Pharmacological interventions for reducing the incidence of myoclonus in patients receiving etomidate for induction of general anesthesia: an umbrella review.

OBJECTIVE: The objective of this umbrella review was to examine various pharmacologic interventions for their potential to reduce etomidate-induced myoclonus. A secondary objective was to compare the relative effectiveness of those medications in reducing the incidence of myoclonus when etomidate is utilized for the induction of general anesthesia. INTRODUCTION: Etomidate is the drug of choice when inducing general anesthesia in hemodynamically unstable patients. However, its use is limited among the general surgical population due to its ability to cause adrenal suppression, vomiting, and myoclonus. Myoclonus can lead to damage of muscle fibers, myalgias, and patient discomfort, and can also be detrimental in patients with low cardiac reserve. Several systematic reviews have reported on the effectiveness of various intravenous medications in reducing mild, moderate, and severe myoclonus; however, a more thorough examination of their influence was lacking. INCLUSION CRITERIA: This review included systematic reviews and meta-analyses of randomized controlled trials involving the use of pharmacologic interventions to reduce etomidate-induced myoclonus. Reviews in English and conducted after 1965 were considered for inclusion. METHODS: A comprehensive search of 11 databases was conducted to identify published and unpublished reviews up to March 2022. Critical appraisal was conducted by 2 independent reviewers using the standardized JBI appraisal tool. Quantitative findings were summarized according to the dose, timing of administration, and relative risk using a data matrix, and were synthesized in tabular format with supporting narrative text. Results were organized by severity of myoclonus (overall, mild, moderate, and severe) and by type of intervention. RESULTS: Eight systematic reviews were included in this umbrella review, which included 48 relevant studies, after removal of duplicates (3909 participants included in the primary studies). Five of the systematic reviews examined the effectiveness of various types of opioids in the prevention of myoclonus, and 3 systematic reviews examined the effectiveness of non-opioid interventions, such as lidocaine, midazolam, and dexmedetomidine. Seven reviews searched at least 4 databases for pertinent studies and specifically indicated that blinded reviewers appraised the articles. All reviews used a published and validated appraisal instrument. The overall quality of all included reviews was judged to be moderate to high. The absolute risk reduction indicating the effectiveness of the prophylactic medications ranged from 47% to 81% for mild, 52% to 92% for moderate, and 61% to 96% for severe myoclonus. Opioids demonstrated the most consistent and substantial effect on the reduction in myoclonus. CONCLUSIONS: All pharmacologic interventions identified in this review demonstrated a statistically significant reduction in the incidence of myoclonus. Future studies and reviews should focus on elucidating the particular dose range and timing that is most effective. Anesthesia providers should consider a pre-treatment dose of one of the medications described in this umbrella review as a means to reduce myoclonus and the untoward effects of that condition.

Effect of dexamethasone administration for postoperative nausea and vomiting prophylaxis on glucose levels in adults with diabetes undergoing elective surgery: a systematic review with meta-analysis.

OBJECTIVE: The objective of this review was to evaluate the effect of intravenous dexamethasone given intraoperatively for postoperative nausea and vomiting prophylaxis on maximal blood glucose level within the initial 24 hours following elective surgery for patients with diabetes. INTRODUCTION: Postoperative nausea and vomiting is a prevalent adverse effect of anesthesia that leads to morbidity, increased health care costs, and unanticipated hospital admissions. Dexamethasone is an effective prophylactic agent that confers secondary analgesic and anti-inflammatory benefits. However, its use in patients with diabetes remains controversial due to the potential for increased postoperative blood glucose levels. INCLUSION CRITERIA: This review considered studies with participants 18 years of age or older with type 1 or 2 diabetes undergoing an elective surgical procedure. Eligible studies reported postoperative blood glucose levels in adults with diabetes after receiving a single 4-10 mg prophylactic dose of intravenous dexamethasone intraoperatively for postoperative nausea and vomiting. The primary outcome was maximum blood glucose level in the first 24 hours after surgery. All study designs were eligible for inclusion. Studies were excluded if they lacked a control group with diabetes or if they did not report maximum blood glucose values in both groups. METHODS: A search of MEDLINE, CINAHL Complete, Embase, Web of Science, TRIP database, and the Cochrane Database of Systematic Reviews was completed in October 2021. Gray literature resources were also searched. No date or language restrictions were applied. Methodological quality was assessed using JBI appraisal tools for randomized controlled trials, cohort studies, and case-control studies. A meta-analysis of maximal postoperative blood glucose level within 24 hours of surgery was performed, as well as subgroup analyses by dexamethasone dose, insulin treatment, and study design type. RESULTS: Eleven studies (4 randomized controlled trials, 6 cohort studies, and 1 case-control study) were included in this review, with 1 study excluded from meta-analysis and results reported narratively. The total sample size of studies included in meta-analysis was 2567. The administration of dexamethasone significantly increased maximal blood glucose levels in the 24 hours immediately following surgery compared with control groups with diabetes, as demonstrated by randomized controlled trials (mean difference [MD] 39.56 mg/dL; 95% CI 16.18 to 62.94; P < 0.001; I2 = 87%) and observational studies (MD 26.31 mg/dL; 95% CI 7.10 to 45.52; P = 0.007; I2 = 92%). This increase in blood glucose was significant for all doses of dexamethasone: 4 mg (MD 40.81 mg/dL; 95% CI 2.42 to 79.19; P = 0.001; I2 = 91%), 8 mg (randomized controlled trials only; MD 39.45 mg/dL; 95% CI 15.32 to 63.58; P = 0.001; I2 = 86%), and mixed 4-10 mg dose (MD 30.82 mg/dL; 95% CI 6.75 to 54.88; P < 0.012; I2 = 93%). Postoperative hyperglycemia persisted in studies using insulin treatment as well as those not using insulin protocols. The overall certainty of the findings ranged from very low for outcomes that included cohort studies to moderate when outcomes from randomized controlled trials were analyzed separately. However, the quantitative findings of the experimental and observational studies were clinically similar. Risk of bias presented minimal concerns in all included studies. CONCLUSIONS: Dexamethasone leads to transient postoperative hyperglycemia in patients with diabetes undergoing elective surgery when given as a single 4-10 mg intravenous dose for postoperative nausea and vomiting prophylaxis. The clinical relevance of hyperglycemia is debatable given its small magnitude and transient nature. Without more tightly controlled data, methodological consistency, and baseline blood glucose values, it is impossible to test causal links between hyperglycemia and pre-existing patient factors (eg, hemoglobin A1C levels) or postoperative complications. REVIEW REGISTRATION: PROSPERO CRD42020185607.

Development and Validation of a Quantitative Grading Rubric for High-Fidelity Simulation Assessment.

High-fidelity simulation scenarios provide trainees the opportunity to demonstrate foundational anesthesia skills, complex prioritization, and decision making. One strategy used in trainee assessment is an objective structured clinical examination (OSCE). The purpose of this study was to design an OSCE with a reliable, quantitative grading rubric that could be used as part of a comprehensive assessment strategy to determine readiness for entry into clinical training for nurse anesthesia residents. An observational correlational study was developed to validate four high-fidelity simulation scenarios and accompanying quantitative grading rubrics. The rubrics were tested on junior nurse anesthesia residents and graded by program faculty members. Interrater reliability was tested using Krippendorff's alpha. Three cohorts of nurse anesthesia residents (n = 83) were assessed yielding 330 unique observations. Interrater reliability increased over the duration of the study with an overall reliability coefficient of 0.9092 (95% CI, 0.8509-0.9062), indicating a very high degree of interrater reliability among a variety of raters in complex simulated environments. Development of a quantitative rubric for high-fidelity simulation is achievable and should be considered as part of a summative assessment to differentiate individual student performance and readiness to proceed to clinical training within a front-loaded nurse anesthesia program.

Safety and effectiveness of regional anesthesia compared with anesthetic techniques not using regional anesthesia on outcomes after free tissue flap surgery: a systematic review protocol.

OBJECTIVE: This systematic review will aim to evaluate the evidence on the effectiveness of regional anesthesia, when compared with general anesthesia alone, on the outcomes of free flap surgeries. INTRODUCTION: Free flap procedures involve complete separation of a flap of tissue from its native vascular bed, followed by reimplantation to a recipient site on the body. Optimal perfusion and successful neovascularization are crucial to survival of the grafted flap. Currently, no best-practice recommendations exist regarding the use of regional anesthesia in free flap surgeries. Regional anesthesia techniques have the potential to alter blood flow and neuroendocrine responses to surgical stress, which may impact perfusion and survival of free flap grafts. This potential for augmentation or hindrance of flap perfusion may have a significant impact on patient outcomes, thus meriting systematic review. INCLUSION CRITERIA: The review will include both experimental and observational (analytical only) study designs that examine the vascular outcomes of regional anesthesia compared with general anesthesia alone in free flap surgery. METHODS: The databases to be searched include PubMed, CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection, Embase, and gray literature sources. Identified studies will be independently assessed by two reviewers utilizing JBI critical appraisal tools. Data will be extracted using a standardized data matrix. Certainty of findings will be conducted using the Grading of Recommendations Assessment, Development and Evaluation approach. Narrative synthesis will be compiled and meta-analysis completed, where possible. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42021283584.

Thinking about the idea of consent in data science genomics: How 'informed' is it?

In this paper we argue that 'informed' consent in Big Data genomic biobanking is frequently less than optimally informative. This is due to the particular features of genomic biobanking research which render it ethically problematic. We discuss these features together with details of consent models aimed to address them. Using insights from consent theory, we provide a detailed analysis of the essential components of informed consent which includes recommendations to improve consent performance. In addition, and using insights from philosophy of mind and language and psycholinguistics we support our analyses by identifying the nature and function of concepts (ideas) operational in human cognition and language together with an implicit coding/decoding model of human communication. We identify this model as the source of patients/participants poor understanding. We suggest an alternative, explicit model of human communication, namely, that of relevance-theoretic inference which obviates the limitations of the code model. We suggest practical strategies to assist health service professionals to ensure that the specific information they provide concerning the proposed treatment or research is used to inform participants' decision to consent. We do not prescribe a standard, formal approach to decision-making where boxes are ticked; rather, we aim to focus attention towards the sorts of considerations and questions that might usefully be borne in mind in any consent situation. We hope that our theorising will be of real practical benefit to nurses and midwives working on the clinical and research front-line of genomic science.

Effectiveness of intravenous magnesium sulfate to attenuate hemodynamic changes in laparoscopic surgery: a systematic review and meta-analysis.

OBJECTIVE: The purpose of this systematic review and meta-analysis was to determine the effectiveness of intravenous magnesium sulfate when used to attenuate hemodynamic fluctuations associated with the creation of pneumoperitoneum in adults undergoing laparoscopic surgery. INTRODUCTION: Laparoscopic surgery has gained popularity as a result of improved patient outcomes postoperatively, but pneumoperitoneum alters the patient's physiology and hemodynamic profile during the intraoperative period. Magnesium sulfate is a nonopioid agent known for its ability to blunt the physiologic sympathetic response associated with exposure to noxious stimuli. Magnesium sulfate may be efficacious in promoting anesthetic management that optimizes a patient's cardiopulmonary function while minimzing opioid use. INCLUSION CRITERIA: Studies with participants at least 18 years old undergoing any elective laparoscopic surgery using pneumoperitoneum with CO2 insufflation were included. Studies were excluded if patients were being treated for pheochromocytoma. Studies eligible for inclusion employed any intravenous dosing strategy of magnesium sulfate, administered at any point in the perioperative period for the purpose of blunting the sympathetic response to creation of a pneumoperitoneum. The comparator utilized was normal saline. METHODS: A systematic search of MEDLINE, CINAHL, Cochrane Library, Google Scholar, Trip Database, MedNar, Grey Literature Report, ClinicalTrials.gov, and ProQuest Dissertations and Theses was conducted to identify both published and unpublished studies. The search was limited to studies written in the English language and performed on human subjects. Studies were selected for review based on inclusion criteria and were appraised by two reviewers using the appropriate JBI standardized appraisal tool. Data extraction was performed for all outcome variables. Data were pooled using the JBI System for the Unified Management, Assessment and Review of Information. Mean differences (95% confidence interval) were calculated for all continuous variables. Meta-analysis using a fixed effects model was performed at various time points for heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure. Standard GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) evidence assessment was also reported. RESULTS: A total of six randomized controlled trials were included in the review. Meta-analysis of data for biophysical parameters (heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure) at five minutes, 10 to 15 minutes, 30 minutes after pneumoperitoneum, and at the end of surgery showed a consistent reduction in the magnesium groups compared to placebo. Support for all outcome variables was determined to be high using the GRADE criteria. CONCLUSION: The administration of magnesium sulfate consistently demonstrated improved hemodynamic measurements during laparoscopic surgery. All doses administered in the included studies proved beneficial compared to placebo. Magnesium sulfate should be considered as an adjunct agent in laparoscopic surgery to blunt the sympathetic nervous system response to surgical stimulation. The quality of the included studies was high, but small sample sizes and selection of healthy participants may limit the generalizability of the results. The use of magnesium sulfate may have improved effects on patients with significant health comorbidities, but the limitations of the included studies related to sample demographics make the evidence inconclusive. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO (CRD42019139991).

Intravenous magnesium sulfate to attenuate hemodynamic changes in laparoscopic surgery: a systematic review protocol.

OBJECTIVE: The objective of this systematic review is to determine the efficacy of intravenous magnesium sulfate when used to attenuate hemodynamic fluctuations associated with the creation of pneumoperitoneum in adults undergoing laparoscopic surgery. INTRODUCTION: Laparoscopic surgery has gained popularity as a result of improved patient outcomes postoperatively, but pneumoperitoneum alters the patient's physiology and hemodynamic profile during the intraoperative period. Magnesium sulfate is a non-opioid agent known for its ability to blunt the physiologic sympathetic response associated with exposure to noxious stimuli. Magnesium sulfate may be efficacious in combating undesirable hemodynamic changes associated with pneumoperitoneum. INCLUSION CRITERIA: Studies that included participants 18 years or older undergoing any laparoscopic surgery using pneumoperitoneum with CO2 insufflation will be considered. Studies will be excluded if patients were being treated for pheochromocytoma. Studies can employ any intravenous dosing strategy of magnesium sulfate, administered at any point in the perioperative period for the purpose of blunting the sympathetic response to creation of a pneumoperitoneum. METHODS: A systematic search of MEDLINE, CINAHL, Cochrane Library, Google Scholar, Trip Database, MedNar, Grey Literature Report and ProQuest Dissertations and Theses will be conducted to identify both published and unpublished studies on the topic of interest. The search will be limited to studies written in English and performed on humans. Studies will be selected for review based on inclusion criteria and will be appraised by two reviewers using a standardized appraisal tool. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42019139991.

Evolution of metazoan morphological disparity.

The animal kingdom exhibits a great diversity of organismal form (i.e., disparity). Whether the extremes of disparity were achieved early in animal evolutionary history or clades continually explore the limits of possible morphospace is subject to continuing debate. Here we show, through analysis of the disparity of the animal kingdom, that, even though many clades exhibit maximal initial disparity, arthropods, chordates, annelids, echinoderms, and mollusks have continued to explore and expand the limits of morphospace throughout the Phanerozoic, expanding dramatically the envelope of disparity occupied in the Cambrian. The "clumpiness" of morphospace occupation by living clades is a consequence of the extinction of phylogenetic intermediates, indicating that the original distribution of morphologies was more homogeneous. The morphological distances between phyla mirror differences in complexity, body size, and species-level diversity across the animal kingdom. Causal hypotheses of morphologic expansion include time since origination, increases in genome size, protein repertoire, gene family expansion, and gene regulation. We find a strong correlation between increasing morphological disparity, genome size, and microRNA repertoire, but no correlation to protein domain diversity. Our results are compatible with the view that the evolution of gene regulation has been influential in shaping metazoan disparity whereas the invasion of terrestrial ecospace appears to represent an additional gestalt, underpinning the post-Cambrian expansion of metazoan disparity.

Anesthetic Implications of Obesity and Obstructive Sleep Apnea.

The incidence of morbid obesity has tripled within the past 25 years in developed countries, with the highest rate of growth noted among people with body mass index (BMI) greater than 50. The physiologic derangements that accompany obesity affect almost every organ system leading to a vast array of comorbid conditions including obstructive sleep apnea (OSA). This review focuses on the unique perioperative management considerations that the nurse anesthetist must address when caring for these patients as well as the impact of obesity and OSA on postoperative complications and mortality rates. Current research is reviewed to highlight best practice recommendations for all phases of anesthetic management including implications for bariatric surgery and office-based practice.

Nutrient enrichment alters storage and fluxes of detritus in a headwater stream ecosystem.

Responses of detrital pathways to nutrients may differ fundamentally from pathways involving living plants: basal carbon resources can potentially decrease rather than increase with nutrient enrichment. Despite the potential for nutrients to accelerate heterotrophic processes and fluxes of detritus, few studies have examined detritus-nutrient dynamics at whole-ecosystem scales. We quantified organic matter (OM) budgets over three consecutive years in two detritus-based Appalachian (U.S.A.) streams. After the first year, we began enriching one stream with low-level nitrogen and phosphorus inputs. Subsequent effects of nutrients on outputs of different OM compartments were determined using randomized intervention analysis. Nutrient addition did not affect dissolved or coarse particulate OM export but had dramatic effects on fine particulate OM (FPOM) export at all discharges relative to the reference stream. After two years of enrichment, FPOM export was 340% higher in the treatment stream but had decreased by 36% in the reference stream relative to pretreatment export. Ecosystem respiration, the dominant carbon output in these systems, also increased in the treatment stream relative to the reference, but these changes were smaller in magnitude than those in FPOM export. Nutrient enrichment accelerated rates of OM processing, transformation, and export, potentially altering food-web dynamics and ecosystem stability in the long term. The results of our large-scale manipulation of a detrital ecosystem parallel those from analogous studies of soils, in which net loss of organic carbon has often been shown to result from experimental nutrient addition at the plot scale. Streams are useful model systems in which to test the effects of nutrients on ecosystem-scale detrital dynamics because they allow both the tracking of OM conversion along longitudinal continua and the integrated measurement of fluxes of transformed material through downstream sites.

The role of theory-constitutive metaphor in nursing science.

The current view of theoretical statements in science is that they should be literal and precise; ambiguous and metaphorical statements are useful only as pre-theoretical, exegetical, and heuristic devices and as pedagogical tools. In this paper we argue that this view is mistaken. Literal, precise statements apply to those experiential phenomena which can be defined either conventionally by criterial attribution or by internal atomic constitution. Experiential phenomena which are defined relationally and/or functionally, like nursing, in virtue of their nature, require metaphorical description and explanation. In such cases, metaphor is theory-constitutive. Using insights from the philosophies of language and mind, and examples from nursing practice, education, and our own empirical research, we explore the nature of metaphor and its role in theory constitution. We argue that the apparent resistance of certain experiential phenomena to literal description and explanation is not necessarily indicative of pre-theoretic linguistic imprecision. We suggest, rather, that such resistance provides useful insights into the nature of such experiential phenomena. We also suggest that the aim of scientific theory should be methodological or epistemological precision and not merely linguistic precision.

Nutrients stimulate leaf breakdown rates and detritivore biomass: bottom-up effects via heterotrophic pathways.

Most nutrient enrichment studies in aquatic systems have focused on autotrophic food webs in systems where primary producers dominate the resource base. We tested the heterotrophic response to long-term nutrient enrichment in a forested, headwater stream. Our study design consisted of 2 years of pretreatment data in a reference and treatment stream and 2 years of continuous nitrogen (N) + phosphorus addition to the treatment stream. Studies were conducted with two leaf species that differed in initial C:N, Rhododendron maximum (rhododendron) and Acer rubrum (red maple). We determined the effects of nutrient addition on detrital resources (leaf breakdown rates, litter C:N and microbial activity) and tested whether nutrient enrichment affected macroinvertebrate consumers via increased biomass. Leaf breakdown rates were ca. 1.5 and 3x faster during the first and second years of enrichment, respectively, in the treatment stream for both leaf types. Microbial respiration rates of both leaf types were 3x higher with enrichment, and macroinvertebrate biomass associated with leaves increased ca. 2-3x with enrichment. The mass of N in macroinvertebrate biomass relative to leaves tended to increase with enrichment up to 6x for red maple and up to 44x for rhododendron leaves. Lower quality (higher C:N) rhododendron leaves exhibited greater changes in leaf nutrient content and macroinvertebrate response to nutrient enrichment than red maple leaves, suggesting a unique response by different leaf species to nutrient enrichment. Nutrient concentrations used in this study were moderate and equivalent to those in streams draining watersheds with altered land use. Thus, our results suggest that similarly moderate levels of enrichment may affect detrital resource quality and subsequently lead to altered energy and nutrient flow in detrital food webs.

Symbolic interactionism in grounded theory studies: women surviving with HIV/AIDS in rural northern Thailand.

Although it is generally acknowledged that symbolic interactionism and grounded theory are connected, the precise nature of their connection remains implicit and unexplained. As a result, many grounded theory studies are undertaken without an explanatory framework. This in turn results in the description rather than the explanation of data determined. In this report, the authors make explicit and explain the nature of the connections between symbolic interactionism and grounded theory research. Specifically, they make explicit the connection between Blumer's methodological principles and processes and grounded theory methodology. In addition, the authors illustrate the explanatory power of symbolic interactionism in grounded theory using data from a study of the HIV/AIDS experiences of married and widowed Thai women.

The acquisition and exercise of nephrology nursing expertise: a grounded theory study.

AIMS AND OBJECTIVES: This purpose of this study was to describe the process of expertise acquisition in nephrology nursing practice. BACKGROUND: It has been recognized for a number of decades that experts, compared with other practitioners in a number of professions and occupations, are the most knowledgeable and effective, in terms of both the quantity and quality of output. Studies relating to expertise have been undertaken in a range of nursing contexts and specialties; to date, however, none have been undertaken which focus on nephrology nursing. DESIGN: This study, using grounded theory methodology, took place in one renal unit in New South Wales, Australia and involved six non-expert and 11 expert nurses. METHODS: Simultaneous data collection and analysis took place using participant observation, semi-structured interviews and review of nursing documentation. FINDINGS: The study revealed a three-stage skills-acquisitive process that was identified as non-expert, experienced non-expert and expert stages. Each stage was typified by four characteristics, which altered during the acquisitive process; these were knowledge, experience, skill and focus. CONCLUSION: This was the first study to explore nephrology nursing expertise and uncovered new aspects of expertise not documented in the literature and it also made explicit other areas, which had only been previously implied. Relevance to clinical practice. Of significance to nursing, the exercise of expertise is a function of the recognition of expertise by others and it includes the blurring of the normal boundaries of professional practice.

Producing the magnum opus: a metaphor for nephrology nursing expertise acquisition.

AIM: This paper elucidates the nature of metaphor and the conditions necessary to its use as an analytic device in qualitative research, and describes how the use of metaphor assisted in the analytic processes of a grounded theory study of nephrology nursing expertise. BACKGROUND: The use of metaphor is pervasive in everyday thought, language and action. It is an important means for the comprehension and management of everyday life, and makes challenging or problematic concepts easier to explain. Metaphors are also pervasive in quantitative and qualitative research for the same reason. In both everyday life and in research, their use may be implicit or explicit. METHODS: The study using grounded theory methodology took place in one renal unit in New South Wales, Australia between 1999 and 2000 and included six non-expert and 11 expert nurses. It involved simultaneous data collection and analysis using participant observation, semi-structured interviews and review of nursing documentation. FINDINGS: A three stage skills-acquisitive process was identified in which an orchestral metaphor was used to explain the relationships between stages and to satisfactorily capture the data coded within each stage. CONCLUSION: Metaphors create images, clarify and add depth to meanings and, if used appropriately and explicitly in qualitative research, can capture data at highly conceptual levels. Metaphors also assist in explaining the relationship between findings in a clear and coherent manner.

Buddhism, the status of women and the spread of HIV/AIDS in Thailand.

The common-sense construction of Buddhism is that of a general power for good; the less positive aspects of Buddhism's power, especially when reinforced by folklore and ancient superstition, is infrequently recognised. In this article we make explicit Buddhism's less positive power, particularly as it relates to the status of women and, by implication, its role in the human immunodeficiency (HIV)/acquired immune deficiency syndrome (AIDS) epidemic in Thailand. The Buddhist, folklore, and superstitious bases of Thai misogyny are explored, together with its expression in the differential gender roles of women and men. In addition, the attitudes of both women and men to commercial sex workers (CSWs) and condom use is discussed. The implications of these attitudinal analyses to the epidemiology of HIV/AIDS in Thailand is outlined. We argue that the current spread of HIV/AIDS in Thailand is primarily a function of the inferior status of women, which, in turn, is a function of Buddhism and Thai cultural beliefs. In light of this, some realistic strategies to address the problem also are discussed.

"Hanging in" with HIV/AIDS in the rural north of Thailand: a grounded theory study.

A study was undertaken in 1997 through 2000 in the rural north of Thailand to describe and theorize the HIV/AIDS experiences of wives and widows there. Participants confronted four causally interrelated problems in their struggle to survive with HIV/ AIDS: physical, economic, psychoemotional, and sociocultural, and they used two social processes to manage them: namely, "hiding out" and "hanging in" with HIV/AIDS. This report describes and discusses the second of these basic social processes through which wives and widows in the rural north of Thailand cope with their HIV/AIDS infection. Hanging in involves a range of very active strategies derived from both traditional Thai culture and Western medicine and aimed at allowing participants to make the best of their predicament. In addition, this report renders explicit what is typically left implicit in grounded theory research; that is, that culture is the source both of the problems participants experienced and the means to their effective amelioration.

The evaluation of a clinical development unit leadership preparation program by focus group interviews - part I: positive aspects.

In 1996, in Western Sydney, Australia, the Area Health Service and the University of Western Sydney entered a strategic alliance to develop a nursing research culture in the health services. One of the strategies implemented to achieve this was the establishment of a network of research-receptive environments known as Clinical Development Units (CDUs). At the time, however, evidence suggested that research receptivity will only develop in units where the leadership style is permissive and participatory; evidence also suggested that the successful establishment of CDUs hinged critically on the effective management of CDU leadership stressors. In light of this, it was agreed to conduct a CDU Leadership Preparation Program in Western Sydney. The aim of the program was to equip CDU leaders with the participatory leadership skills required to develop and manage their units. It was anticipated that the acquisition of these leadership skills would, in turn, help them minimise the leadership stressors to which they could expect to become subject. This paper provides details of the first CDU leadership preparation course: how participants were selected, the aims of the course and its content. It focuses, however, on a discussion of the positive evaluative data harvested through 2 focus group interviews which were conducted 5 months following participants' successful completion of the program.A second paper focuses on the more negative evaluative data, 2 themes which unexpectedly emerged during data analysis and how the current program has been modified in light of this data.

The evaluation of a clinical development unit leadership preparation program by focus group interviews - part 2: negative aspects.

In Western Sydney, Australia, in 1996, the Area Health Service and the University of Western Sydney entered a strategic alliance to develop a nursing research culture in the health services. One of the strategies implemented to achieve this was the establishment of a network of research-receptive environments known as Clinical Development Units (CDUs). In terms of research receptivity, evidence at the time suggested that it could only be developed in units where the leadership style is democratic and participatory. In terms of CDUs, evidence suggested that their successful development depended critically on the effective management of CDU leadership stressors. In light of this, it was agreed to conduct a CDU leadership preparation program in Western Sydney. The program aimed to furnish CDU leaders with the participatory leadership skills required to develop and manage their units. It was expected that the acquisition of such leadership skills would serve to minimize the leadership stessors they could expect to experience. This is the second of two papers which report course evaluation data. The first focused on the more positive evaluation data; this paper focuses on the negative evaluation data and outlines how the current program has been modified in light of these data. In addition, it discusses two themes which emerged during data analysis. These were nurses' apparent mutual lack of trust and their pressing needs to be recognized as valuable and merit-worthy.