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Biomedical subjects

Peter Gallagher

Publications and source records attributed to Peter Gallagher.

35 records · Page 2Linked to original sources
PubMed2004

How the metaphor of a gap between theory and practice has influenced nursing education.

The metaphor of a gap between theory and practice is firmly established in nursing education. Furthermore, it is embedded in conventional professional wisdom to the extent that when it used in professional reports, academic writing or in the conversations amongst nurses, it often requires no further explanation. The notion of a gap between theory and practice has proven to be a most fertile and an especially helpful concept which has enabled educators, clinicians and students to devise practical strategies, intended to resolve problems associated with the gap. However, that nursing has so enthusiastically embraced the notion of a gap between theory and practice may also have inhibited creativity in the design and delivery of programmes and thereby missing other opportunities for student nurses to learn from practical contexts.

Clinical Competence↗
PubMed2004

A retrospective data analysis of the impact of the New York triplicate prescription program on benzodiazepine use in medicaid patients with chronic psychiatric and neurologic disorders.

BACKGROUND: Benzodiazepines are treatment mainstays for several disorders, but there is often concern about dependency and addiction. In January 1989, New York implemented regulations requiring physicians to order benzodiazepines using state-monitored triplicate prescription forms. OBJECTIVE: The purpose of this study was to assess the effects of the triplicate prescription program (TPP) on changes in use of benzodiazepines and other psychoactive drugs in clinically vulnerable Medicaid populations. METHODS: Using an interrupted time series with comparison series design, psychoactive medication use was examined in the New York (intervention) and New Jersey (control) Medicaid programs before and after implementation of the New York benzodiazepine TPP among community-dwelling Medicaid beneficiaries aged >/=19 years continuously enrolled from January 1988 through December 1990 in New York or New Jersey with diagnoses of schizophrenia, schizophreniform disorder, schizoaffective disorder, schizoid personality disorder, or schizotypal personality disorder; bipolar disorder; epilepsy; and/or panic disorder, agoraphobia without history of panic disorder, social phobia, or specific phobia. RESULTS: A total of 125,837 New York and 139,405 New Jersey Medicaid beneficiaries were continuously enrolled and met the study inclusion criteria. Of these, there were 6054 Medicaid enrollees in New York and 6875 enrollees in New Jersey who were clinically vulnerable patients with >/=1 of the specified diagnoses. New York Medicaid patients with any of these diagnoses experienced a -48.1% relative change (95% CI, -50.0% to -46.2%) in benzodiazepine use at 6 months after TPP implementation, with no decline in use in New Jersey patients. The largest reduction in benzodiazepine use was seen among patients with seizure disorder (-59.9% at 6 months; 95% CI, -63.9% to -55.9%). Although use of substitute drugs increased slightly in New York after the TPP, it did not offset reductions in benzodiazepine use. The effects of TPP were sustained for 7 years of follow-up and had the greatest impact on nonproblematic benzodiazepine use. CONCLUSIONS: During the time period studied in this analysis, the New York TPP reduced benzodiazepine use among chronically ill patients for whom these agents represent effective treatment. Our findings suggest that many patients previously receiving benzodiazepines did not receive any pharmacologic intervention.

Adult↗
PubMed2004

Improvements in neurocognitive function and mood following adjunctive treatment with mifepristone (RU-486) in bipolar disorder.

High cortisol levels are found in severe mood disorders, particularly bipolar disorder. Hypercortisolaemia may cause or exacerbate both neurocognitive impairment and depressive symptoms. We hypothesized that antiglucocorticoid treatments, particularly corticosteroid receptor antagonists, would improve neurocognitive functioning and attenuate depressive symptoms in this disorder. To test this hypothesis, 20 bipolar patients were treated with 600 mg/day of the corticosteroid receptor antagonist mifepristone (RU-486) or placebo for 1 week in a double-blind crossover design. Over the total 6 weeks of the study, neurocognitive and neuroendocrine function were evaluated at baseline, days 21 and 42. Mood symptoms were evaluated weekly. Nineteen subjects completed the protocol; there were no drop-outs due to adverse events. Following treatment with mifepristone, selective improvement in neurocognitive functioning was observed. Spatial working memory performance was significantly improved compared to placebo (19.8% improvement over placebo). Measures of verbal fluency and spatial recognition memory were also improved after mifepristone. Beneficial effects on mood were found; Hamilton Depression Rating Scale scores were significantly reduced compared to baseline (mean reduction of 5.1 points) as were Montgomery-Asberg Depression Rating Scale scores (mean reduction of 6.05 points). No significant change occurred after placebo. These data require replication but provide preliminary evidence that glucocorticoid receptor antagonists may have useful cognitive-enhancing and possibly antidepressant properties in bipolar disorder.

Adult↗
PubMed2004

Hypothalamic-pituitary-adrenal axis function in patients with bipolar disorder.

BACKGROUND: Hypothalamic-pituitary-adrenal (HPA) axis function, as variously measured by the responses to the combined dexamethasone/corticotrophin-releasing hormone (dex/CRH) test, the dexamethasone suppression test (DST) and basal cortisol levels, has been reported to be abnormal in bipolar disorder. AIMS: To test the hypothesis that HPA axis dysfunction persists in patients in remission from bipolar disorder. METHOD: Salivary cortisol levels and the plasma cortisol response to the DST and dex/CRH test were examined in 53 patients with bipolar disorder, 27 of whom fulfilled stringent criteria for remission, and in 28 healthy controls. Serum dexamethasone levels were measured. RESULTS: Patients with bipolar disorder demonstrated an enhanced cortisol response to the dex/CRH test compared with controls (P=0.001). This response did not differ significantly between remitted and non-remitted patients. These findings were present after the potentially confounding effects of dexamethasone levels were accounted for. CONCLUSIONS: The dex/CRH test is abnormal in both remitted and non-remitted patients with bipolar disorder. This measure of HPA axis dysfunction is a potential trait marker in bipolar disorder and thus possibly indicative of the core pathophysiological process in this illness.

Adult↗
PubMed2004

A controlled study of the effects of state surveillance on indicators of problematic and non-problematic benzodiazepine use in a Medicaid population.

OBJECTIVE: Benzodiazepines (BZs) are safe, effective drugs for treating anxiety, sleep, bipolar, and convulsive disorders, but concern is often expressed about their overuse and potential for abuse. We evaluated the effects of physician surveillance through a Triplicate Prescription Program (TPP) on problematic and non-problematic BZ use. METHOD: This study uses interrupted time series analyses of BZ use in the New York (intervention) and New Jersey (control) Medicaid programs for 12 months before and 24 months after the New York BZ TPP. The regulation required NY physicians to order BZs on triplicate prescription forms with one copy forwarded by pharmacies to a state surveillance unit. Study participants were community-dwelling persons over age 18 continuously enrolled between January 1988 and December 1990 in New York (n = 125,837) or New Jersey Medicaid (n = 139,405). RESULTS: During the baseline year, 20.2% of New York and 19.3% of New Jersey cohort members received at least one BZ prescription. After the TPP, there was a sudden, sustained reduction in BZ use of 54.8% (95% CI = [51.4%, 58.3%]) in New York with no changes in New Jersey. Significantly greater reductions were experienced by young women, and persons living in zip codes that were urban, predominantly Black, or with a high density of poor households. Increases in potential substitute medications were modest. At baseline, nearly 60% of BZ recipients had no evidence of potentially problematic use. Despite a somewhat greater likelihood of discontinuation of BZ therapy among those with potentially problematic use, the largest impact of the TPP was a substantially greater relative reduction in access to BZs among non-problematic users. CONCLUSIONS: State-mandated physician surveillance dramatically reduces BZ use with limited substitution of alternative drugs, lowers rates of possible abuse, but may severely limit non-problematic BZ use.

Adult↗
PubMed2003

Effect of sub-chronic hydrocortisone on responses to amphetamine in normal male volunteers.

RATIONALE: Enhancement of dopamine (DA) release by corticosteroids may be of aetiological importance in substance misuse. OBJECTIVES: To examine the effect of sub-chronic administration of hydrocortisone on the response to amphetamine in healthy male volunteers. METHODS: Following baseline assessment, 20 volunteers were pretreated for 7 days with 20 mg of hydrocortisone or placebo at 0800 hours and 2000 hours in a double-blind, random order, cross-over design prior to receiving 0.15 mg/kg metamphetamine intravenously. Blood samples for cortisol and prolactin were taken every 15 min. Subjects also underwent tests of neuropsychological function including sustained attention using the rapid visual information processing test (RVIP), which has been shown to be sensitive to changes in DA function. RESULTS: Metamphetamine produced a substantial reduction in prolactin levels, and increased subjective mood ratings of "mind-race" and "buzz". Sub-chronic hydrocortisone administration had no effect on these neuroendocrine responses, subjective mood changes or neurocognitive performance on a task of sustained attention (RVIP). CONCLUSIONS: Despite measurable changes in neuroendocrine and affective functioning in response to metamphetamine, pretreatment with hydrocortisone did not significantly affect any of the variables measured. This suggests that this model of DA function is not affected by this regimen of corticosteroid administration.

Adolescent↗
PubMed2003

Effects of acute tryptophan depletion on executive function in healthy male volunteers.

BACKGROUND: Neurocognitive impairment is frequently described in a number of psychiatric disorders and may be a direct consequence of serotonergic dysfunction. As impairments in executive functions are some of the most frequently described, the purpose of this study was to examine the performance of normal volunteers on a range of executive tasks following a transient reduction of central serotonin (5-HT) levels using the method of acute tryptophan depletion (ATD). METHODS: Fifteen healthy male subjects participated in a within-subject, double-blind, counterbalanced crossover study. ATD was induced by ingestion of a 100 g amino-acid drink. Executive function was evaluated using the Wisconsin Card Sorting Test, Stroop, Verbal Fluency and Trail Making. Visual analogue scales were administered to assess mood. RESULTS: Plasma free and total tryptophan concentrations were significantly reduced by the depleting drink (P < 0.001). ATD selectively improved motor speed/ attention on the Trails A test (P = 0.027), with no effect on subjective ratings of mood. Interaction effects between drink and the order of drink administration were observed on most neurocognitive tests. CONCLUSIONS: The improvement in simple motor speed/ attention following ATD is in keeping with the ascribed role of 5-HT in the cortex, however performance on tests of executive function is not robustly altered. The presence of interaction effects on most tasks suggests that subtle changes may occur but are masked, possibly by simple learning effects, in the context of a crossover design. This has implications for the design of future studies, particularly those examining executive functions.

Adolescent↗
PubMed2003

Elevated prolactin responses to L-tryptophan infusion in medication-free depressed patients.

RATIONALE: Several previous neuroendocrine studies have demonstrated reduced 5-HT1A receptor function in major depressive disorder (MDD). However, hypercortisolaemia or previous drug treatment may have been significant confounds. OBJECTIVES: To replicate previous studies in subjects with MDD who had been drug free for at least 8 weeks and to relate the findings to measures of HPA axis function. METHODS: Hormonal responses to l-tryptophan infusion were measured in patients with MDD (n=20) and healthy controls (n=20). Basal salivary cortisol and DHEA were also profiled. RESULTS: No attenuation of 5-HT1A receptor-dependent neuroendocrine responses (growth hormone, prolactin) was observed in patients with MDD. The prolactin response to l-tryptophan was significantly greater in MDD patients than in healthy controls (P=0.008). There was a significant negative correlation between prolactin response and basal salivary cortisol secretion over the 3 days prior to the test. CONCLUSIONS: These data do not support previous findings of reduced 5-HT1A function in MDD and suggest that hypercortisolaemia or psychotropic medication may have accounted for the attenuation. Basal cortisol, DHEA and the cortiso l-DHEA ratio did not differ between patients and controls, and all patients were psychotropic medication-free. The greater prolactin response to l-tryptophan infusion in depressed subjects may be the result of an increase in dopamine receptor sensitivity, secondary to reduced dopamine levels.

Adolescent↗
PubMed2003

Effects of state surveillance on new post-hospitalization benzodiazepine use.

BACKGROUND: Benzodiazepines (BZD) effectively treat anxiety and insomnia accompanying major health events, including hospitalizations. Prescribing regulations to decrease BZD misuse may negatively impact therapeutic uses. OBJECTIVE: To assess the impact of a Triplicate Prescription Program (TPP) on initiation of post-hospitalization BZD prescribing, both overall and among cardiac and cancer patients in the United States. DESIGN: Interrupted time-series of post-hospitalization BZD dispensing events to enrollees in the US Medicaid program in the states of New York (intervention group) and New Jersey (control group), before and after implementation of a TPP. STUDY PARTICIPANTS: Community-dwelling Medicaid enrollees in New York State (n = 67 962) and New Jersey (n = 71 701), hospitalized between 1 January 1988 and 30 November 1990. INTERVENTION: The New York State TPP, implemented on 1 January 1989, requires physicians to prescribe BZD on triplicate prescription forms for state surveillance. OUTCOME MEASURES: Rates and duration of new post-hospitalization use of BZD and substitute medications. RESULTS: Overall, a sudden and sustained 63.5% decrease [95% confidence interval (CI) -58.6% to -68.3%] in new post-hospitalization BZD dispensing-from a baseline rate of 44 discharges with BZD dispensing per 1000 discharges per month-followed the TPP in New York State, without discontinuity in the control state. Patients hospitalized for acute ischemic cardiac events experienced a 72.5% reduction (95% CI -55.5% to -89.4%), and cancer patients a 69.4% reduction (95% CI -36.7% to -100.0%). The TPP did not preferentially reduce BZD use lasting >2 months. Increased substitute use did not offset reductions in BZD use. CONCLUSIONS: By decreasing new short-term post-hospitalization BZD use, the New York State TPP also had unintended effects.

Adult↗
PubMed2003

The effects of acute tryptophan depletion on neuropsychological function.

Serotonin (5-HT, 5-hydroxytryptamine) may have an important role in the maintenance of normal neuropsychological functioning. The method of acute tryptophan depletion (ATD) provides a pharmacological challenge by which central 5-HT levels can be temporarily decreased and effects on learning, memory and mood examined. Twenty healthy male volunteers were recruited to take part in this within-subject, double-blind, crossover study. Neuropsychological function was evaluated 4-6 h after ingestion of a control or 52 g tryptophan (TRP) depleting amino-acid drink. ATD significantly lowered levels of plasma total and free TRP (p < 0.001), but this did not affect mood or performance on tests of verbal and visuo-spatial learning and memory, attention or executive function. These results contradict previous findings; however, the degree of disruption of central 5-HT levels resulting from the use of the 52 g amino-acid protocol may be an important factor in explaining the lack of effect. By utilizing more specific probes of individual 5-HT receptor subtypes, future studies can fully explore the role of 5-HT in neuropsychological functioning and may elucidate the factors determining vulnerability to the effects of serotonergic dysfunction.

Adult↗
PubMed2003

Neurocognitive impairment in drug-free patients with major depressive disorder.

BACKGROUND: Although neurocognitive impairment has been widely reported in major depressive disorder (MDD), confounding factors, such as the effects of psychotropic medication, have rarely been controlled for. AIMS: To examine neurocognitive function in medication-free patients with MDD and healthy controls. METHOD: Forty-four patients meeting DSM-IV criteria for MDD, all psychotropic-medication-free for at least 6 weeks, and 44 demographically matched, healthy comparison subjects completed a comprehensive neurocognitive battery. RESULTS: Patients with depression were impaired significantly in a range of cognitive domains, including attention and executive function and visuospatial learning and memory, compared with controls. Motor and psychomotor functions were intact. Severity of depression correlated with learning and memory performance, but not executive function. CONCLUSIONS: Pronounced neurocognitive impairment was found in this sample of young adult out-patients with MDD. This is not attributable to the confounding effects of psychotropic medication and could therefore provide an objective marker of brain dysfunction in depression.

Adolescent↗
PubMed2003

Re-thinking the theory-practice relationship in nursing: an alternative perspective.

The alleged gap between theory and practice in nursing is usually understood as dissonance between what is taught in educational institutions and that which is performed in the every day world of nursing practice. Historically strategies devised to enhance the relationship between theory and practice have focused upon manipulating factors in the environment in which learning takes place. Thus far, this has at best proved to be only partially successful. To increase understanding of the relationship this paper proposes the emerging and complementary theory of enactivism. Enactivism is a theory that enfolds the student, the context for learning and the leaned as intimate components.

Education, Nursing↗
PubMed2002

The effects of sub-chronic administration of hydrocortisone on hormonal and psychological responses to L-tryptophan in normal male volunteers.

RATIONALE: 5-Hydroxytryptamine(1A) (5-HT(1A)) receptor function has been shown to be attenuated by corticosteroid hormones in a variety of animal experimental paradigms. It has been suggested that this effect may be central to the pathophysiology of severe depressive illness in humans, a condition in which 5-HT(1A) receptor function is reduced and corticosteroid hormone levels are elevated. Evidence suggests that the hormonal response to L-tryptophan ( L-TRP) is mediated by 5-HT(1A) receptors. This response has been shown to be reduced following acute administration of hydrocortisone, and we hypothesised that sub-chronic administration of hydrocortisone would also blunt it. OBJECTIVES: To examine the effects of sub-chronic administration of hydrocortisone on hormonal and psychological responses to L-TRP infusion in healthy male subjects. To ascertain whether cortisol was exerting effects on prolactin release directly at the pituitary rather than via hypothalamic 5-HT(1A) receptors, a thyroid-releasing hormone (TRH) challenge test was performed. METHODS: Fourteen healthy male volunteers took part in a random-order, double-blind, placebo-controlled study, in which 20 mg hydrocortisone or placebo was administered twice daily for 7 days before infusion of L-TRP. A TRH challenge was administered to eight of the subjects following the L-TRP infusion. RESULTS: Pre-treatment with hydrocortisone significantly reduced the growth hormone (GH) and cortisol responses, but not the prolactin (PRL) response to the infusion. TRH administration caused a robust increase in PRL, but this response was not attenuated by hydrocortisone pre-treatment. The TSH response to TRH was blunted. There was no effect of pre-treatment on psychological responses to L-TRP. CONCLUSIONS: The attenuation in GH response following hydrocortisone pre-treatment could indicate a reduction in 5-HT(1A) receptor function, although it is probable that it is attributable to the action of hydrocortisone at the pituitary level. More precise, non-neuroendocrine models of 5-HT(1A) receptor function are necessary to clarify this.

Adult↗
PubMed2002

Effects of acute tryptophan depletion on cognitive function in euthymic bipolar patients.

Decreasing brain 5-HT levels by acute tryptophan depletion has been shown to selectively impair cognition in healthy volunteers. In bipolar disorder, ATD causes measurable neurophysiological effects without altering mood. The purpose of this study was to examine the effects of ATD on neuropsychological performance in 14 euthymic bipolar patients. Cognitive function was evaluated 4-6 h after ingestion of a control or depleting amino-acid drink. Plasma tryptophan levels fell significantly following the depleting drink, however there were no main effects on the ID/ED set-shift task, Paired Associates Learning or Vigil. A trend towards a decrease in the proportion of perfect solutions on the Tower of London task was observed when depleted. While ATD reduces 5-HT levels in the brain, it does not appear to alter neuropsychological performance on tests of sustained attention or associative learning. Effects on specific 'executive' functions are less clear, and should be the focus for future research.

Adult↗
PubMed2002

Elevation of the cortisol-dehydroepiandrosterone ratio in drug-free depressed patients.

OBJECTIVE: Elevated basal cortisol levels are a feature of depressive illness and cause deficits in learning and memory. The adrenal steroid dehydroepiandrosterone (DHEA) has antiglucocorticoid properties that may offer protection against the deleterious effects of cortisol. The authors examined the ratio of cortisol to DHEA in drug-free depressed patients and a matched comparison group. METHOD: Cortisol and DHEA were measured in saliva samples from 39 patients with unipolar depression who had been medication free for at least 6 weeks and 41 healthy comparison subjects. RESULTS: The molar cortisol-DHEA ratio was significantly higher in the depressed patients than in the healthy comparison subjects. Cortisol-DHEA ratios from saliva samples taken at 8:00 p.m. correlated positively with length of current depressive episode. CONCLUSIONS: Elevated cortisol-DHEA ratios may be a state marker of depressive illness and may contribute to the associated deficits in learning and memory. Administration of DHEA or other antiglucocorticoid treatments may reduce neurocognitive deficits in major depression.

Adolescent↗
PubMedDate not supplied

Synchronous computer mediated group discussion.

Over the past 20 years, focus groups have become increasingly popular with nursing researchers as a data collection method, as has the use of computer-based technologies to support all forms of nursing research. This article describes the conduct of a series of focus groups in which the participants were in the same room as part of a "real-time" discussion during which they also used personal computers as an interface between each other and the moderator. Synchronous Computer Mediated Group Discussion differed from other forms of focus group discussion in that participants used personal computers rather than verbal expressions to respond to specific questions, engage in communication with other participants, and to record their thoughts. This form of focus group maintained many of the features of spoken exchanges, a cornerstone of the focus group, while capturing the advantages of online discussion.

Computers↗