Comparative health systems immersion in South Korea: A constructivist competency-based approach to educating master's nursing students.

Nursing education is being challenged to rapidly evolve in order to meet the complex and systemic health care demands facing societies globally. International immersion is one educational strategy promoted to help prepare nursing students to meet these challenges. The Comparative Health Care Immersion Course in South Korea was created to educate entry-level master of science in nursing (MSN) students studying to become Clinical Nurse Leaders (CNL) to meet the complex systems level challenges facing health care organizations in the United States. Teaching adults in a cross-cultural setting required a complex philosophical and andragogical approach weaving together cultural constructivism, cultural attunement, anti-imperialism, critical theory, and experiential learning.

An immersion program for clinical nurse leader students: Comparing health care systems in South Korea and the United States.

We examine the import of a Comparative Health Care Immersion Program in South Korea to prepare entry-level Master of Science in Nursing (MSN) students studying to become clinical nurse leaders (CNLs) who can dynamically engage the complex issues facing health systems in the United States (U.S.). Following passage of the Affordable Care Act, clinical nurse leaders are being expected to have insight into systems level issues and ameliorate them when they are related to poor patient outcomes. Examination of South Korea's health care system provides U.S. students an opportunity to see the design and action of a highly functional system and thus benchmark the U.S health care system. South Korea provides a useful comparator given their rapid development of a universal, single-payer health care system that uses advanced centralized computing and provides outcomes on par and surpassing the U.S. We explore implementation of a CNL competency-based curriculum, including financing, informatics, and health care efficiencies within the context of short-term study abroad.

Detecting sarcasm from paralinguistic cues: anatomic and cognitive correlates in neurodegenerative disease.

While sarcasm can be conveyed solely through contextual cues such as counterfactual or echoic statements, face-to-face sarcastic speech may be characterized by specific paralinguistic features that alert the listener to interpret the utterance as ironic or critical, even in the absence of contextual information. We investigated the neuroanatomy underlying failure to understand sarcasm from dynamic vocal and facial paralinguistic cues. Ninety subjects (20 frontotemporal dementia, 11 semantic dementia [SemD], 4 progressive non-fluent aphasia, 27 Alzheimer's disease, 6 corticobasal degeneration, 9 progressive supranuclear palsy, 13 healthy older controls) were tested using the Social Inference - Minimal subtest of The Awareness of Social Inference Test (TASIT). Subjects watched brief videos depicting sincere or sarcastic communication and answered yes-no questions about the speaker's intended meaning. All groups interpreted Sincere (SIN) items normally, and only the SemD group was impaired on the Simple Sarcasm (SSR) condition. Patients failing the SSR performed more poorly on dynamic emotion recognition tasks and had more neuropsychiatric disturbances, but had better verbal and visuospatial working memory than patients who comprehended sarcasm. Voxel-based morphometry analysis of SSR scores in SPM5 demonstrated that poorer sarcasm comprehension was predicted by smaller volume in bilateral posterior parahippocampi (PHc), temporal poles, and R medial frontal pole (pFWE<0.05). This study provides lesion data suggesting that the PHc may be involved in recognizing a paralinguistic speech profile as abnormal, leading to interpretive processing by the temporal poles and right medial frontal pole that identifies the social context as sarcastic, and recognizes the speaker's paradoxical intentions.

Difficulties in detecting behavioral symptoms of frontotemporal lobar degeneration across cultures.

Cross-cultural studies of neurodegenerative disorders are especially important when the disease in question is difficult to diagnose, particularly if symptoms of the illness include behavioral disturbances that may be interpreted differently in different cultures. One such disease is frontotemporal lobar degeneration (FTLD), an early-age-of-onset dementia that disproportionately affects social behavior. We report the demographic and neuropsychologic characteristics of more than 300 patients diagnosed with FTLD in the United States, Greece, and Turkey. We find that patients with the frontal variant of frontotemporal dementia (FTD) are diagnosed at an earlier age and report earlier symptom onset in the United States than in Greece or Turkey. Furthermore, neuropsychologic measures indicate that at diagnosis, FTD patients in the United States are less impaired than patients in Greece and Turkey. Patients with FTD in Greece and Turkey are diagnosed later in the disease, presumably because their behavioral symptoms are not easily detected by the medical system in these countries. Our study underscores the need to create culturally appropriate indices of the behavioral symptoms of FTLD, so that patients may be diagnosed and treated at an earlier stage.

An open-label study of memantine treatment in 3 subtypes of frontotemporal lobar degeneration.

There are currently no Food and Drug Administration-approved treatments for frontotemporal lobar degeneration (FTLD). The objectives of this study were to explore the tolerability of memantine treatment in FTLD and to monitor for possible effects on behavior, cognition, and function. Forty-three individuals who met clinical criteria for FTLD [21 with frontotemporal dementia (FTD), 13 with semantic dementia (SD), and 9 with progressive nonfluent aphasia (PA)] received 26 weeks of open-label treatment with memantine at a target dose of 20 mg daily. Concurrent treatment with acetylcholinesterase inhibitors was prohibited. Cognitive and functional outcome measures included the Mini Mental State Examination, Alzheimer's Disease Assessment Scale-Cognitive (ADAS-cog), clinical dementia rating-sum of boxes, Neuropsychiatric Inventory (NPI), Frontal Behavior Inventory, Executive Interview (EXIT25), Texas Functional Living Scale (TFLS), Geriatric Depression Scale, and Unified Parkinson's Disease Rating Scale-motor scale. Most subjects were able to tolerate the target dose of memantine. A transient improvement was observed on the total NPI score primarily in the FTD group. Variable declines were observed on the ADAS-cog, EXIT25, Frontal Behavior Inventory, NPI, TFLS, and UPDRS scores. The FTD and SD groups declined on most of the cognitive and behavioral outcome measures, but remained stable on the UPDRS, whereas the progressive nonfluent aphasia group remained relatively stable on the ADAS-cog, NPI, and TFLS, but declined on the UPDRS. Memantine was well-tolerated in these subjects. Future placebo-controlled trials of memantine in FTLD are warranted and may have greater power to detect behavioral and cognitive effects if focused on the FTD and SD clinical syndromes.

Spontaneous social behaviors discriminate behavioral dementias from psychiatric disorders and other dementias.

OBJECTIVE: Changes in social behavior are often the first symptoms of neurodegenerative disease. Patients with frontotemporal lobar degeneration (FTLD) often go undiagnosed, or are misclassified as psychiatric patients, because in the absence of cognitive deficits, nonexperts fail to recognize these social changes as dementia symptoms. The object of this study was to improve screening for behavioral dementias in primary care and mental health settings by quantifying spontaneous social behaviors specific to FTLD. METHOD: In a university hospital dementia clinic, examiners blind to subject diagnosis performed 1 hour of cognitive testing, then completed the Interpersonal Measure of Psychopathy, an 18-item checklist of observed inappropriate behaviors. Patients then underwent a multidisciplinary evaluation to derive a neurodegenerative or psychiatric diagnosis. Data were collected from 288 subjects: 45 Alzheimer's disease (National Institute of Neurologic and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association research criteria); 40 frontotemporal dementia, 21 semantic dementia, and 13 progressive nonfluent aphasia (Neary research criteria); 14 corticobasal degeneration and 21 progressive supranuclear palsy (Litvan research criteria); 37 dementia with Lewy bodies (McKeith research criteria); 16 vascular dementia (Ischemic Vascular Disease research criteria); 29 mixed vascular and Alzheimer's disease (Alzheimer's Disease Diagnostic and Treatment Centers criteria); and 35 primary psychiatric disorder (DSM-IV) patients and 17 normal older controls. The study was conducted from March 2002 to January 2005. RESULTS: Statistical item analyses demonstrated specific patterns of social behavior that differentiated both frontotemporal dementia and semantic dementia patients from (1) nondementing older adults, (2) nondementing individuals with psychiatric conditions, (3) individuals with cerebrovascular disease, and (4) individuals with other neurodegenerative disorders. Semantic dementia patients verbally and physically interrupted evaluations, spoke perseveratively and tangentially, and resisted clinician redirection. Frontotemporal dementia patients were apathetic or disinhibited and were unconcerned about meeting clinician expectations. CONCLUSION: Specific, abnormal, interpersonal behaviors can alert nonexperts to the need for specialized dementia referral.