Driving behavior under the influence of cannabis or cocaine.

OBJECTIVE: The purpose of this study is first to describe perceptions of driving under the influence of cannabis or cocaine among clients in treatment and, second, to assess whether these perceptions are related to the frequency of driving under the influence of cannabis or cocaine. METHODS: A questionnaire was administered to clients in treatment for abuse of either cocaine or cannabis, many of whom also had a problem with alcohol; additional groups of clients consisted of those in smoking cessation and gambling programs (N = 1021). Open-ended and close-ended questions were used to assess self-reported effects of cannabis or cocaine on driving and frequency of driving under the influence of cannabis, cocaine, or alcohol. RESULTS: Two dimensions of driving behavior under the influence of cocaine or cannabis were found in both qualitative and quantitative analyses: 1) physical effects and 2) reckless styles of driving. Common physical effects for both drugs were heightened nervousness, greater alertness, and poorer concentration. In terms of driving behavior, cautious or normal driving was commonly reported for cannabis, whereas reckless or reduced driving ability was frequently reported for cocaine. When comparing negative physical effects and reckless style of driving with frequency of driving under the influence of cannabis or cocaine, increased negative physical effects from cannabis were inversely related to frequency of driving under the influence of cannabis (p = .001), but other relationships were not significant. CONCLUSIONS: The findings indicate that both cannabis and cocaine have detrimental but different effects on driving. The negative physical effects of cannabis may reduce the likelihood of driving under the influence of cannabis.

School-age children's safety attitudes, cognitions, knowledge, and injury experiences: how do these relate to their safety practices?

BACKGROUND: A variety of factors affect the safety and risk practices of school-age children, but rarely have multiple factors been considered simultaneously. OBJECTIVE: To examine children's safety attitudes and cognitions more thoroughly and assess how these factors, along with children's safety knowledge and injury experiences, relate to children's safety practices. METHODS: Over several classroom sessions, boys and girls in two age groups (7-9, 10-12 years) completed a psychometrically sound questionnaire that indexes their behaviors, attitudes, cognitions, knowledge, and injury experiences. RESULTS: Fewer safety practices were reported by older than younger children and boys than girls. Children's attitudes, cognitions, knowledge, and injury experiences each correlated with safety practices, but only safety attitudes and injury experiences predicted practices in a multivariate model. CONCLUSION: Exploring the relative influence of numerous factors on safety practices highlights the important role that attitudes play in predicting children's safety practices. Implications of these results for injury prevention programming are discussed.

Cataract surgery rates in Ontario, Canada, from 1992 to 2004: more surgeries with fewer ophthalmologists.

BACKGROUND: To evaluate trends in cataract surgeries in Ontario between 1992 and 2004. METHODS: A retrospective analysis of the number of cataract surgeries performed in Ontario from April 1992 to March 2005. The estimated prevalence of cataract and cataract surgeries per 1000 persons at risk was calculated. RESULTS: The number of cataract surgeries in Ontario increased from 44,943 in 1992 to 109,506 in 2004 (143.6%, 12.08% annual increase). The number of cataract surgeries per 1000 patients at risk of cataract increased from 64.6 in 1992 to 115.65 in 2004 (79%, 4.97% increase per year). This rate was strongly positively correlated with time and with the increase in the Ontario population (r = 0.920 and r = 0.922, respectively; p < 0.001). The number of ophthalmologists increased by 5.3% from 1992 to 1997 and then decreased by 2.9% by 2004. This change was not correlated with the cataract surgery rates (r = 0.475; p = 0.10). However, the number of ophthalmologists per million population decreased by 13.4% between 1992 and 2004. This number had a statistically negative correlation with cataract surgery rates (r = -0.757; p < 0.01). INTERPRETATION: There has been a significant increase in the number of cataract surgeries in Ontario despite a decrease in the number of ophthalmologists per million population.

Geomatics in injury prevention: the science, the potential and the limitations.

BACKGROUND: Geomatics describes the activities involved in acquiring and managing geographical data and producing geographical information for scientific, administrative and technical endeavors. As an emerging science, geomatics has a great potential to support public health. Geomatics provides a conceptual foundation for the development of geographic information systems (GIS), computerized tools that manage and display geographical data for analytical applications. As descriptive epidemiology typically involves the examination of person, place and time in the occurrence of disease or injury, geomatics and GIS can play an important role in understanding and preventing injury. AIM: This article provides a background to geomatics for those in the injury prevention field who are unfamiliar with spatial analysis. We hope to stimulate researchers and practitioners to begin to use geomatics to assist in the prevention of injury. METHODS: The authors illustrate the potential benefits and limitations of geomatics in injury prevention in a non-technical way through the use of maps and analysis. RESULTS: By analysing the location of patients treated for fall injuries in Central Toronto using GIS, some demographic and land use variables, such as household income, age, and the location of homeless shelters, were identified as explanatory factors for the spatial distribution. CONCLUSION: By supporting novel approaches to injury prevention, geomatics has a great potential for efforts to combat the burden of injury. Despite some limitations, those with an interest in injury prevention could benefit from this science.

Economic disparity in bicycle helmet use by children six years after the introduction of legislation.

BACKGROUND: Studies evaluating the effectiveness of bicycle helmet legislation often focus on short term outcomes. The long term effect of helmet legislation on bicycle helmet use is unknown. OBJECTIVE: To examine bicycle helmet use by children six years after the introduction of the law, and the influence of area level family income on helmet use. METHODS: The East York (Toronto) health district (population 107,822) was divided into income areas (designated as low, mid, and high) based on census tract data from Statistics Canada. Child cyclists were observed at 111 preselected sites (schools, parks, residential streets, and major intersections) from April to October in the years 1995-1997, 1999, and 2001. The frequency of helmet use was determined by year, income area, location, and sex. Stratified analysis was used to quantify the relation between income area and helmet use, after controlling for sex and bicycling location. RESULTS: Bicycle helmet use in the study population increased from a pre-legislation level of 45% in 1995 to 68% in 1997, then decreased to 46% by 2001. Helmet use increased in all three income areas from 1995 to 1997, and remained above pre-legislation rates in high income areas (85% in 2001). In 2001, six years post-legislation, the proportion of helmeted cyclists in mid and low income areas had returned to pre-legislation levels (50% and 33%, respectively). After adjusting for sex and location, children riding in high income areas were significantly more likely to ride helmeted than children in low income areas across all years (relative risk = 3.4 (95% confidence interval, 2.7 to 4.3)). CONCLUSION: Over the long term, the effectiveness of bicycle helmet legislation varies by income area. Alternative, concurrent, or ongoing strategies may be necessary to sustain bicycle helmet use among children in mid and low income areas following legislation.

Castleman's disease and HIV infection in Australia.

OBJECTIVES: To describe, retrospectively, the Australian experience of multi-centric Castleman's disease (MCD) in the setting of HIV infection, specifically with the advent of HAART, and newer chemotherapeutic agents. PATIENTS AND METHODS: HIV-infected patients diagnosed with MCD since 1994, were identified from three major HIV treatment centres in Australia. Demographic and disease characteristic variables were collated by the National Centre in HIV Epidemiology and Clinical Research. RESULTS: Eleven patients were identified with MCD. Medial follow up was 46 (18-57) months. All had CD4 cell counts less than 500 cells/microL. All but one patient was receiving HAART at the time of diagnosis. Nine of the 11 patients had Kaposi's sarcoma (KS) and two patients also developed non-Hodgkin's Lymphoma (NHL). All patients received chemotherapy for MCD. The response rate from Chemotherapy was 64%. Only two patients achieved sustained remissions. The median survival was 21.9 (1-52) months. The mortality was 45% from MCD and its related complications. CONCLUSION: MCD in HIV infected patients is a rare and life-threatening disorder. There is limited recent information on optimal treatment for MCD. MCD in our series appeared to be a chemo-responsive disease. In our experience, treatment with liposomal anthracycline was associated with good response rates and acceptable toxicity in several patients, and therefore merits further exploration to establish its role. Treatment in the future may concentrate on novel agents such as anti-interleukin 6, anti-CD20 antibodies, thalidomide and viral ablation.

Chronic noncancer pain and the long term utility of opioids.

OBJECTIVE: To report on a long term experience in treating patients with chronic noncancer pain (CNCP). METHODS: One hundred two patients with CNCP were seen every three months and followed for one year or more (median eight years, range one to 22). Demographic data, diagnostic categories and response to therapies were recorded. The utility and safety of opioid therapy, adverse events, impact on disability and issues related to previous psychiatric or chemical dependency history were documented. RESULTS: Most patients reported a variety of neuropathic pain problems and most required chronic opioid therapy after the failure of other treatments. Although 44% reported being satisfied with pain relief despite adverse events, it is noteworthy that the remaining patients chose to continue therapy for the modest benefit of pain relief despite adverse events. Moreover, 54% were less disabled on opioid therapy. CONCLUSIONS: This is a large sample of CNCP patients, most taking opioids over a long period of time. CNCP can be treated by opioids safely and with a modest effect, with improvement in functioning in some patients who are refractory to other measures. If care is taken, opioids may even be used effectively for patients with a history of chemical dependency.

A phase II study of escalated-dose docetaxel with granulocyte colony-stimulating factor support in patients with advanced breast cancer.

PURPOSE: Docetaxel is highly active in the treatment of patients with breast cancer. The principal dose-limiting toxicities of the 3-weekly regimen are neutropenia and febrile neutropenia. In a previous phase I dose-escalation study with granulocyte colony-stimulating factor (G-CSF) support, the recommended dose was determined to be docetaxel 160 mg/m(2) 3-weekly. The objectives of this phase II study were to determine the response rate and toxicity of this dose and schedule, given as first-line in patients with advanced breast cancer. Mobilisation of peripheral blood stem cells (PBSCs) was also investigated. PATIENTS AND METHODS: Eligible women had metastatic breast cancer and were aged 18-75 years with ECOG performance status < or =2. Strict criteria for liver function were followed, and adjuvant chemotherapy must have been completed at least 6 months previously. Treatment was docetaxel 160 mg/m(2) over 60-90 min every 21 days with G-CSF 5 micro g/kg/day until neutrophil recovery, for up to six cycles. A 3-day corticosteroid prophylaxis was given. Bloods samples to determine PBSC levels [CD34+, granulocyte-macrophage colony-forming cells (GM-CFC) and burst-forming units-erythroid (BFU-E)] were taken on days 6, 8, 9 and 11 following docetaxel. RESULTS: Twenty-five women with median age 50 years (range 35-66) were included. Seventeen (68%) had previously received adjuvant chemotherapy. In total, 112 cycles were delivered (median four per patient), with dose reductions required in 12.5% of cycles. G-CSF was given for a median of 6 days. The median neutrophil nadir was 0.5 x 10(9)/l and occurred a median 5 days after treatment. The median duration of grade 3 or 4 neutropenia was 2 days (range 1-7). Grade 4 neutropenia occurred in 44% of patients, but there was only one episode of febrile neutropenia. Five patients were taken off study due to toxicities that included oedema, neurosensory toxicity and asthenia. Confirmed partial response was seen in nine patients (37.5%; 95% confidence interval 19% to 59%). CD34+ cells, GM-CFC and BFU-E levels peaked at day 8 following docetaxel administration. The median CD34+ cell peak was 6.5 x 10(4)/ml, with only 20% of patients <2 x 10(4)/ml, a level below which leukapheresis is not usually attempted. CONCLUSIONS: Docetaxel 160 mg/m(2) was delivered with G-CSF support with a very low rate of febrile neutropenia. Non-haematological toxicity was significant, causing five patients to go off study. Effective mobilisation of PBSCs was seen. The response rate of 37.5% was less than that obtained in first-line studies using standard-dose docetaxel 100 mg/m(2), suggesting that there is no additional benefit in dose escalation of this cytotoxic agent in breast cancer patients using this schedule.

Child safety education and the world wide web: an evaluation of the content and quality of online resources.

The purpose of this study was to assess the content, quality, and type of internet resources available for safety education. Using 19 search engines with search strings targeting major forms of injury, identified resources were classified by audience group, accessibility, and authorship. Two independent reviewers rated each resource on the basis of its content and a set of quality criteria using a three point scale. Overall, 10 (18.2%) resources were of highest quality, four (7.3%) were intermediate, and 41 (74.5%) were not recommended. Eighteen months after the original search, 67.3% of all resources and 90% of the highest quality resources were still on the internet. This study provides a methodology for evaluating child safety resources on the world wide web and demonstrates that most internet resources for safety education are of dubious quality. A rating system such as the one developed for this study may be used to identify valuable internet materials.

Being "at fault" in traffic crashes: does alcohol, cannabis, cocaine, or polydrug abuse make a difference?

OBJECTIVE: To compare associations of alcohol, cannabis, and cocaine abuse and traffic crash risk for "at fault" crashes and all crashes. DESIGN: A historical cohort study. SETTING: Toronto, Ontario. Patients or subjects: Subjects beginning treatment at the Centre for Addictions and Mental Health (CAMH) in 1994 for abuse of alcohol, cannabis, cocaine, and all combinations of these substances (n = 590, with 411 drivers). A control group consisted of 518 records from the Ontario registry of registered drivers, frequency matched for age and sex and residence. INTERVENTIONS: CAMH subjects took part in therapeutic programs. Pre-intervention (11 115 driver-years) and post-intervention intervals (8550 driver-years) were defined and compared. MAIN OUTCOME MEASURES: Crash and collision rates, adjusted relative risks (ARRs) of crash involvement and of "at fault" crashes were computed using Poisson regression to control for variations in time at risk, age, and sex of participants. RESULTS: Pre-treatment, significant ARRs of 1.49 to 1.79 for all crashes were found for abusers of cannabis, cocaine, or a combination. ARRs increased by 10%-15% for "at fault" crashes. Post-treatment, all associations were very modest for all abuse types. Only younger and male drivers had a significantly increased risk, which was stronger for "at fault" than for all crashes. CONCLUSIONS: Abuse of cannabis and cocaine pre-treatment was more strongly related to "at fault" crashes than to all crashes. Interaction between these substances means that the effects of combined abuse cannot be predicted from simple main effects.

Evaluation of the ThinkFirst Canada, Smart Hockey, brain and spinal cord injury prevention video.

OBJECTIVE: The ThinkFirst Canada Smart Hockey program is an educational injury prevention video that teaches the mechanisms, consequences, and prevention of brain and spinal cord injury in ice hockey. This study evaluates knowledge transfer and behavioural outcomes in 11-12 year old hockey players who viewed the video. DESIGN: Randomized controlled design. SETTING: Greater Toronto Minor Hockey League, Toronto Ontario. SUBJECTS: Minor, competitive 11-12 year old male ice hockey players and hockey team coaches. INTERVENTIONS: The Smart Hockey video was shown to experimental teams at mid-season. An interview was conducted with coaches to understand reasons to accept or refuse the injury prevention video. MAIN OUTCOME MEASURES: A test of concussion knowledge was administered before, immediately after, and three months after exposure to the video. The incidence of aggressive penalties was measured before and after viewing the video. RESULTS: The number of causes and mechanisms of concussion named by players increased from 1.13 to 2.47 and from 0.67 to 1.22 respectively. This effect was maintained at three months. There was no significant change in control teams. There was no significant change in total penalties after video exposure; however, specific body checking related penalties were significantly reduced in the experimental group. CONCLUSION: This study showed some improvements in knowledge and behaviours after a single viewing of a video; however, these findings require confirmation with a larger sample to understand the sociobehavioural aspects of sport that determine the effectiveness and acceptance of injury prevention interventions.

A phase I dose-escalation study of docetaxel with granulocyte colony-stimulating factor support in patients with solid tumours.

BACKGROUND: Docetaxel is a widely active cytotoxic agent. The principal dose-limiting toxicities (DLTs) of the 3-weekly regimen are neutropenia and febrile neutropenia. Use of prophylactic granulocyte colony-stimulating factor (G-CSF) may allow higher doses of docetaxel to be administered with potentially greater anticancer efficacy. The objectives of this study were to determine the maximum tolerated dose (MTD) and toxicity profile of docetaxel given with G-CSF support. PATIENTS AND METHODS: Eligible patients had solid tumours and were aged 18-75 years with a WHO performance status of up to 2. Strict criteria for liver function were followed. Patients may have received one previous regimen of chemotherapy in addition to adjuvant chemotherapy. Cohorts of three to six patients received docetaxel over 60-90 min every 3 weeks, commencing at 110 mg/m(2) and escalating at 10 mg/m(2) increments. Patients also received G-CSF 5 micro g/kg/day until neutrophil recovery. A 3-day corticosteroid prophylaxis was given. RESULTS: Twenty-nine patients with median age 55 years (range 29-75) were included. Fourteen (48%) had previously received chemotherapy. At the 170 mg/m(2) dose level (the MTD), two of three patients had DLTs and 160 mg/m(2) was determined to be the recommended dose. The principal DLTs were skin and neurosensory toxicity. Asthenia was frequent, especially at dose levels >/=140 mg/m(2). Grade 4 neutropenia occurred in only 10 patients (35%) and was not dose related, with febrile neutropenia in three patients (10%). CONCLUSIONS: Docetaxel may be escalated considerably above standard doses when administered with G-CSF support. The recommended dose for phase II studies is 160 mg/m(2). With escalated-dose docetaxel, DLTs were non-haematological and qualitatively similar to the toxicity profile at standard doses.

Nortriptyline versus amitriptyline in postherpetic neuralgia: a randomized trial.

UNLABELLED: OBJECTIVE (BACKGROUND): Amitriptyline (AT) is a standard therapy for postherpetic neuralgia (PHN). Our hypothesis was that nortriptyline (NT), a noradrenergic metabolite of AT, may be more effective. METHODS: A randomized, double-blind, crossover trial of AT versus NT was conducted in 33 patients. RESULTS: Thirty-one patients completed the trial. Twenty-one of 31 (67.7%) had at least a good response to AT or NT, or both. We found no difference with regard to relief of steady, brief, or skin pain by visual analog scales for pain and pain relief; mood; disability; satisfaction; or preference between the two drugs. Intolerable side effects were more common with AT. Most patients (26/33) were not depressed, and most responding showed no change in rating scales for depression despite the occurrence of pain relief. CONCLUSIONS: We concluded that this study provides a scientific basis for an analgesic action of NT in PHN because pain relief occurred without an antidepressant effect, and that although there were fewer side effects with NT, AT and NT appear to have a similar analgesic action for most individuals.

To drive or not to drive: the influence of social factors on the decisions of elderly drivers.

Being able to drive is considered to be an important, if not vital, component of mobility in many jurisdictions. From a large population-based health survey, carried out in Ontario, Canada in 1990 it is estimated that 37.5% of the population aged 80 or older drives a motor vehicle at least once a year. Data from the survey have been used to make comparisons of drivers and non-drivers: people who drive are more likely to be male, to be married and to report no more than one chronic disease. People who do not drive are more likely to live in larger households and to report two or more chronic diseases. Although many of these factors are clearly related to one another, they exert independent associations with whether people drive after other factors have been controlled. Drivers and non-drivers have similar frequency of contact with family and friends after other variables have been controlled for.

The prevalence of positive hepatitis B, hepatitis C, and HIV serology in cornea donors prescreened by medical and social history in Ontario, Canada.

PURPOSE: To determine the prevalence of hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV) in the serum of cornea donors who had been previously screened by social and medical history by the Eye Bank of Canada, Ontario Division. METHOD: A retrospective examination of the donor records of the Eye Bank of Canada, Ontario Division, was conducted. A total of 3,228 records were examined covering the period from May 17, 1993 to May 31, 1996. RESULTS: The prevalence of HBV was determined to be 0.25%, HCV, 0.93%; and HIV, 0.031%. CONCLUSION: The data revealed that despite the use of medical and social history to prescreen, a small percentage of prescreened donors test serologically positive. A comparison of the prevalence of HBV, HCV, and HIV in the prescreened cornea donors to a similarly screened cohort of blood donors over a similar time period reveals a higher prevalence in all three diseases in the cohort of cornea donors. An examination of the demographic characteristics of the population as a whole versus the three groups with confirmed serology failed to show a significant difference between the seropositive and seronegative groups. This study confirms the value and necessity of serologic prescreening of cornea donors as is currently the standard of practice.

Systemic metal ion levels in dental implant patients.

Metal ion release from metallic implants is known to occur, but its extent and implications are controversial. In spite of the rapidly growing use of such implants, little is known about metal ion release. Blood levels of titanium, aluminum, and vanadium were measured using an atomic absorption spectrophotometric technique preoperatively and at intervals over a 3-year period for 52 patients (17 men, 35 women), each of whom had three mandibular porous-surface endosseous dental implants. The results showed that there was no evidence of change from preoperative to long-term values for the three metals measured in the study. These findings are reassuring, but do not rule out local or remote accumulation of released ions, which was not measured in this study.

Stalkers and other obsessional types: a review and forensic psychological typology of those who stalk.

Stalking, an age-old phenomenon, was discussed in the ancient writings of Hippocrates, researched extensively in the early 20th century by French psychiatrist G.G. de Clerambault, given notoriety with the tragic death of former Beatle John Lennon, and viewed as 'Fatal Attraction' in local theaters across the world. Stalking is unique as the repetitive, harassing, long-term course of conduct and behaviour reflects the internal dynamics of the stalker's motivating mental disorder. Furthermore, the investigation of stalking is difficult. The numerous and progressive acts, comprising the intentional course of conduct, require a continuity of purpose: harassment designed to control the victim. A multi-disciplinary approach, utilizing law enforcement, legal, medical and mental health professionals, is necessary to effectively eradicate this encroaching behaviour. In 1990, the first Anti-Stalking legislation was passed in California, USA. In just 6 years, all 50 states have followed suit. Public awareness has encouraged federal legislation to stop stalking behaviour as a course of conduct crime and to give victims a measure of protection. This research paper overviews periodicals, law review articles, studies and projects of law enforcement, legal counsel, medical professionals, forensic mental health professionals, forensic examiners and criminologists since 1992. The study of stalkers and stalking behaviour is a work in progress. As questions are answered, statutes are amended and diagnoses are distinguished, it becomes a stepping stone to the future understanding of the pervasive stalking phenomenon facing our culture and society today.

Clinical outcomes following penetrating keratoplasty using the Barron-Hessburg and Hanna corneal trephination systems.

Two corneal suction trephination systems currently in use are the Barron-Hessburg and the Hanna trephine. This study assessed the outcome of patients who received penetrating keratoplasty using these two systems. One hundred twenty-four eyes (62 with the Hanna system, 62 with the Barron-Hessburg system) from 98 patients undergoing penetrating keratoplasty were evaluated retrospectively. Best corrected spectacle acuity and corneal astigmatism were assessed 6 and 12 months after surgery. No significant difference was noted between the groups 6 months after surgery. At 12 months, a significant improvement in spectacle acuity was present with 55% of the Hanna group having visual acuity of 20/40 or better compared with 33% of the Barron-Hessburg group (p < 0.005). This difference was greater if eyes having the best visual prognoses were separately evaluated: 74% of the Hanna group had 20/40 vision or better compared with 41% of the Barron-Hessburg group (p < 0.005). In eyes having a good visual prognosis, a significant improvement in visual acuity was present, with 33% of the Hanna group improving nine or more lines compared with 9% of the Barron-Hessburg group (p < 0.05). Postoperative keratometric and refractive astigmatism were not different at 6 or 12 months. We found that visual recovery at 1 year is better using the Hanna system, especially in eyes with good visual prognoses.

Medications as risk factors for farm injury.

A case-control study was used to determine whether cases of farm injury were more likely than controls to have been regularly exposed to certain types of medication including those that cause side effects which may predispose to injury. Persons reporting an injury (n = 176) were identified in a population-based mail survey of people on 1364 Ontario farms, and compared to people without injuries using a 4:1 control: case ratio. Bivariate, stratified, and multivariable analyses were used to quantify the strength of associations between exposures to certain medications and the occurrence of farm injury. Those who regularly used certain types of medication were separated into two groups: people who used the medications in isolation, and those who used the medications in combination with other medications. Response to the survey was 77.3% among cases and 82.6% among controls. Strong and statistically significant increases in risk for injury were observed in association with the regular use of stomach remedies or laxatives by males (OR 2.8; 95% CI: 1.0,7.7), and regular use of heart of circulatory medications by men over the age of 45 (OR 4.2; 95% CI: 1.2,14.7). The identified associations remained after adjustment for age, co-morbidity, tillable farm acreage, education, income, alcohol consumption and tobacco use. Several possible explanations for the occurrence of the identified associations, other than the etiological hypothesis originally advanced, are discussed.

A strategy to promote research-based nursing care: effects on childbirth outcomes.

Studies at area hospitals revealed many gaps between research evidence and intrapartum nursing practices. A randomized controlled trial involving 20 hospitals was used to evaluate the effectiveness of a marketing strategy to promote research-based nursing care. It was hypothesized that the strategy would result in lower rates of epidural analgesia, through increasing the amount of support nurses provided to their patients. Other outcomes included rates of narcotic analgesia, episiotomy, and operative delivery. The marketing strategy was unsuccessful in improving intrapartum nursing care. Much more research is needed about the factors that facilitate improvements in nursing practice.