Managing asthma within the context of the rural family.

The purpose of this qualitative study was to describe the experiences of rural families caring for children with asthma. The chief caregivers from six rural families were interviewed about the family's daily experiences in living with asthma, their knowledge of asthma triggers, and strategies for managing asthma. Parental knowledge about asthma and asthma management strategies was quite good. The cost of asthma regimens and school policies about medications were major barriers to better control. Other management strategies were directed at maintaining normality of family life.

A retrospective review of clinical characteristics and treatment response in body dysmorphic disorder versus obsessive-compulsive disorder.

BACKGROUND: Although body dysmorphic disorder (BDD) has many features in common with obsessive-compulsive disorder (OCD) and is frequently comorbid with OCD, few studies have directly compared the 2 disorders. Although BDD and OCD respond to similar medications and cognitive-behavioral therapy (CBT), their response to treatment has never been directly compared. METHOD: We studied 107 consecutive patients with DSM-III-R OCD (N = 96) or BDD (N = 11) treated openly for 6 weeks with intensive CBT, medication, and psychosocial rehabilitation, in a specialized partial hospitalization program for severely ill OCD patients. All patients were assessed, before and after treatment, with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Hamilton Rating Scale for Depression (HAM-D), Hamilton Rating Scale for Anxiety (HAM-A), and Global Assessment Scale (GAS). Retrospectively, we compared the clinical characteristics, symptom severity, and response to treatment of BDD patients with those of OCD patients. RESULTS: BDD patients and OCD patients had similar sex ratio, age, treatment duration, prevalence of comorbid major depression, and pretreatment Y-BOCS and GAS scores. BDD patients had significantly higher pretreatment HAM-D and HAM-A scores. The proportions of patients treated with serotonin reuptake inhibitors and antipsychotics did not differ between groups. Both groups improved with treatment, with significant (p < .001) changes in Y-BOCS, HAM-D, HAM-A, and GAS scores. Change in Y-BOCS did not differ between groups, but changes in HAM-D and HAM-A were significantly greater in BDD patients than in OCD patients. CONCLUSION: While BDD may be associated with greater severity of depressive and anxiety symptoms than OCD, this study suggests that BDD may respond to intensive, multimodal treatment.

Executive dysfunction predicts nonresponse to fluoxetine in major depression.

BACKGROUND: Functional brain imaging studies of major depression have consistently revealed hypometabolism or hypoperfusion in specific regions of the prefrontal cortex and basal ganglia. Studies of cognitive functioning in major depression have suggested that some but not all subjects exhibit cognitive deficits that are consistent with frontal-subcortical dysfunction, although the reasons for this heterogeneity are unclear. In this study, we explored this heterogeneity among depressed subjects by examining the relationship between cognitive functioning and treatment outcome. METHOD: Subjects with major depression were administered a complete neuropsychological test battery prior to treatment with fluoxetine. RESULTS: There were no significant differences between responders and nonresponders to fluoxetine in terms of age, educational achievement, number of past episodes of depression, and estimated premorbid IQ. However, nonresponders performed significantly worse than responders on several pretreatment measures of executive functioning, after controlling for baseline group differences in depression severity. LIMITATIONS: The results are based on a small sample of primarily female subjects, resulting in low statistical power and less generalizability to samples of male subjects with depression. CONCLUSIONS: The findings suggest that subtle prefrontal dysfunction in subjects with major depression may be predictive of poor response with particular medications. Assessment of the executive functions may play a particular role in pretreatment identification of subjects likely to respond to specific medications.

Neurophysiologic predictors of treatment response to fluoxetine in major depression.

Treatment with antidepressants is marked by heterogeneity of response; predicting individual response to any given agent remains problematic. Neuroimaging studies suggest that response is accompanied by physiologic changes in cerebral energy utilization, but have not provided useful markers at pretreatment baseline. Using quantitative EEG (QEEG) techniques, we investigated pretreatment neurophysiologic features to identify responders and non-responders to fluoxetine. In a double-masked study, 24 adult subjects with current major depression of the unipolar type were studied over 8 weeks while receiving fluoxetine (20 mg QD) or placebo. Neurophysiology was assessed with QEEG cordance, a measure reflecting cerebral energy utilization. Response was determined with rating scales and clinical interview. Subjects were divided into discordant and concordant groups based upon the number of electrodes exhibiting discordance. The concordant group had a more robust response than the discordant group, judged by lower final Hamilton Depression (HAM-D) mean score (8.0+/-7.5 vs. 19.6+/-4.7, P = 0.01) and final Beck Depression Inventory (BDI) mean score (14.0+/-9.4 vs. 27.8+/-3.7, P = 0.015), and by faster reduction in symptoms (HAM-D: 14.0+/-5.0 vs. 23.8+/-4.1, P = 0.004 at 1 week). Groups did not differ on pretreatment clinical or historical features. Response to placebo was not predicted by this physiologic measure. We conclude that cordance distinguishes depressed adults who will respond to treatment with fluoxetine from those who will not. This measure detects a propensity to respond to fluoxetine and may indicate a more general responsiveness to antidepressants.

Localized orbitofrontal and subcortical metabolic changes and predictors of response to paroxetine treatment in obsessive-compulsive disorder.

Previous positron emission tomography (PET) studies of patients with obsessive-compulsive disorder (OCD) have found elevated glucose metabolic rates in the orbitofrontal cortex (OFC) and caudate nuclei that normalize with response to treatment. Furthermore, OCD symptom provocation differentially activates specific subregions of the OFC, which have distinct patterns of connectivity and serve different functions. Therefore, we sought to determine the role of specific subregions of the OFC and associated subcortical structures in mediating OCD symptoms, by determining how glucose metabolism in these structures changed with paroxetine treatment of OCD patients. We also sought to determine whether pretreatment OFC metabolism would predict response to paroxetine, as it has for other OCD treatments. Twenty subjects with OCD received [18F]-fluorodeoxyglucose (FDG)-PET scans before and after 8 to 12 weeks of treatment with paroxetine, 40 mg/day. In patients who responded to paroxetine, glucose metabolism decreased significantly in right anterolateral OFC and right caudate nucleus. Lower pretreatment metabolism in both left and right OFC predicted greater improvement in OCD severity with treatment. These results add to evidence indicating that orbitofrontal-subcortical circuit function mediates the symptomatic expression of OCD. Specific subregions of the OFC may be differentially involved in the pathophysiology of OCD and/or its response to pharmacotherapy.

Recruitment barriers in rural community hospitals: a comparison of nursing and nonnursing factors.

Despite encouraging signs suggesting that many rural hospitals are experiencing less severe staff shortages, the challenge of successfully recruiting nurses to rural practice settings continues to be a major obstacle. Based on a 1993 survey of 164 directors of nursing (DONs) practicing in rural community hospitals, exploratory factor analysis (EFA) was used to cluster 21 DON-rated recruitment barriers into factors associated with nursing delivery, local community, and professional interaction. DONs, most notably those practicing in the smallest rural facilities (< or = 25 beds), reported community-related barriers such as spouse's employment as the most severe obstacles to successful registered nurse (RN) recruitment. However, upon examination conducted by using multiple regression analyses, only those factors related to nursing delivery and professional interaction were found to be statistically significant predictors of existing staff RN full-time equivalency vacancy rates. Given that barriers related to individual nursing staffs are likely to be far more amenable to change than those associated with rural environments, these findings offer encouragement to nursing administrators who are faced with the difficulties of attracting RNs to rural practice settings.

Dementia caregiver burden: a review of the literature and guidelines for assessment and intervention.

Alzheimer's disease (AD) and other dementias are common degenerative disorders in the elderly. Most AD patients are cared for at home by family members, usually elderly spouses. Although caregiving is associated with significant psychological and physical morbidity, there are wide individual differences among caregivers in how well they adapt to caregiving demands. In addition, recent data suggest that caregiver variables can be important determinants of AD patient institutionalization and that AD patients living with highly distressed caregivers may exhibit higher frequencies of behavioral problems and agitation than those living with less distressed caregivers. Predictors of caregiver outcome, predictors of institutionalization, and the effect of the caregiver on the course and symptomatology of dementia are described. A model of assessment and intervention for the physician, referral processes, and resources for the caregiver are presented.

Brain structure and function and the outcomes of treatment for depression.

BACKGROUND: Depressed patients have a variety of brain structural alterations, the most common being atrophy and deep white-matter lesions. Alterations in brain function also are common, particularly regional decreases in cerebral metabolism and perfusion. METHOD: We review here the evidence that alterations in brain structure and function may explain some of the heterogeneity in outcomes of depression. We also report initial results suggesting that measurement of brain structure and function may help to predict outcomes of treatment for depression. Brain structure was examined using three-dimensional reconstruction and volumetric analysis of magnetic resonance imaging (MRI) scans. Brain function was examined using quantitative electroencephalography (QEEG), performed at baseline and serially during the course of treatment. QEEG measures included coherence (a measure of synchronized activity between brain regions) and cordance (a measure strongly associated with regional cerebral perfusion). RESULTS: Depressed patients have been reported to have larger volumes of white-matter lesions than controls. We have found that some types of white-matter lesions are associated with lower coherence and that subjects with low coherence had significantly poorer outcomes of treatment for depression at 2-year follow-up. Depressed subjects had low cordance at baseline, which decreased further during the course of effective treatment. Subjects who did not improve had little or no change in cordance. Changes in cordance were detected prior to the onset of clinical response, with decreases seen as early as 48 hours after the initiation of treatment in subjects who showed eventual response. CONCLUSION: These preliminary results suggest that functional imaging using QEEG may be useful for assessing, and possibly predicting, outcomes of treatment for depression.

Why rural practice?

In a national study of rural registered nurses, over 3,500 listed family or community-related reasons for practicing in rural areas. On the other hand, at least half stated that job-related factors would influence them to leave their present positions.

Retainment incentives in three rural practice settings: variations in job satisfaction among staff registered nurses.

Researchers have demonstrated repeatedly the importance of the relationship linking job satisfaction to employee retention. In rural areas of the country, where a persistent maldistribution of nurses continues to hamper health care delivery, the potential benefits of bolstering retention via enhancements in job satisfaction are of utmost utility to administrators and providers alike. Data were gathered from a multistate survey of registered nurses (RNs) practicing in rural hospitals, skilled nursing facilities, and community/public health settings (N = 1,647; response rate = 40.3%). The investigators found that the use of tuition reimbursement corresponded significantly with increased levels of job satisfaction among nurses in all three practice environments, as did day care services for nurses in acute care settings. Also, among hospital-based RNs, level of nursing education was found to be a significant factor in the relationship between tuition reimbursement and job satisfaction, with the highest level occurring among diploma-prepared nurses.

A logit analysis of the likelihood of leaving rural settings for registered nurses.

This study examined the net effects of individual and community factors on the likelihood of registered nurses leaving current jobs using a logit analysis. Based on data from a survey of 2,509 rural nurses, four separate models were estimated and compared: one for nurses in rural settings as a whole and the other three for nurses in hospitals, skilled nursing facilities, and community/public health agencies. Results of the general model indicated that nurses' marital status, age, position, income, job satisfaction, and satisfaction with the community were significant determinants of the likelihood of leaving current jobs. Job satisfaction was the most significant factor, followed by satisfaction with the community. Findings from the models for three different employment settings were similar to those of the general model. However, the significance of factors and their strength of effect on nurses' decisions to leave or stay in their current jobs differed across the three types of facilities. Based on these findings rural nursing administrators and policy-makers should give priority to retention strategies that focus on improving the job environment. The development of different strategies for different groups of nurses (i.e., by age or marital status) and different types of facilities should increase the benefit/cost ratio. In addition, programs that involve rural health care agencies in community and economic development should be further explored as an avenue to increased nurse retention in rural areas.

Redefining the nursing shortage: a rural perspective.

A number of researchers have suggested that nursing shortages are closely related to geographic maldistribution, specialty areas, and even individual shifts. As these findings have documented, the nursing shortage, as defined by the federal government, exists predominantly in rural areas of the country that are not adjacent to metropolitan areas. As a result, many of the economic, demographic, and health-related disparities that exist between rural and urban populations are mirrored in shortage and nonshortage counties. Higher unemployment rates and lower per capita incomes suggest an underlying relationship between economic vitality and the recruitment and retention of health care personnel. This suggests that a fundamental obstacle to staffing adequate numbers of qualified nurses in rural areas may not be a shortage of nurses, but economic barriers (domestic and health care related) deeply rooted in the rural settings themselves. In those states burdened with significant shortage areas, emphasis must be placed on easing the maldistribution of available nurses away from rural, often medically underserved settings. However, while the notion of producing appropriate "types" of nurses is well founded, the temptation to "solve" the problem simply by producing more providers should be resisted, since it will not markedly benefit those areas that are currently in greatest need. The time frame necessary for such "trickle down" approaches to affect rural areas could, when combined with other factors, render many health care delivery systems virtually unsalvageable. To address the persistent distribution problem, we could change how health professionals are educated.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationships between EEG coherence and neuropsychological tests in dementia.

Previous research has demonstrated differences in resting state EEG coherence among groups of subjects with dementia of the Alzheimer type (DAT), multi-infarct dementia (MID), and normal elderly controls. Since reduced coherence between brain sites has been thought to reflect functional disconnection between brain areas, we hypothesized that decreased coherence would be associated with cognitive dysfunction as assessed by neuropsychological tests. We correlated several neuropsychological tests with four coherence variables and found that reduced coherence was associated with impairment on specific neuropsychological tests in ways that conform to and supplement current knowledge about the localization of brain functions. The results are consistent with the hypothesis that coherence reflects a functional breakdown in communication between brain areas, and that coherence may be a more precise way to localize brain function than other EEG variables.

Effect of white matter disease on functional connections in the aging brain.

Periventricular white matter hyperintensities (PVHs) seen on T2 weighted MRI studies are common in elderly people and often represent demyelination of fibres. Damage to these fibres could lead to functional disconnection between brain regions. Electroencephalographic coherence, a measure of shared electrical activity between regions, was examined to determine if there was evidence for such disconnection. Twenty two subjects with clinically diagnosed dementia of the Alzheimer's type, 16 with multi-infarct dementia, and 18 normal controls were studied. It was hypothesised that coherence between areas presumably linked by fibres that traverse the periventricular region would be decreased in subjects with PVHs, and that PVHs would have a stronger association with decreased coherence than clinical diagnosis. It was also hypothesised that coherence between areas presumably connected by long corticocortical tracts that are neuroanatomically separated from the ventricles would be low in patients with Alzheimer's disease because of pyramidal cell death in this group, but would not be affected by the presence of PVHs. Patients with PVHs in fact had lower coherence than those without PVHs in the pre-Rolandic and post-Rolandic areas, where connecting fibres traverse the periventricular region. There was no effect of PVHs, however, on coherence between areas separated by the Rolandic fissure that were connected by long corticocortical tracts; this coherence was lowest among the patients with Alzheimer's disease. These patterns of association suggest that coherence may detect different types of neurophysiological "disconnection," and may be sensitive to selective damage to different fibre pathways.

Assessment of cerebral perfusion using quantitative EEG cordance.

Brain electrical activity is related to cerebral perfusion. The nature of this relationship is unclear, however, and surface-recorded activity has not been a reliable indicator of brain perfusion. We studied 27 subjects, all of whom were examined with single photon emission tomography (SPECT) and quantitative electroencephalography (QEEG), to assess associations between QEEG cordance and relative brain perfusion. Cordance has two indicator states: concordance, which may indicate high perfusion; and discordance, which may indicate low perfusion. We used multiple linear regression to assess the association between cordance and SPECT values, and found that cordance values were strongly associated with tissue perfusion. Concordance in the alpha band was associated both with mean tissue perfusion and the volume of normally perfused tissue, and it had a stronger association with perfusion than any other QEEG variable. Discordance in the beta 1 band was associated with mean perfusion, and it had a stronger association than did relative but not absolute power. These data suggest that cordance may be useful for the noninvasive assessment of brain perfusion.

Reduced EEG coherence in dementia: state or trait marker?

Recent work from our laboratory demonstrated that quantitative electroencephalographic (EEG) coherence between brain areas linked by long cortico-cortical fibers (termed "fascicle" coherence) was differentially reduced in subjects with Alzheimer's disease, whereas coherence between brain areas linked by short cortico-cortical and cortico-subcortical fibers in postcentral areas (termed "visual" coherence) was differentially reduced in subjects with multi-infarct dementia. In this study, we investigated whether these differences in coherence represent "trait" or "state" markers for dementia. Visual coherence demonstrated high stability in both demented groups as assessed by both one-year test-retest reliabilities and analysis of group mean change. Fascicle coherence demonstrated good stability in multi-infarct dementia and control subjects, but some variability was observed in Alzheimer's subjects, suggesting both state and trait factors may be involved. These findings complement neuropathologic studies, and suggest that decreases in coherence may serve as a diagnostic trait markers for these two types of dementia. The role of state factors in Alzheimer's disease requires further investigation.

Cordance: a new method for assessment of cerebral perfusion and metabolism using quantitative electroencephalography.

Increased slow-wave and decreased fast-wave activity on the electroencephalogram is common in brain dysfunction and may be caused by partial cortical deafferentation. No measure that is specific or sensitive for this deafferentation, however, has yet been reported. We studied a series of subjects with white-matter lesions undercutting the cortex and developed a method for analyzing electrical activity called "cordance" that has face validity as a measure of cortical deafferentation. Cordance is measured along a continuum of values: positive values denote "concordance," an indicator associated with normally functioning brain tissue; negative values denote "discordance," an indicator associated with undercutting lesions, low perfusion, and low metabolism. We present a series of subjects studied with magnetic resonance imaging, positron emission tomography, and single-photon emission computed tomography that demonstrate strong associations between cordance and other measures of brain structure and function.

Regional differences in brain electrical activity in dementia: use of spectral power and spectral ratio measures.

The pathologic changes in dementia of the Alzheimer's type (DAT) commonly affect selected brain regions. The cortical areas affected in multi-infarct dementia (MID) are less predictable and may be secondary to subcortical gray or white matter damage that is widespread in MID. We compared several types of quantitative EEG power measures (absolute and relative power, and ratios of power) to determine their regional distribution, and their association with changes in cognitive status and age. We examined 49 subjects with clinically diagnosed mild-to-moderate DAT, 29 with mild-to-moderate MID, and 38 elderly controls (CON). We used discriminant analysis to identify, for each parameter type, the brain region and frequency band where the parameter best distinguished between groups of subjects. The parameters showed regional differences in distinguishing between DAT and MID subjects, and in their association with age and cognitive status. All parameters were useful for detecting differences between normal and demented subjects and correctly identified comparable proportions of subjects as having dementia. Subjects who were abnormal on several parameters were much more likely to have dementia. The additive effects of these parameters in correct classification suggest that they may be monitoring different physiologic processes. Combinations of several types of parameters may be more useful than individual parameters for distinguishing demented from non-demented subjects.

Recruiting registered nurses to rural practice settings: an assessment of strategies and barriers.

It has been suggested that in rural settings, the primary difficulty that faces nursing administrators is recruitment of registered nurses (RNs). This study examines the impact of recruitment strategies and barriers by comparing and contrasting corresponding RN full-time equivalent (FTE) vacancy rates. Data were gathered from a multistate telephone survey of directors of nursing (DONs) practicing in rural hospitals, skilled nursing facilities (SNFs), and public health settings (N = 556, response rate = 89.5%). The investigators found that DONs who perceived scheduling amenities and autonomy enhancements corresponded with RN FTE vacancy rates that were most reduced from the mean of the overall sample. Regarding recruitment barriers, geographic locale/isolation and job-related factors corresponded with RN FTE vacancy rates that were most elevated from the overall sample mean.