strong research evidence about successful community-based interventions that address the needs of homeless clients experiencing concurrent mental health and substance use disorders. We undertook a collaborative research effort between academic-based and community-based partners to conduct a systematic evidence synthesis drawing heavily from Pawson's realist review methodology to focus on both whether programs are successful and why and how they lead to improved outcomes. We examined scholarly and nonscholarly literature to explore program approaches and program elements that lead to improvements in mental health and substance use disorders among homeless individuals with concurrent disorders (CD). Information related to program contexts, elements, and successes and failures were extracted and further supplemented by key informant interviews and author communication regarding reviewed published studies. From the ten programs that we reviewed, we identified six important and promising program strategies that reduce mental health and, to a far lesser degree, substance use problems: client choice in treatment decision-making, positive interpersonal relationships between client and provider, assertive community treatment approaches, providing supportive housing, providing supports for instrumental needs, and nonrestrictive program approaches. These promising program strategies function, in part, by promoting and supporting autonomy among homeless adults experiencing CD. Our realist informed review is a useful methodology for synthesizing complex programming information on community-based interventions.

The Floppy Infant: Evaluation of Hypotonia

Hypotonia is characterized by reduced resistance to passive range of motion in joints versus weakness, which is a reduction in the maximum muscle power that can be generated. (Dubowitz, 1985; Crawford, 1992; Martin, 2005) Based on strong research evidence, central hypotonia accounts for 60% to 80% of cases of hypotonia, whereas peripheral hypotonia is the cause in about 15% to 30% of cases. Disorders causing hypotonia often are associated with a depressed level of consciousness, predominantly axial weakness, normal strength accompanying the hypotonia, and hyperactive or normal reflexes. (Martin, 2005; Igarashi, 2004; Richer, 2001; Miller, 1992; Crawford, 1992; Bergen, 1985; Dubowitz, 1985) Based on some research evidence, 50% of patients who have hypotonia are diagnosed by history and physical examination alone. (Paro-Panjan, 2004) Based on some research evidence, an appropriate medical and genetic evaluation of hypotonia in infants includes a karyotype, DNA-based diagnostic tests, and cranial imaging. (Battaglia, 2008; Laugel, 2008; Birdi, 2005; Paro-Panjan, 2004; Prasad, 2003; Richer, 2001; Dimario, 1989) Based on strong research evidence, infant botulism should be suspected in an acute or subacute presentation of hypotonia in an infant younger than 6 months of age who has signs and symptoms such as constipation, listlessness, poor feeding, weak cry, and a decreased gag reflex. (Francisco, 2007; Muensterer, 2000)

Asthma, smoking and BMI in adults with intellectual disabilities: a community‐based survey

Recent research evidence from the general population has shown that tobacco smoking and raised body mass index (BMI) are associated with worse asthma outcomes. There are indications that asthma morbidity and mortality may be higher among people with intellectual disabilities (ID) than the general population, but the reason for this is not known. This is the first study to investigate the extent of smoking and higher than recommended BMI among adults with ID and a diagnosis of asthma. Health-related data for 1097 adults with ID were collected from 28 primary care practices in Bristol, UK. Prevalence of asthma in this sample of adults with ID was 12% which was much higher than among the general population living in the region. The 132 patients with asthma were found to be nearly twice as likely to be current smokers as patients with ID who did not have asthma (29.5% vs. 15.6%). Smoking rates were higher among men than women with asthma (35.7% vs. 22.6%). Patients diagnosed with asthma were also more likely to be obese (BMI >or= 30) than patients with ID but no asthma (42.7% vs. 31.6%). Obesity was particularly a problem among women with asthma as more than half (52.1%) had a BMI >or= 30. A very high proportion of patients with ID and asthma were found to be current smokers and/or obese. There is now strong research evidence that both smoking and obesity are implicated in the development of asthma and associated with worse disease outcomes. This study highlights the urgent need for programmes aimed at providing support for people with ID and asthma to stop smoking and to achieve a healthy body weight.

Research Evidence for the Use of Preoperative Exercise in Patients Preparing for Total Hip or Total Knee Arthroplasty

Preoperative exercise/rehabilitation is currently being considered to improve outcomes for orthopaedic surgery. This article presents an evidence-based practice review of the current research literature from 1998 to 2008 to determine whether preoperative exercise alone will be beneficial to patients preparing for total knee or hip arthroplasty. Only 3 studies met the inclusion criteria of preoperative exercise as the sole intervention. Each of these studies indicated that preoperative exercise had some postoperative benefit to total knee or hip arthroplasty patients. In general, the results are inconclusive due to the lack of strong research evidence, and only a pragmatic recommendation for preoperative exercise prior to total hip or knee arthroplasty is supported. More research is needed in the area of preoperative exercise for persons preparing for total hip or knee arthroplasty.

From the Editor-in-Chief: Leadership for the Information Age: The Time for Action is Now

Dr. Lynn Nagle, the Senior Nursing Advisor for Canada Health Infoway, writes the column on nursing informatics for this journal. She and I have both been involved in the development and now the implementation of HOBIC (Health Outcomes for Better Information and Care), a province-wide initiative funded by the Ontario Ministry of Health and Long-Term Care: I am the executive lead and Lynn is the informatics lead. HOBIC seeks to bring online functionality to nurses that supports systematic assessment of patients on eight outcomes upon admission and discharge in acute care, chronic hospital care, long-term care and home care, and quarterly for people in residential settings. There is strong research evidence that nurses make a difference in how well patients do on these outcomes. Nurses can now access the results of their assessments online throughout a patient's stay, compare them to other patients of similar age or gender and begin to set benchmarks for improving these outcomes. Unit managers and chief nursing officers receive an array of monthly reports on the admission and discharge status of patients - information that can also be reviewed on the basis of gender and age group. HOBIC will be a critical component of the electronic health record when it is wholly adopted throughout Ontario.

Management of Diabetic Ketoacidosis in Children and Adolescents: Figure.

* Based on some research evidence, DKA is a significant contributor to morbidity and mortality in children who have type 1 diabetes, and cerebral edema is responsible for most of the deaths during DKA in children. (Dunger, 2004). * Based on strong research evidence, treatment of DKA requires replacement of water and electrolytes and correction of the insulin deficiency. (Dunger, 2004). * Based on some research data and consensus opinion, after providing initial volume expansion (if needed), fluid resuscitation of children who have DKA should be calculated to rehydrate evenly over at least 48 hours. Initial fluid resuscitation should be with an isotonic solution; subsequent fluid management should be with a solution that has a tonicity of at least 0.45% saline. (Dunger, 2004). * Based on strong research evidence, insulin treatment for DKA should begin at a dose of 0.1 units/kg per hour and generally should remain at or above this level until the ketoacidosis is resolved. (Dunger, 2004). * Based on some research evidence, risk factors for the development of cerebral edema during treatment of DKA include the severity of acidosis, greater hypocapnia (after adjusting for the degree of acidosis), higher blood urea nitrogen concentration at presentation, and treatment with bicarbonate. (Dunger, 2004; Glaser, 2002).

UK consensus statement on the content of communication curricula in undergraduate medical education

The teaching and assessment of clinical communication have become central components of undergraduate medical education in the UK. This paper recommends the key content for an undergraduate communication curriculum. Designed by UK educationalists with UK schools in mind, the recommendations are equally applicable to communication curricula throughout the world. This paper is intended to assist curriculum planners in the design, implementation and review of medical communication curricula. The document will also be useful in the education of other health care professionals. Designed for undergraduate education, the consensus statement also provides a baseline for further professional development. The consensus statement, based on strong theoretical and research evidence, was developed by an iterative process of discussion between communication skills leads from all 33 UK medical schools conducted under the auspices of the UK Council of Clinical Communication Skills Teaching in Undergraduate Medical Education. How this framework is used will inevitably be at the discretion of each medical school and its implementation will be determined by different course designs. Although we believe students should be exposed to all the areas described, it would be impractical to set inflexible competency levels as these may be attained at different stages which are highly school-dependent. However, the framework will enable all schools to consider where different elements are addressed, where gaps exist and how to generate novel combinations of domains within the communication curriculum. It is hoped that this consensus statement will support the development and integration of teaching, learning and assessment of clinical communication.

Improving Colorectal Cancer Screening in Primary Care Practice: Innovative Strategies and Future Directions

Colorectal cancer (CRC) screening has been supported by strong research evidence and recommended in clinical practice guidelines for more than a decade. Yet screening rates in the United States remain low, especially relative to other preventable diseases such as breast and cervical cancer. To understand the reasons, the National Cancer Institute and Agency for Healthcare Research and Quality sponsored a review of CRC screening implementation in primary care and a program of research funded by these organizations. The evidence base for improving CRC screening supports the value of a New Model of Primary Care Delivery: 1. a team approach, in which responsibility for screening tasks is shared among other members of the practice, would help address physicians' lack of time for preventive care; 2. information systems can identify eligible patients and remind them when screening is due; 3. involving patients in decisions about their own care may enhance screening participation; 4. monitoring practice performance, supported by information systems, can help target patients at increased risk because of family history or social disadvantage; 5. reimbursement for services outside the traditional provider-patient encounter, such as telephone and e-mail contacts, may foster enhanced screening delivery; 6. training opportunities in communication, cultural competence, and use of information technologies would improve provider competence in core elements of screening programs. Improvement in CRC screening rates largely depends on the efforts of primary care practices to implement effective systems and procedures for screening delivery. Active engagement and support of practices are essential for the enormous potential of CRC screening to be realized.

Flightless I: An actin-remodelling protein and an important negative regulator of wound repair

Flightless I: An actin-remodelling protein and an important negative regulator of wound repair

Family interventions after acquired brain injury and other chronic conditions: A critical appraisal of the quality of the evidence

Family caregivers of individuals with acquired brain injury (ABI) and other chronic disabilities typically experience long-term adjustment difficulties within the entire family system. Interventions to assist parents and spouses are rare, and for siblings and offspring even more so. Among the few existing interventions, only a very small number have been evaluated in any scientifically sound manner for effectiveness in alleviating stress and burden. A highly targeted literature search of family caregiver intervention studies identified 31 articles, only four of which were in brain injury, which met specific inclusion criteria. Randomized controlled trial studies of six types of family caregiver interventions were systematically assessed for their quality of design and evidence of effectiveness. The results revealed a body of literature lacking in methodological rigor. At present there is no strong research evidence supporting any specific intervention method for family caregivers of individuals with ABI or any of the other chronic condition groups surveyed, although an abundance of anecdotal, descriptive, and quasi-experimental support exists in the rehabilitation literature. This conclusion points to the need for launching new pilot studies and rigorous evaluations of caregiver intervention effectiveness, some of which are now emerging or in process in several locations across the United States.

Fuel taxes: An important instrument for climate policy

Fuel taxes: An important instrument for climate policy

Critical thinking as an outcome of context-based learning among post RN students: A literature review

Critical thinking as an outcome of context-based learning among post RN students: A literature review

Psychological Outcomes for Women After Assisted Reproductive Technology Treatment

Psychological Outcomes for Women After Assisted Reproductive Technology Treatment

An Australian childhood obesity summit: the role of data and evidence in 'public' policy making.

BackgroundOverweight and obesity in Australia has risen at an alarming rate over the last 20 years as in other industrialised countries around the world, yet the policy response, locally and globally, has been limited. Using a childhood obesity summit held in Australia in 2002 as a case study, this paper examines how evidence was used in setting the agenda, influencing the Summit debate and shaping the policy responses which emerged. The study used multiple methods of data collection including documentary analysis, key informant interviews, a focus group discussion and media analysis. The resulting data were content analysed to examine the types of evidence used in the Summit and how the state of the evidence base contributed to policy-making.ResultsEmpirical research evidence concerning the magnitude of the problem was widely reported and largely uncontested in the media and in the Summit debates. In contrast, the evidence base for action was mostly opinion and ideas as empirical data was lacking. Opinions and ideas were generally found to be an acceptable basis for agreeing policy action coupled with thorough evaluation. However, the analysis revealed that the evidence was fiercely contested around food advertising to children and action agreed was therefore limited.ConclusionThe Summit demonstrated that policy action will move forward in the absence of strong research evidence. Where powerful and competing groups contest possible policy options, however, the evidence base required for action needs to be substantial. As with tobacco control, obesity control efforts are likely to face ongoing challenges around the nature of the evidence and interventions proposed to tackle the problem. Overcoming the challenges in controlling obesity will be more likely if researchers and public health advocates enhance their understanding of the policy process, including the role different types of evidence can play in influencing public debate and policy decisions, the interests and tactics of the different stakeholders involved and the part that can be played by time-limited yet high profile events such as Summits.

From research evidence to context: the challenge of individualising care

When strong research evidence supports a low risk intervention that is easy to implement, the practice of medicine may seem straightforward. The decision, for instance, to prescribe a β blocker...

Operant therapy with pain patients: evidence for its effectiveness

Operant therapy with pain patients: evidence for its effectiveness

Delays in adopting evidence-based dosages of conventional antipsychotics.

By the 1980s, strong research evidence had emerged supporting the use of moderate doses of conventional antipsychotics-between 300 and 1,000 mg of chlorpromazine equivalent daily. We conducted a cross-sectional study of dosages of antipsychotics prescribed for 936 veterans with schizophrenia in 14 facilities between 1991 and 1995. Only 52 percent of these patients received prescriptions for recommended dosages; dosages were below the recommended range for 20 percent and above the range for 28 percent. African Americans were more likely than others to have received high dosages. These data suggest that there was considerable delay in the adoption of evidence-based dosing of conventional antipsychotics. Efforts must be made to transfer research findings more rapidly into practice.

An exploration into the role of the teacher/lecturer in practice: findings from a case study in adult nursing

An exploration into the role of the teacher/lecturer in practice: findings from a case study in adult nursing

Applying research evidence to individuals in primary care: a study using non-rheumatic atrial fibrillation.

There is strong research evidence that anticoagulation of patients with nonrheumatic atrial fibrillation reduces the morbidity and mortality of stroke. This evidence is incompletely applied. We aimed to report consequences associated with the intention to apply evidence about anticoagulation for non-rheumatic atrial fibrillation (NRAF) to individuals in general medical practice. The study involved prospective structured reporting of the processes of applying evidence about NRAF to individual patients in six general practices in Cambridge. The subjects were patients identified to have NRAF in these practices. The intervention consisted of a practice-based review of evidence and the construction of a practice-owned protocol. This was followed by a review of individual patients' records according to protocol criteria. The main outcomes were indentification of the characteristics of the patients, quantitation of GPs' intention to change treatment, explicit reporting of the reasons for not anticoagulating individuals and time to achieve the practice protocol. The data collected confirmed that patients excluded from the authoritative randomized controlled trials predominate among patients cared for in general medical practice. Practitioners overestimated the prevalence of NRAF in their patients and underestimated the extent to which their current practice offered intervention. Practitioners initially overestimated the amount of change required in patient management. In reviewing their patients' records with the intention of following evidence-based practice, practitioners explicitly described and regarded as appropriate their reasons for not prescribing anticoagulation to certain individuals. The review process was time-consuming and will need to be repeated as further evidence emerges.