Kenyan palliative care providers' and leaders' perceptions of palliative care research needs and support to facilitate rigorous research.

BACKGROUND: Palliative care (PC) can reduce symptom distress and improve quality of life for patients and their families experiencing life-threatening illness. While the need for PC in Kenya is high, PC service delivery and research is limited. Qualitative research is needed to explore potential areas for PC research and support needed to enable that research. This insight is critical for informing a national PC research agenda and mobilizing limited resources for conducting rigorous PC research in Kenya. OBJECTIVES: To explore perceptions of priority areas for PC research and support needed to facilitate rigorous research from the perspective of Kenyan PC providers and leaders. METHODS: Focus groups (FGs) were conducted in November and December of 2018 using a semi-structured interview guide. FGs were audio-recorded, transcribed, and analyzed using a thematic content analysis approach. RESULTS: Three FGs were conducted (n = 22 participants). Ten themes related to PC research emerged, including research on: 1) beliefs about death, disease, and treatment to inform PC; 2) awareness about PC, 3) integration of PC within the health system; 4) understanding caregiver experiences and needs; 5) community health volunteers (CHVs) and volunteer programs; 6) evaluation of costs and benefits of PC; 7) treatment approaches, including complementary and alternative medicine (CAM) and advanced diagnostics at end of life; 8) other suggestions for research, 9) populations in need of PC research; and 10) resources for enabling research. CONCLUSIONS: Kenyan PC providers and leaders identified key areas requiring increased scientific inquiry and critical resources needed to enable this research. These findings can help to focus future PC research in Kenya and encourage funding agencies to prioritize the issues identified.

Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Africa: a report from the Global Opioid Policy Initiative (GOPI).

With nearly 1.1 billion inhabitants living in more than 50 countries, Africa is the world's poorest and most socioeconomically underdeveloped continent. Despite some advances for individual states, many African countries have very low opioid consumption and, overall, the continent has the lowest consumption per capita of any in the world. This article presents the findings of the first systematic study of the availability and accessibility of opioids for the management of cancer pain across the continent. Data are reported on the availability and accessibility of opioids for the management of cancer pain in 25 of 52 countries, with 744 million of the region's 1127 million people (66%) covered by the survey. Many countries had severely restricted formularies of opioids and only 15 of 25 had morphine available in oral IR, CR and injectable formulations. Even when opioids are on formulary they are often unavailable, and access is significantly impaired by widespread over-regulation that is pervasive across the region.

Out of the shadows: non-communicable diseases and palliative care in Africa.

Non-communicable diseases (NCDs) in Africa have been comparatively neglected, partly due to donor-driven funding priorities. This is despite NCDs being the principal cause of mortality globally, with the majority incidence occurring in low-income and middle-income nations. Most of the patients with NCDs will suffer from pain, breathlessness and other physical symptoms, or need support with psychosocial or spiritual problems. Reflecting regional disease prevalence, late-stage clinical presentation, limited funding and restricted access to curative therapies, palliative care need in Africa is significantly high. Although palliative care provision has advanced significantly on the continent in the past decade, much of this development was driven by services for adult HIV patients. However, recent international and regional political declarations and commitments constitute a new global NCD agenda that calls for the integration of palliative care into the NCD response. This could be achieved under a chronic care model of service provision in partnership with other clinical providers in an integrated care continuum spanning prevention, early detection, diagnosis, treatment, survivorship and the end of life. Four important challenges have to be addressed if palliative care is to contribute meaningfully to this NCD agenda: (1) existing variation in the ability of countries to deal with NCDs per se; (2) ensuring clinical partners are integrated effectively with palliative care; (3) agreeing implementation is linked to relevant national-level and patient-level metrics; and (iv) underpinning palliative care and NCD care with a rigorous and locally relevant evidence base demonstrating appropriate, feasible and effective care.

Dissociative identity disorder and the sociocognitive model: recalling the lessons of the past.

In a recent article in this journal, D. H. Gleaves (1996) criticized the sociocognitive model (SCM; N. P. Spanos, 1994) of dissociative identity disorder (DID) and argued in favor of a posttraumatic model (PTM) in which DID is conceptualized as a consequence of childhood abuse and other traumatic events. The present authors demonstrate that (a) many of Gleaves's arguments were predicated on misunderstandings of the SCM, (b) scrutiny of the evidence regarding the psychopathology and assessment of DID raises questions concerning the PTM's conceptual and empirical underpinnings, (c) the treatment literature suggests that iatrogenic factors play an important role in the etiology of DID, and (d) the evidence linking child abuse to DID is more problematic than implied by Gleaves. The present authors conclude that Gleaves's analysis underemphasized the cultural manifestations of multiple role enactments and that the history of DID imparts a valuable lesson to contemporary psychotherapists.

A voice-enabled, structured medical reporting system.

Kurzweil Applied Intelligence received a research grant from the National Institute of Standards and Technology (NIST) Advanced Technology Program to develop a prototype voice-enabled, structured medical reporting system. In typical usage, the physician dictates to the system, which then uses automatic speech recognition and medical knowledge bases to produce a structured report. This report can then be formatted and viewed on a computer screen, stored in databases of patient information, transmitted to other systems, used to support outcome studies, or viewed on a Web browser. The output reports are structured according to two standard, platform-independent formats: SGML and CORBA. These formats represent the data in a way that can be read by both computers and humans, and efficiently communicated to a wide range of databases and communications protocols.

Construction of a Cerenkov light source.

A radiation source has been developed and implemented from Cerenkov emission that is intended to provide an intense continuum from the infrared to 600 A. Parasitic use of the primary electron beam at the Stanford Linear Accelerator Center (SLAC) together with a novel optical geometry for light collection can give a focused and tunable ultraviolet beam with 10(4) kW/m(2)sr brightness, 10(-2) spectral purity, and with the pulsed, 5 ps time structure of the SLAC electron beam. Measurements of emission characteristics in the visible part of the spectrum correlate closely with the predicted performance.

Determinants of choice for pigeons and humans on concurrent-chains schedules of reinforcement.

Concurrent-chains schedules of reinforcement were arranged for humans and pigeons. Responses of humans were reinforced with tokens exchangeable for money, and key pecks of 4 birds were reinforced with food. Variable-interval 30-s and 40-s schedules operated in the terminal links of the chains. Condition 1 exposed subjects to variable-interval 90-s and variable-interval 30-s initial links, respectively. Conditions 2 and 3 arranged equal initial-link schedules of 40 s or 120 s. Experimental conditions tested the descriptive adequacy of five equations: reinforcement density, delay reduction, modified delay reduction, matching and maximization. Results based on choice proportions and switch rates during the initial links showed that pigeons behaved in accord with delay-reduction models, whereas humans maximized overall rate of reinforcement. As discussed by Logue and associates in self-control research, different types of reinforcement may affect sensitivity to delay differentially. Pigeons' responses were reinforced with food, a reinforcer that is consumable upon presentation. Humans' responses were reinforced with money, a reinforcer exchanged for consumable reinforcers after it was earned. Reinforcers that are immediately consumed may generate high sensitivity to delay and behavior described as delay reduction. Reinforces with longer times to consumption may generate low sensitivity to delay and behavior that maximizes overall payoff.

Sex preference and contraceptive behaviour among men in Mbeya region, Tanzania.

While recent studies confirm parental child sex preference in less developed countries, its pattern varies. Son preference is especially prevalent in Bangladesh, China, India, and Pakistan. Sex preference in sub-Saharan Africa is a neglected area of enquiry. Completed research focuses on women's views to the neglect of men, despite the latter's importance as primary decision-makers. This study identifies factors influencing contraceptive behaviour among men in Mbeya region, Tanzania, demonstrating how it is affected by their preferred family sex composition. Data used were collected from a cross-sectional survey of 600 men aged 16-50 and six focus groups conducted in the region's rural and urban areas. Using single statements and Coombs' Scales, sex preference was found to be prevalent in the study area, with sons strongly preferred to daughters. Sex preference is significantly associated with the number of existing daughters a man has, his marital status, residence and occupation. Findings suggest programmes should be initiated to challenge men's attitudes towards one-sex family composition. Men should be educated about the advantages of small family sizes and persuaded that both children's sexes are equally important. Such measures can assist men in reconsidering their desired family sizes, reduce biases towards one sex, minimise marital problems and improve women's status. Efforts to increase contraceptive use in Tanzania will be hampered, however, if men maintain their preference for sons over daughters.

Was Anna O.'s black snake hallucination a sleep paralysis nightmare? Dreams, memories, and trauma.

The final traumatic event recalled by Anna O. during her treatment with Josef Breuer was a terrifying hallucination she once had of a black snake attacking her ailing father. This event has been variously interpreted as indicating an underlying psychodynamic conflict, as a temporal lobe seizure, and as an hypnotic confabulation. We argue, however, that the hallucination--during which Anna O.'s arm was reportedly "asleep" due to nerve blockage--was probably a sleep paralysis nightmare. Sleep paralysis nightmares continue to be overlooked or misdiagnosed in clinical practice, and, in recent years, have been implicated in the controversy surrounding memories of trauma and sexual abuse.

Focus groups in mental health research: enhancing the validity of user and provider questionnaires.

Most mental health researchers rely upon quantitative methods of data collection. Whilst such methods are commonly seen as reliable, qualitative methods are often seen as more valid. Despite the value of qualitative methods of data collection, however, many researchers denigrate their use. Qualitative research is often viewed as lacking in scientific rigour. This paper explores the use of the focus group as a qualitative instrument to enhance the validity of existing questionnaires for mental health service users and providers. Between July and August 1995 four focus groups were conducted in Exeter and Taunton among service users (with severe or long-term mental health problems) and providers (community psychiatric nurses, social workers and occupational therapists). It is demonstrated that focus groups enhance the validity of existing questionnaires by highlighting those concerns held by users and providers that would otherwise have been neglected.

Speculations in "Temporal delays in incorporation of events into dreams": a reply to Roll.

Previously we pointed out similarities between patterns of delayed incorporations of daytime stimuli into dreams and delayed memory processes in rats. In commenting upon this article, Roll argued that this reductionistic leap is unwarranted. We contend that it would be remiss not to make note of this potential connection, especially in view of recent major contributions of animal research to the understanding of REM sleep and dreams. We also suggest that the disruption-avoidance-adaptation model constitutes a preferable psychological explanation for the dream-lag effect than Roll's psychoanalytic model of repression and repetition compulsion.

Temporal delays in incorporation of events into dreams.

20 subjects viewed an emotionally arousing video and then recorded their dreams at home for seven nights. Dreams were subsequently rated for the likelihood that some aspect of the video had been incorporated. For subjects who showed strong evidence of incorporation, mean likelihood of incorporation ratings followed a U-shaped pattern, with significantly higher scores on Nights 1, 6, and 7 than on Night 4. The similarity of this temporal pattern with REM sleep patterns observed in rats exposed to various learning experiences is noted, and the role of the hippocampus as a possible neural mechanism for delayed incorporations is discussed.

Effectiveness of treatment for dissociative identity disorder.

In a recent study by Ellason and Ross, patients with Dissociative Identity Disorder reported a decrease in symptoms on the Millon Clinical Multiaxial Inventory-II over a 2-yr. follow-up period. Patients judged to have achieved integration of their personalities rated themselves as more substantially improved on the Millon-II than did patients judged not to have achieved integration. Ellason and Ross suggested that this improvement reflected the influence of treatment; however, for several reasons, their findings are open to alternative interpretations. First, in the absence of proper control conditions, one cannot rule out the contribution of other factors to the over-all improvement of patients such as regression of symptoms toward the mean following the initial assessment. Second, patients self-reported improvement was less substantial when data were reanalyzed using more appropriate statistical criteria. Third, the greater improvement observed among integrated patients relative to nonintegrated patients may reflect influences other than differential responsiveness to treatment, such as less severe pathology prior to treatment. More systematic research is needed to clarify the effect of treatment on Dissociative Identity Disorder.

Did Freud mislead patients to confabulate memories of abuse?

Freud's abandonment of the seduction theory within a year of first proposing it has been the subject of considerable recent debate and speculation. Closer examination of Freud's writings, however, shows that he had often used highly suggestive procedures to elicit the memories of childhood "seductions" from his patients. Moreover, he had not considered alternative explanations for the evidence he presented when first claiming that these recovered memories of sexual abuse were real. Nevertheless, some present-day authors have argued for the validity of recovered memories by presenting much the same type of evidence that Freud once did. Research is needed to assess the extent to which recovered memories can be clearly corroborated and to establish rules for distinguishing between real and false memories of abuse.

Did Freud misinterpret reported memories of sexual abuse as fantasies?

While serious questions have arisen concerning the validity of Freud's seduction theory of neurosis, a related issue concerns the extent to which Freud, following the abandonment of the seduction theory, may have misinterpreted real memories of sexual abuse as imaginary. Certain theoretical statements by Freud as well as his advice to Jung concerning a 6-yr.-old patient who had accused her foster-father of sexual abuse indicate that he may have been significantly biased toward interpreting certain types of incest allegations as fantasies. Increased awareness of Freud's biases, both in his early tendency to pressure patients into believing that they were victims of abuse and in his later tendency to regard certain types of incest allegations as unreal, may contribute to a more objective approach to the diagnosis and treatment of sexual abuse in the future.