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PubMed1999

Ideological implications of paradigm discourse.

Whilst the notions of paradigm and paradigm shift have become popularized in nursing's scholarly literature, there has been relatively little critical analysis of their impact upon theoretical understanding. In this paper, the authors attempt to deconstruct the ways in which paradigm discourse has been applied in nursing scholarship, looking beyond the claims that are made in the name of paradigm shifts to the apparent motivation underlying those claims. Comparing discourse associated with the paradigm shifts that have emerged in nursing education, research and practice theory, they reveal an inherently divisive purpose to which paradigm language is commonly used, and examine the implications of the discourse for nursing knowledge development. On the basis of this analysis, the authors urge a cautious approach to the extremes of paradigm claims, and argue for a more thoughtful and lively dialogue regarding the interests served by locating ideological positions within paradigm language.

Education, Nursing↗

PubMed2004

The paradigm has shifted to systolic blood pressure.

Since the middle of the 20th century, most physicians and epidemiologists assessed the risks associated with hypertension based on the level of diastolic blood pressure (DBP). In a classic paper in 1971, the Framingham Heart Study clearly showed that systolic BP more accurately described the risk of all the complications we attribute to hypertension. It took 22 years until JNC V in 1993 also used systolic blood pressure (SBP) to define hypertension in US national guidelines. Since then, the paradigm has shifted dramatically. In JNC VI (1997) and JNC VII (2003), SBP has become the primary focus of risk stratification and treatment goals. This shift is a result of the Framingham results being confirmed by many others analyses, the most compelling of which is the recently published report of the Prospective Collaborative Study Group, which pooled 61 observational studies in more than 1 million volunteers with a collective experience of more than 12 million person-years. This group showed that the SBP level at baseline was a significantly more informative reading than DBP for predicting strokes and coronary heart disease (CHD). Furthermore, three trials of older individuals with isolated systolic hypertension, SHEP, SYST-Eur, and SYST-China, unambiguously demonstrated that effective antihypertensive therapy lowered the rate of strokes, heart failure, CHD, and even all-cause mortality. Finally, the World Health Organization (WHO)/International Society of Hypertension (ISH) Hypertension Trialists also showed that the level of SBP achieved in clinical trials comparing different antihypertensives with placebo and with each other was the strongest determinant of how effectively strokes and CHD events were reduced, although a similar relationship was not evident for heart failure. A recent metaregression analysis using new trials, many of which were used by the Trialists, and older studies not included in their analysis also showed that small differences in SBP can have a dramatic impact on cardiovascular outcomes. If there is one thing we have learned in the recent past, it is the need for us to focus on lowering SBP and getting it down to a reasonable goal. We have also learned that to do so, we will need to combine a variety of lifestyle and pharmacological approaches, always with combinations of drugs that will usually contain a low-dose thiazide-type diuretic with other antihypertensives.

Adolescent↗

PubMed2004

[Philosophical background of evidence-based medicine].

Through the whole history of medicine, there runs a long struggle between two principal tendencies - empiricism and rationalism. The empirical trend lays its emphasis on "experience" for the cure of the sick. The rationalistic trend lays its main emphasis on "mechanism" for the causes of diseases. The term "evidence-based (EBM)", defined as "the conscious, explicit and judicious use of the best current evidence in making decisions about the individual patients", was introduced about ten years ago. The proponents has been described EBM as a "paradigm shift" that will change medical practice in the years ahead. But there has been considerable debate about the value of EBM. The modern medicine, following philosophy of modern science such as the 'realism controlled by empiricism', has developed biomedical model. But the EBM wrapped with clinical epidemiology and statistics, represents response of empiricism to the rationalism (realism). The roots of EBM extend back at least as far as the Paris clinical school, and the work of Pierre Louis in Paris in the early 19th century.Is EBM a paradigm shift? To answer this question, we have to specify the alternative with which we are comparing EBM. The alternative to EBM is the basic science approach: studying the pathophysiological mechanism of the body. But EBM is so clearly intertwined with and complementary to the basic science that it would make little sense to see EBM as a paradigm shift away from basic science. In a sense, evidence-based medicine shows only methodological contribution aimed at improving the gathering and sorting of the best information published by biomedical scientists and clinical epidemiologists for use in clinical practice. Although EBM and the traditional medicine embody different approaches, this does not mean that they are competitors. In fact, the two approach need each; neither can stand alone for the development of clinical practice.

Evidence-Based Medicine↗

PubMed2005

Diabetes, prediabetes, and cardiovascular risk: shifting the paradigm.

As the prevalence of diabetes continues to increase worldwide, diabetes-related macrovascular morbidity and mortality are becoming major health care problems. Epidemiologic evidence suggests this relationship begins early in the progression from normal glucose tolerance to frank diabetes. This report reviews this epidemiologic evidence linking early stages of glucose dysregulation with cardiovascular disease and discusses the results of major clinical trials demonstrating that lifestyle or pharmacologic intervention can reduce the incidence of diabetes in high-risk individuals. These observations indicate that early identification and aggressive treatment of subjects with impaired fasting glucose or impaired glucose tolerance have the potential to reduce both the incidence of diabetes and its related cardiovascular disease. Three clinical trials are being conducted to test whether early pharmacotherapy can reduce or delay the incidence of diabetes, and their results may well begin to shift the treatment paradigm toward earlier intervention.

Angiotensin II Type 1 Receptor Blockers↗

PubMed2006

Minimally invasive repair of pectus excavatum - shifting the paradigm?

PURPOSE: The "minimally invasive repair of pectus excavatum" (MIRPE) has increasingly become the standard operation for the repair of pectus excavatum. The aim of the present study was to report on our first-line postoperative results, including a survey of patients and to elucidate the acceptance of MIRPE. PATIENTS AND METHODS: All MIRPE patients, who were operated on between 2000 and 2004 in our departments, were included in a retrospective study. In 2002, a retrospective questioning of 57 patients was initiated by sending identical questionnaires separately to both the patients and their parents asking for individual reasons for choosing and/or agreeing to MIRPE. RESULTS: Complications were seen in 25 out of 84 MIRPE patients (mean 14 years, range from 5 to 20 years), but most of them were minor. Removal of the bar was necessary in 6 cases, due to bar displacement, secondary haematothorax, pericardial effusion, and local infection, respectively. No major complications occurred in the age group between 9 and 14 years. More than 90 % of the patients and their parents were satisfied or highly satisfied with the MIRPE procedure. CONCLUSION: General and specific complications are similar to other series and they decrease with the surgeon's experience. The most severe problem, occurring in older patients, is how to avoid dislocation of the pectus bar. In the light of the complication rate, the acceptance of MIRPE is still high, especially in adolescents and young adults who had refused operation with the open techniques. In this way, a shifting of a paradigm is taking place.

Adolescent↗

PubMed2000

Comprehensive integrated primary mental health care for South Africa. Pipedream or possibility?

While the vision for restructuring health care in South Africa is based on a comprehensive primary health care system, care at the primary level remains largely biomedical in orientation. Given this, I argue that whilst adding mental health care to primary level care may increase accessibility of psychiatric care. it will not, however, provide for comprehensive integrated primary mental health care as planned. This would require a paradigm shift towards a comprehensive discourse of care which includes mental health care. While efforts towards reorienting health care personnel in South Africa towards the primary health care approach have been initiated, an examination of the primary health care system in one sub-district in South Africa, reveals that the delivery of biomedical care is sustained by a number of factors within the primary health care system as well as within the macro-context. A shift in the paradigm of care provided would therefore require the transformation of the system on many fronts. Of central importance would be the restructuring of the primary health care system to be supportive of emotional labour, health promotion, empowerment of service users and of care which takes the subjectivity of the illness experience for the patient into account.

Culture↗

PubMed1996

Cancer as a complex adaptive system.

The second leading cause of death in the USA is cancer. Institutions worldwide are devoting significant resources to the treatment of cancer, and the elucidation of the disease pathway. While great progress has been made in understanding and treating carcinogenesis, many aspects of the disease remain intractable. Throughout the history of science many other disciplines--astronomy, particle physics, etc.--have been advanced when the fundamental ideas governing the discipline were redefined. These redefinitions are often termed 'paradigm shifts'. The new sciences of chaos theory and complexity have led to paradigm shifts in many unrelated disciplines such as economics, meteorology and seismology. Our current understanding of carcinogenesis has resulted from a conventional view of the disease process. In this perception, the mutation of a gene, or several genes, leads to cancer. Applying the formalism of chaos theory and complexity to carcinogenesis, however, leads to a different perception of the disease. If we look closer, cancer can be viewed as a complex adaptive system. Redefining our perception of cancer may lead to a deeper understanding of the disease, and possibly result in novel methods of therapeutic intervention.

Adaptation, Physiological↗

PubMed1998

Resynchronisation of a diurnal rodent circadian clock accelerated by a melatonin agonist.

Using 'jet lag' paradigms involving phase shifts in the light-dark (LD) cycle, we studied the effects of S-20098 on the circadian clock of a diurnal rodent. Arvicanthis mordax, entrained to a regular LD cycle, were subjected to advance shifts (i.e. 4, 6 or 8 h) in the LD cycle and injected with vehicle or the melatonin agonist S-20098 (20 mg/kg) the day of the shift (and also on subsequent days in the 6 h or 8 h shift paradigms). In each condition, S-20098 accelerated by about 30% resynchronization to the new LD cycle. These data, which are the first to demonstrate the chronobiotic effects of a melatonin agonist in a diurnal rodent, provide new insights for the design of human chronopharmacological protocols.

Acetamides↗

PubMed1998

Toward a new paradigm in substance abuse and other problem behavior prevention for youth: youth development and empowerment approach.

The purpose of this article is to 1) address a paradigm shift taking place in the field of substance abuse prevention directed for youth and 2) to introduce an innovative approach to substance abuse and other problem behavior prevention that reflects this shift in prevention paradigm. The new path introduced is youth development and empowerment (YD&E) approach. In order to establish a conceptual foundation for this approach, this article 3) reviews the theoretical advances made in the field of substance abuse prevention during the last three decades. This is followed by a conceptualization of the processes of implementing the YD&E program by 4) specifying the mechanism used for the empowering processes and by 5) identifying the structural components of the youth empowerment model that serve the empowering processes. It is hoped that this article serves as a conduit for an improved approach to adolescent substance abuse prevention and youth development that goes beyond, rather than against, the traditional risk-factor approach. In this new approach, youths are viewed as assets and resources to our community rather than social problems or community liabilities. The organizing concept of this new paradigm is: social, economic, and public opportunity denied to youth is equal to social problems imposed on youth by adults.

Adolescent↗

PubMedDate not supplied

Paradigms and pragmatism: approaches to medical statistics.

Until recently, the dominant philosophy of science was that due to Karl Popper, with its doctrine that the proper task of science was the formulation of hypotheses followed by attempts at refuting them. In spite of the close analogy with significance testing, these ideas do not fit well with the practice of medical statistics. The same can be said of the later philosophy of Thomas Kuhn, who maintains that science proceeds by way of revolutionary upheavals separated by periods of relatively pedestrian research which are governed by what Kuhn refers to as paradigms. Through there have been paradigm shifts in the history of statistics, a degree of continuity can also be discerned. A current paradigm shift is embodied in the spread of Bayesian ideas. It may be that a future paradigm will emphasise the pragmatic approach to statistics that is associated with the name of Daniel Schwartz.

Clinical Trials as Topic↗

PubMed2001

An admission model for medical schools.

Complex societal issues affect medical education and thus require new approaches from medical school admission officers. One of these issues--the recognition that the attributes of good doctors include character qualities such as compassion, altruism, respect, and integrity--has resulted in the recent focus on the greater use of qualitative variables, such as those just stated, for selected candidates. In addition, more emphasis is now being placed on teaching and licensure testing of the attributes of the profession during the four-year curriculum. The second and more contentious issue concerns the system used to admit white and minority applicants. Emphasizing character qualities of physicians in the admission criteria and selection process involves a paradigm shift that could serve to resolve both issues. To make this or any paradigm shift in admission policy, medical schools must think about all the elements of admission and their interrelationships. A model of medical school admission is proposed that can provide understanding of the admission system and serve as a heuristic guide. This model consists of (1) the applicant pool; (2) criteria for selection; (3) the admission committee; (4) selection processes and policies; and (5) outcomes. Each of these dimensions and the interrelationships among the dimensions are described. Finally, a hypothetical example is provided in which the model is used to help a medical school change its admission process to accommodate a new emphasis in the school's mission.

Evaluation Studies as Topic↗

PubMed2005

Incorporating healthcare informatics into the strategic planning process in nursing education.

The purpose of this article is to describe the incorporation of healthcare informatics into the strategic planning process in nursing education. An exemplar from the University at Buffalo, the State University of New York School of Nursing, is interwoven throughout the article. The challenges and successes inherent in a paradigm shift embracing the multifaceted adoption of technology in higher education are illustrated. The paradigm shift that necessitated this change, the need for informatics standards and competencies identified by regulatory agencies and the relationship of the triad mission of the Academy which includes research, teaching and service are then elucidated. Information pertinent to the strategic planning process is described including the use of a strengths, weaknesses, opportunities and threats (SWOT) analysis to facilitate the integration of a healthcare informatics model into a nursing curriculum.

Curriculum↗

PubMed1994

Radiation paradigm and its shift.

By adopting the concept of scientific paradigm after L. Sagan, the history of paradigm shift in 1950 in radiation protection standard by ICRP from a threshold to a non-threshold model was critically reviewed. The motives for the shift were found later to be scientifically inappropriate. But the present paradigm of a linear, non-threshold model introduced at the 1950s' shift has been accepted in general for main radiation risk, i.e., for carcinogenesis, though there have been many controversies on risk at low dose effects. We can find some motives for another shift among these controversies now. It is the purpose of the present review to stimulate the discussion on a possible new paradigm.

Humans↗

PubMed2002

Understanding resistance to the data-model relationship in Rasch's paradigm: a reflection for the next generation.

The case for the Rasch models, that The comparison between two stimuli should be independent of which particular individuals were instrumental for the comparison; and vice versa (Rasch, 1961), does not depend on the models accounting for any data set. This has two distinctive consequences on the data-model relationship for the Rasch models. First, and this was recognized by Rasch, when there are deviations of one sort or another, it turns upside down the question of whether it is the model or the test that has gone wrong (Rasch, 1960). Second, because the invariance of comparisons among stimuli, and vice versa, is built into the model rather than being merely a requirement of data, further implications of this requirement can be derived mathematically. These implications, too, inevitably turn some questions, and their solutions, upside down. It is argued that having to look at these implications upside down produces substantial psychological and intellectual resistance amongst those schooled in looking at them in the traditional way. It is also argued that in turning the question upside down, Rasch had an insight that goes beyond the mathematical derivations, and that to sustain this insight requires a paradigm shift (Kuhn, 1970) in the data-model relationship. Using an illustrative example, it is suggested that to maintain this paradigm shift, even by those who research the Rasch models, requires the same uncompromising consistency and passion that Rasch displayed in maintaining faith in his insight.

Humans↗

PubMed1984

Eleanor Clarke Slagle Lectureship, 1984: transformation of a profession.

Professional evolution includes a period of disunity, a phase when old values and concepts are being examined, and new perspectives emerge. Disunity can be a positive impetus for dynamic change. Transformation provides a higher level reintegration through which new understanding and progress unfold. Occupational therapy's transformation is now; it is time for careful analysis and creative synthesis. Transformation is a three-fold process of integration of past, present, and future into an upward spiral of professional development. Transformation is a constant flow of activities influenced by both internal and external factors. Although there are multidimensions that influence occupational therapy's transformation, three major components are inherent in the profession's paradigm shift: society's decline in patriarchal authority; decline in allegiance to a biomedical model; and shift in values, dimensions of practice, and education that form the reality of occupational therapy. Transformation of our profession will be a paradigm shift: in our value system of purposeful activity to a new perspective of occupation and occupational, in our quest to develop a unifying theory for recognition of the unifying force of values, in our concepts and theories to include the science of occupation and the art of purposefulness from total allegiance to scientific knowledge to include intuitive knowledge, from being an allied medical field to an independent health profession that is both educationally and medically related, from a biomedical model to a paradigm of wellness, in balancing of feminine and masculine values of human nature in organizing educational curricula and entry-level requirements that reflect our value system and predicted practice dimensions.

Forecasting↗

PubMed1999

siRNA-mediated transcriptional gene silencing: the potential mechanism and a possible role in the histone code.

Epigenetics is the study of meiotically and mitotically heritable changes in gene expression which are not coded for in the DNA. Three distinct mechanisms appear intricately related in initiating and sustaining epigenetic modifications: RNA-associated silencing, DNA methylation and histone modification. Recently, in human cells small-interfering RNAs (siRNAs) have been shown to mediate transcriptional gene silencing (TGS). The observation that siRNAs can function to suppress gene expression at the level of transcription has created a major paradigm shift in mammalian RNA interference. The putative mechanism(s) of siRNA-mediated TGS in both yeast and human cells will be discussed. Undoubtedly, the ramifications from this paradigm shift in which RNA has demonstrated a potent and specific capability to regulate the expression of the gene are immeasurable both therapeutically (i. e. directed control of gene expression) and biologically in understanding the evolution of the cell.

Animals↗

PubMed2001

Cochlear implant/Deaf World dispute: different bottom elephants.

OBJECTIVE: To examine the controversy between the proponents of cochlear implantation in children and the Deaf World opponents with the hope of offering a method for decreasing the acrimony of opposing positions. STUDY DESIGN AND SETTING (METHODS): The opposing arguments will be presented from a review of pertinent literature. The systemic philosophic process of bottom elephant analysis will be elucidated. Contrasting models of power will be described. RESULTS: The application of the bottom elephant analysis of each group's position plus a paradigm shift in the utilization of power offers possibilities for the implementation of mutually respectful dialogue that does not undermine each group's stature. CONCLUSION AND SIGNIFICANCE: Philosophic analysis and paradigm shift could lead to improvement in the interaction of cochlear implant proponents and Deaf World opponents.

Cochlear Implants↗