Mild-to-moderate uncomplicated hypertension: further analysis of a cost-effectiveness study of five drugs.

A cost-effectiveness model was designed to explore the effect of adding a new angiotensin-II inhibitor, telmisartan, to the therapeutic options for treating mild-to-moderate uncomplicated hypertension. Incorporating the cost of drugs, physician visits, and adverse-event treatments, the model concluded that availability of telmisartan on formulary may shorten the mean time and costs to control. The stability of the initial findings over a range of sensitivity analyses lends credence to the model conclusions that availability of telmisartan on formulary improves the therapeutic options of care for hypertension.

Delphi panel study of current hypertension treatment patterns.

OBJECTIVE: The purpose of this study was to assess whether, and to what extent, usual practice in the management of patients with mild to moderate hypertension differs from that recommended in the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-VI). The results were used as input for a clinical decision analytic model to assess the cost-effectiveness of a new treatment for hypertension. METHODS: A Delphi panel survey of general practitioners and cardiologists in the United States was conducted to determine current strategies for the treatment of mild to moderate uncomplicated hypertension. The purpose of the panel survey was to reach consensus on 3 key facets of the JNC-VI guidelines and how they relate to the respondents' clinical practices: (1) the definition of mild to moderate hypertension, (2) the treatment that adult patients with uncomplicated mild to moderate hypertension should receive, and (3) the management of patient follow-up. RESULTS: Of the 20 physicians contacted for the survey, 10 responded to both rounds of the questionnaire. There was considerable variation in the responses for defining the ranges of healthy, acceptable, unacceptable, and serious blood pressure. In general, the Delphi panel respondents cited higher limits than stated in the JNC-VI guidelines. Physicians followed the guidelines approximately 60% of the time. Primary determinants of initial drug choice among the panelists were comorbid conditions and the severity of hypertension; patients' age, race, and sex were secondary determinants. Follow-up typically occurred 1 month after therapy initiation. Panelists reported titrating the dose of new therapies upward once or twice before discontinuing the drug for lack of efficacy. Once adequate blood pressure control was achieved, patient follow-up was reported to occur every 3 to 4 months. CONCLUSIONS: This Delphi panel study highlights the differences between clinical practice and the JNC-VI guidelines in the treatment of hypertension. The results were used as a basis for defining a structure for a cost-effectiveness model and provided the management practice and prescribing practice patterns required by the model.

Maternal assignment of fetal personhood to a previous pregnancy loss: relationship to anxiety in the current pregnancy.

The degree of personhood a mother assigns to her dead fetus (i.e., whether she felt she lost a pregnancy or a baby) may help explain the meaning of a perinatal loss and the amount of anxiety experienced in a subsequent pregnancy. This descriptive study of 72 multigravidas with a history of one or two perinatal losses was conducted to understand the relationships between the assignment of fetal personhood and the influence of that assignment on state anxiety and pregnancy anxiety in a subsequent pregnancy. Assignment of personhood was significantly related to pregnancy anxiety and to the gestational age of the first loss but not to state anxiety. Understanding and responding to women's perceptions of perinatal losses and their significance for women may be one way to support them in subsequent pregnancies.

Clinical supervision: a three-way mirror.

The principles and process of a model of clinical supervision for psychotherapy are presented and described through two cases. The model draws heavily from Bowen's family systems theory and Peplau's theory of interpersonal relations. The relationships in the client-family, client-therapist, and therapist-supervisor systems mirror each other, and changes in self-definition, and in the management of anxiety of persons in one system catalyzes changes in parallel systems. Two cases illustrate the model. In the first case, anxiety needed to be raised to levels optimal for learning. In the second case, no learning occurred until levels of anxiety were reduced.

Dream telling: a means of spiritual awareness.

The article describes how a dream-sharing group facilitated by a nurse therapist can become the means by which the participants gain spiritual awareness. First, the characteristics of spiritual awareness are identified and discussed. Second, the practice, structure, and process of a dream-sharing group are described, with dream narratives and interactions from a particular group being used as illustrations. Finally, the attributes of a sensitive and caring listener and the leadership qualities of a nurse facilitator of such a group are outlined in the hope that nurses in different settings will be enabled and encouraged to provide this important aspect of nursing care.

The contexts of caring: conscience and consciousness.

In this paper, I have maintained a distinction between person and self in order to describe and analyze contexts of caring in nursing encounters. As the nursed person's perspectives are examined in light of the nurse's capacity to engage his or her own experience, four contextual categories emerge: comprehension, consideration, concern, and communion. Such concepts can help us describe and analyze many situations in clinical nursing and in nursing education. The following paragraphs describe several of the possibilities for future research. It is important to study in which contexts in nursing personhood and selfhood are enhanced and when they are diminished. Diminishment of personhood leads to depersonalization which describes a condition of loss of agency and helplessness in a world where others are in control. This can happen to the nursed person and to the nursing person. When nurses are placed in contexts where they experience lack of agency and authority in their practice settings (even when they attempt to engage others with concern and compassion), they can start to feel and become depersonalized. Diminishment of self leads to dehumanization, which describes a loss of contact with one's own experience. Rules and relationships are oppressive or inflexible and the participants experience meaninglessness. For example, how long can nurses be in daily situations of administering painful procedures to patients without experiencing dehumanization? The same question can be asked of nurses at all levels in hierarchies, and in all relationships, for example, nursing instructors with students, nurse administrators with staff nurses, faculty in academic institutions, and staff nurses with each other. Depersonalization and dehumanization eventually lead to one another. Another significant question to explore could be this: In which of the four contexts defined above does the nurse experience most satisfaction, most dissatisfaction, and the condition we call burnout? We live in a world, a society, and a profession where depersonalization and dehumanization are the plight of many. How can personhood and selfhood be enhanced or even restored in our hospitals, clinics, classrooms, and academic institutions? I propose that investigations of the contexts of caring can help us explore, discover, describe, and analyze these questions.

Learning through symbol, myth, model, and ritual.

An interdisciplinary course entitled "Religious and Spiritual Issues in Health Care" was offered for nursing students, medical students, and seminary students. The course was designed to explore religious responses to human suffering and to examine the role of different health care professionals with regard to spiritual concerns of patients.The identification of symbol, the retelling of myth, the presentation of model, and the enactment of ritual enhanced the learning process. In the context of the universality of human suffering, professional differences were recognized and respected.Teamwork in health care is a process which can be learned cognitively and affectively by affirming and sharing professional values with other health care professions.

Spiritual issues in mental health care.

Religious and spiritual issues in mental health are explored in the context of four conceptual models: the medical, the nursing, the humanistic, and the pastoral. This is done by looking at each model in terms of content, diagnostic focus, language and treatment goals, and primary qualities in the health provider.The models are illustrated by case studies gathered from a multidisciplinary setting. The discovery that each model can incorporate the religious and spiritual dimension in mental health care, but that each model does this in distinctive ways, is a key point.