Time-intensive behavioural activation for depression: A multiple baseline study.

BACKGROUND AND OBJECTIVES: Depression is the second leading cause of disability, worldwide, and increasing access to its effective/preferred treatment requires more attention. Behavioural activation and time-intensive treatment delivery both show promise in this regard, yet research into their combination is limited. This study aimed to investigate the feasibility, effectiveness, and acceptability of time-intensive behavioural activation (BA) for depression METHODS: Eight adults with major depressive disorder were recruited from three outpatient IAPT services in London. The study employed a single case experimental design with multiple baselines. All participants completed time-intensive BA, consisting of up to seven twice weekly sessions with daily prompting in-between and three optional booster sessions. Idiographic, standardised and process measures of depression symptomatology were collected. RESULTS: Treatment recruitment and retention indicated that the intervention was feasible. Visual and statistical analyses showed that relative to baseline, 6 out of 8 participants made significant improvements in all idiographic symptoms of depression following the intervention. According to standardised measures of depression, four out of eight participants were considered treatment responders. Five participants completed follow-up measures and the majority of progress was maintained after the withdrawal of the intervention. The intervention was also considered highly acceptable by participants and therapists. LIMITATIONS: Conclusions cannot be drawn about the generalizability or the long-term durability of the findings CONCLUSIONS: Overall this study provides new, but tentative evidence highlighting the potential of time-intensive BA as a feasible, effective and acceptable treatment for some adult outpatients with depression. The findings now warrant further, more rigorous evaluation of the treatment.

Interdecadal changes in the community, population and individual levels of the fish fauna of an extensively modified estuary.

This study examined inter-period changes over two to three decades in the fish fauna of an urbanized estuary experiencing rapid population growth and a drying climate (Swan-Canning Estuary, Western Australia). Responses were compared at the fish community level (species composition; 1978-2009 in the shallows and 1993-2009 in deeper waters) and at the population and individual levels of an estuarine indicator species, black bream Acanthopagrus butcheri (biomass-abundance and per capita mass at age, respectively; 1993-2009). All three levels showed distinct shifts from earlier to later periods, but their patterns, sensitivity and breadth differed. Community composition changed markedly in the shallows of the lower-middle estuary between the late 1970s and all later periods and moderately between more disparate periods from 1995 to 2009. Several species trends could be linked to the increasing salinity of the estuary or declining dissolved oxygen levels in its middle-upper reaches. Community changes were, however, small or insignificant in the shallow and deeper waters of the upper estuary and deeper waters of the middle estuary, where environmental perturbations are often most pronounced. This may reflect the resilience of the limited suite of species that typify those reaches and thus their lack of sensitivity in reflecting longer-term change at the coarser level of mean abundance. One such species, the selected indicator, A. butcheri, did, however, show marked temporal changes at both the population and individual levels. Biomass decreased markedly in deeper waters while increasing in the shallows from earlier to later periods, presumably reflecting an onshore movement of fish, and per capita body mass in the 2+, 3+ and 4+ year classes fell steadily over time. Such changes probably indicate deteriorating habitat quality in the deeper waters. The study outcomes provide support for a multifaceted approach to the biomonitoring of estuaries using fishes and highlight the need for complementary monitoring of relevant stressors to better disentangle cause-effect pathways.

Diel shifts in the structure and function of nearshore estuarine fish communities.

Day-night shifts in the nearshore fish fauna of a temperate microtidal estuary were assessed using a holistic suite of structural and functional community attributes. Mean fish species richness and diversity (taxonomic distinctness) were higher at night across all regions of the estuary and seasons, concurring with the findings of numerous comparable studies reviewed worldwide, while the diel period in which mean abundance was higher varied among seasons. Likewise, species and functional guild compositions (the latter based on feeding modes and habitat use) both differed significantly between day and night, with the extent of the diel shift again varying seasonally. Daytime fish communities were characterized by higher abundances of Atherinidae, Sillaginidae and Mugilidae, while Gobiidae were far more abundant at night. Marked shifts in size composition were also evident, with smaller fishes (<100 mm total length, LT ) being more prevalent during the day and larger fishes (≥200 mm LT ) proportionally more abundant at night. The above diel shifts were feasibly related to a range of predator-prey interactions and feeding-related movements, namely a nocturnal decrease in top-order avian piscivory coupled with an increase in invertebrate prey availability, resulting in changes in the presence and catchability of certain fish species in shallow estuarine waters.

Characteristics of the ichthyofauna of a temperate microtidal estuary with a reverse salinity gradient, including inter-decadal comparisons.

Data on the fish fauna of the Leschenault Estuary on the lower west coast of Australia were collected and used as a model to elucidate the characteristics of permanently open estuaries with a reverse salinity gradient, which undergo seasonal changes similar to many other estuaries with Mediterranean climate. Focus was placed on determining (1) the relationships of the number of species, density, life cycle category and species composition of fishes with region (within estuary), season and year and salinity, (2) whether species are partitioned along the lengths of such systems and (3) the extent and significance of any inter-decadal changes in species composition. The analyses and interpretation involved using multi-factorial permutational multivariate analysis of variance (PERMANOVA) and analysis of similarity (ANOSIM) designs, and three new or recently published visualization tools, i.e. modified non-metric multidimensional scaling (nMDS) plots, coherent species curves and segmented bubble plots. The base, lower, upper and apex regions of the Leschenault Estuary, along which the salinity increased in each season except in winter when most rainfall occurs, were sampled seasonally for the 2 years between winter 2008 and autumn 2010. Estuarine residents contributed twice as many individuals, but less than half the number of species as marine taxa. While the numbers of marine species and estuarine residents declined between the base or lower and apex regions, the individuals of marine species dominated the catches in the base region and estuarine residents in the other three regions. Ichthyofaunal composition in each region underwent conspicuous annual cyclical changes, due to time-staggered differences in recruitment among species, and changed sequentially along the estuary, both paralleling salinity trends. Different groups of species characterized the fauna in the different regions and seasons, thereby partitioning resources among species. The ichthyofauna of the apex region, in which salinities reached 54 and temperatures 36° C, recorded the highest maximum density and, in terms of abundance, was dominated (90%) by three atherinid species, emphasizing the ability of this family to tolerate extreme conditions. Comparisons between the data for 2008-2010 and 1994 demonstrate that the spotted hardyhead Craterocephalus mugiloides and the common hardyhead Atherinomorus vaigiensis had colonized and become abundant in the Leschenault Estuary in the intervening period. This represents a southwards extension of the distribution of these essentially tropical species during a period of increasing coastal water temperatures as a result of climate change. The abundance of weed-associated species, e.g. the western gobbleguts Ostorhinchus rueppellii and the soldier Gymnapistes marmoratus, increased, whereas that of the longfinned goby Favonigobius lateralis decreased, probably reflecting increases in eutrophication and siltation, respectively.

Patients' perceptions of hospice day care: a phenomenological study.

This study explored the perceptions of 12 patients attending a day care unit in June/July 1996, with the purpose of finding out what was important to these people about their day care experiences. It used a phenomenological methodology derived from Paterson and Zderad's Humanistic Nursing Theory. The patients described numerous aspects of the day care service that were important to them. All 12 people interviewed considered the service satisfactory, and a number considered it to be more than anyone could or should expect. Day care was found to help them feel comfortable, to feel of value and to feel less isolated. In addition, the participants were found to be living with cancer in two different ways. All 12 knew they had cancer and might be terminally ill. Yet some seemed to "tolerate" their life with cancer, whereas others saw it as requiring "adaptation". The day care service was supporting both these styles of managing life with cancer. The interpretation of the findings suggests that the reason patients expressed such satisfaction with the service offered was because the care was humanistic. It responded to individual opinions, feelings and understandings of health and well-being, by giving people time and responding to their individual concerns. In this way, it was flexible enough to support people in managing their illness using their own preferred style.

Salmeterol 100 microg: an analysis of its tolerability in single- and chronic-dose studies.

BACKGROUND: A combination product containing fluticasone propionate 100 or 250 microg and salmeterol 50 microg has recently been made available in the United States. Some patients, if previously instructed to double their inhaled corticosteroids, may double this product, inadvertently receiving higher doses of salmeterol, potentially causing systemic beta2-agonist-related effects. OBJECTIVES: To examine the systemic effects of single and chronic doses of salmeterol 100 microg. METHODS: Forty-four studies including a salmeterol 100 microg treatment arm were identified. Data on predictable systemic effects were available in 10 single-dose and 9 chronic-dose studies lasting more than 7 days, in patients with asthma (6 adult, 2 pediatric) or chronic obstructive pulmonary disease (1 study), which were included in a weighted, pooled analysis. RESULTS: Single 100-microg dose studies: mean change from baseline in heart rate was +2.3 beats per minute and systolic blood pressure +0.4 mm Hg. Tremor and palpitations were reported in 5.7% and 2.8%. Other systemic effects included a decrease in serum potassium for 3 subjects (2.1%); an increase in serum glucose, 1 subject (0.7%); and electrocardiographic (ECG) events, 24 cases (17.0%). Twenty-three of these were from one crossover study which reported 27 ECG events after placebo. Chronic dose studies (salmeterol 100 microg): mean change in heart rate and systolic blood pressure were +1.8 beats per minute and -0.2 mm Hg. Tremor and palpitations were reported in 5.6% and 1.7% of 1,504 patients. Thirteen recorded a decrease in serum potassium (0.9%) and 5 an increase in serum glucose (0.3%). Nine patients had ECG events (0.6%). Eight of these were "arrhythmia" from one study, which also reported 12 events before treatment. CONCLUSIONS: The mean systemic effects of salmeterol 100 microg are small and of doubtful clinical relevance. Patients (and their caregivers) can be reassured that inadvertently taking double doses of the new combination product are unlikely to affect them adversely.

Infection control in wound care: a study of fatalism in community nursing.

As part of a study of community nurses' perceptions of quality in nursing care, the author conducted in-depth qualitative interviews with seven community-based nurses. As part of the study, nurses were asked to describe episodes of wound care and to discuss the factors which could affect the quality of such care. One of the most interesting themes to emerge from the data was the apparent ambivalence of the nurses' attitudes towards infection control in wound care. Nurses discussed the concept of 'aseptic technique' in fatalistic terms and seemed uncertain about what could be achieved in terms of infection control. Although their policy guidelines referred to 'aseptic technique', their educational experience appeared to have made them feel uncertain about the implementation of the measures involved. With the proviso that this was a small scale qualitative study, the author concludes by suggesting that there is a need for greater clarity, both in what is taught and in what is included in practice policy with regard to infection control in wound care.

Palliative care: community nurses' perceptions of quality.

OBJECTIVES: To identify community nurses' perceptions of quality care provision for patients requiring palliative care. DESIGN: Semi-structured interviews were conducted with community nurses working within the district nursing service. An adaptation of Flanagan's critical incident technique was employed to elicit factors associated with high or poor quality palliative care. Interviews were tape recorded and transcribed. Data were analysed using thematic content analysis, recurrent themes being agreed by the research team. SETTING: One community healthcare trust. SUBJECTS: 62 members of the district nursing team (grades B-H). RESULTS: Respondents recounted the context in which high quality palliative care could be provided, the actions required, and the indicators that suggested the desired level of care had been achieved. Key factors identified were: the early referral of patients to the district nursing service, family circumstances, the availability of time, the accessibility of services and equipment, and the relationship with other healthcare professionals and informal carers. There was a general view that a positive outcome had been achieved when patients retained control over their circumstances and died a peaceful death, in the place of their choice, supported by their family. CONCLUSIONS: Community nurses were able to articulate clearly the essential components of high quality care. Whilst these factors do not represent a comprehensive list, they are put forward as a useful starting point for standard setting and subsequent audit.

Community nurses' perceptions of patient 'compliance' in wound care: a discourse analysis.

As part of an interview study of community nurses' perceptions of their work, 62 staff working within the district nursing service in one English National Health Service Trust (grades B-H) were asked to recount occasions when they had been involved in wound care and to discuss the ways in which working with patients who required such care could be either enhanced or made difficult. A large number of respondents expressed the view that non-compliance could pose serious problems for the management of wounds. Data relating to compliance are presented here and are interpreted in the light of discourse analysis, an approach which permits the researcher to focus on the meanings underlying the communications of research participants and to interpret those meanings in the light of social and cultural mores and influences. The authors found that non-compliance could be explained by nurses in a number of different ways. These ranged from passive resistance, which could be due to ignorance or lack of motivation, through overt refusal, to deliberate interference in order to prolong treatment. It also seeks to outline some of the factors that appear to motivate the nurses' desire to achieve compliance.

Wound care in the community setting: clinical decision making in context.

Sixty-two community nurses in northern England of grades B and D to H were interviewed by a team of four researchers. The interviews were semi-structured, and were tape-recorded, fully transcribed and content analysed. They were conducted as part of a larger study, the aim of which was to examine community nurses' perceptions of quality in nursing care. One of the main themes the work focused on was decision-making as an element of quality. Data relating to wound care were considered from the perspective of the insights they offered into clinical decision-making. Data were interpreted in the light of a literature review in which a distinction had been made between theories which represented clinical decision-making as a linear or staged process and those which represented it as intuitive. Within the former category, three sub-categories were suggested: theorists could be divided into 'pragmatists', 'systematisers' and those who advocated 'diagnostic reasoning'. The interpretation of the data suggested that the clinical decisions made by community nurses in the area of wound care appeared largely intuitive, yet were also closely related to 'diagnostic reasoning'. They were furthermore based on a range of sources of information and justified by a number of different types of rationale.

The importance of 'knowing the patient': community nurses' constructions of quality in providing palliative care.

This paper reports findings from a study conducted in one community health care trust where 62 members of the district nursing team (grades B-H) were interviewed. An adaptation of the critical incident technique was used to determine factors which contributed or detracted from high quality care for a number of key areas including palliative care. The centrality of knowing the patient and his/her family emerged as an essential antecedent to the provision of high quality palliative care. Factors enabling the formation of positive relationships were given prominence in descriptions of ideal care. Strategies used to achieve this included establishing early contact with the patient and family, ensuring continuity of care, spending time with the patient and providing more than the physical aspects of care. The characteristics described by the community nurses are similar to those advocated in 'new nursing' which identifies the uniqueness of patient needs, and where the nurse-patient relationship is objectified as the vehicle through which therapeutic nursing can be delivered. The link with 'new nursing' emerges at an interesting time for community nurses. The past decade has seen many changes in the way that community nursing services are configured. The work of the district nursing service has been redefined, making the ideals of new nursing, for example holism, less achievable than they were a decade ago. This study reiterates the view that palliative care is one aspect of district nursing work that is universally valued as it lends itself to being an exemplar of excellence in terms of the potential for realizing the ideals of nursing practice. This is of increasing importance in the context of changes that militate against this ideal.

An Exploratory Study of a Meditation-based Intervention for Binge Eating Disorder.

The efficacy of a 6-week meditation-based group intervention for Binge Eating Disorder (BED) was evaluated in 18 obese women, using standard and eating-specific mindfulness meditation exercises. A single-group extended baseline design assessed all variables at 3 weeks pre-and post-, and at 1, 3, and 6 weeks; briefer assessment occurred weekly.Binges decreased in frequency, from 4.02/week to 1.57/week (p < .001), and in severity. Scores on the Binge Eating Scale (BES) and on the Beck Depression and Anxiety Inventories decreased significantly; sense of control increased. Time using eatingrelated meditations predicted decreases on the BES (r 5 .66, p < .01). Results suggest that meditation training may be an effective component in treating BED.

Clinical experience with fluticasone propionate in asthma: a meta-analysis of efficacy and systemic activity compared with budesonide and beclomethasone dipropionate at half the microgram dose or less.

The relative clinical efficacy and systemic effects of different inhaled corticosteroids is controversial. To obtain further information on this matter, the authors have performed meta-analysis of seven trials comparing fluticasone propionate (FP) with budesonide (Bud), and seven trials comparing FP with beclomethasone dipropionate (BDP) for the treatment of asthma of all severities in adult and paediatric patients. In all cases, the drugs were compared at clinically equivalent doses, i.e. FP was given at half (or less) the microgram dose. The total number of patients was 1980 (1000 treated with FP 200-800 micrograms day-1 and 980 with Bud 400-1600 micrograms day-1), and 1584 patients in the second analysis (780 treated with FP 200-1000 micrograms day-1 and 804 with BDP 400-2000 micrograms day-1). FP significantly improved mean morning peak expiratory flow rate (PEFR) compared with Bud, with an overall difference of +11 l min-1. Analysis of serum cortisols showed no differences between FP and Bud treatment at low doses, but at higher dosages, and overall, significant differences in favour of FP were observed. In the second meta-analysis, no significant differences in PEFR were observed between FP and BDP in any of the seven individual studies or in the pooled analysis. Analysis of serum cortisols showed a similar trend to the previous analysis, however, no overall difference in serum cortisol results were seen between FP and BDP. In conclusion, the pooled analysis shows that FP at half the dose (or less) is more effective than Bud and as effective as BDP in improving PEFR; in addition, these improvements were achieved with a reduction in cortisol suppression compared with BUD and with no greater degree of cortisol suppression compared with BDP. This demonstrates, in patients with asthma, that FP has an improved efficacy to safety ratio compared with older inhaled corticosteroids.

Peripheral blood from human immunodeficiency virus type 1-infected patients displays diminished T cell generation capacity.

An organ culture chimera system was used to assess the effect of human immunodeficiency virus type 1 (HIV-1) infection on the T cell-generation capacity of precursors derived from human peripheral blood. Peripheral blood mononuclear cells from HIV-1-infected patients and uninfected controls were placed on fetal thymus lobes of NOD/LtSz-scid/scid mice. Blood from the HIV-1-infected patients consistently produced fewer CD4 and CD8 cells compared with blood from controls (P < .01). Addition of zidovudine to the cultures did not alter this profile. Limit dilution experiments suggested that there were fewer functional precursors in the infected patients. These results were not dependent on the patient's level of peripheral CD4 cells; even samples from patients with normal CD4 cell counts were unable to generate T cells in organ cultures. The results are consistent with a loss in the capacity of HIV-1-infected patients to produce functional T cell progenitors in their peripheral blood.

Learning through reflection in the community: the relevance of Schon's theories of coaching to nursing education.

In 1992, as part of a study funded by the English National Board for Nursing, Midwifery and Health Visiting, the author conducted 26 interviews, 12 with students on the newly-introduced Diploma in Higher Education for Nurses, and 14 with District Nursing Sisters who supervised them during their community placements. The approach to the work was interpretive and was guided by phenomenology. It was discovered that one of the most valuable contributions of their 'community experience' was the opportunities it gave the students to 'think through' and develop their own ideas about their practice. The author's interpretation of these findings was influenced by Donald Schon's ideas about reflective practice and coaching. His theory that professional practice is based on 'knowing-in-action' and 'theories-in-use' which are formulated and modified through a process of 'reflection-in-action' seemed to have direct relevance for the learning acquired by students. The help and guidance given to students by their supervisors bore some resemblance to the types of coaching advocated by Schon, to which he gave the names 'Joint Experimentation', 'Follow Me' and 'Hall of Mirrors'. The interpretation placed on the data discussed here also, however, differs from Schon's theories in advocating that more attention should be given to the academic theory referred to by him as 'technical rationality'.

Managing change in nurse education: the introduction of Project 2000 in the community.

The United Kingdom Central Council's proposals for nurse education (Project 2000: A New Preparation for Practice) were implemented in 13 demonstration districts in England in 1989. In 1991, as part of an English National Board-funded research study, the author conducted 15 interviews with first line managers from three of these demonstration districts. The data were reinterpreted in 1995; the experience of implementing educational change in the community setting was discovered to be a complex and difficult process for the managers involved. They found themselves confronted with sometimes conflicting responsibilities; their perception of their role encompassed the meeting of a range of needs, which are presented in this paper within three categories. Firstly, the managers felt they had an obligation to meet the needs of students and of education in general in order both to provide an adequate experience for each individual student and to safeguard standards in community nursing in the long-term. Secondly, they were confronted with the need to mitigate the pressures of Project 2000 placed on 'their' staff. The new educational programme meant that community nurses spent much more time with students than formerly, and the difficulties they encountered were exacerbated by uncertainty about their role with these elements. Finally, and most importantly, managers were responsible for ensuring that clients' needs were met. In particular, they saw it as their role to ensure that the presence of large numbers of students in the community for long periods of time did not compromise standards in the delivery of community nursing services.

The helping relationship in the community setting: the relevance of Rogerian theory to the supervision of Project 2000 students.

A series of twenty-six interviews, fourteen with district nursing sisters and twelve with students they supervised, was conducted in 1992 in one Project 2000 demonstration district in England. The data were collected as part of an English National Board funded research study; data were reinterpreted in 1994 and formed one element in the author's PhD thesis. Participants described the ways in which a supervisor might enable a student to learn during a community placement. One of the most important means by which supervisors could provide assistance was by creating an environment in which the students felt supported. Students described how supervisors demonstrated concern, acceptance and understanding, attributes which bore striking resemblance to the qualities of congruence, unconditional positive regard and empathic understanding identified by Carl Rogers as enabling learning.

The learning career in the community setting: a phenomenological study of a Project 2000 placement.

The findings of one element of an English National Board-funded research study conducted in two phases between 1989 and 1992 are discussed. The study examined one aspect of the new Project 2000 courses introduced in 13 'demonstration districts' in England in the autumn of 1989. During Phase 2 of the study (1991-1992). 14 district nursing sisters and 12 of the students they supervised were interviewed. Data were re-transcribed and interpreted in 1993; the interpretation was based on a phenomenological paradigm which focused on the subjective perceptions of students and supervisors. Participants identified 'learning', as it took place in the community setting, as a sequential process, which is referred to here as the 'learning career'. Using terminology adopted by participants themselves; the authors identify the stages of the 'learning career' as:'encountering reality'; 'having a go' 'gaining confidence'; 'thinking through and understanding'; 'developing ideas'; 'being independent'; and 'being assessed'. Supervisors could ease their students' passage through this complex and anxiety-provoking sequence of events in a number of ways. They could demonstrate their practice and provide opportunities for students to gain experience for themselves; they could teach their students about nursing, and enable them to reflect on their own practice; and they could also monitor and assess their students' work.