Experiences With COVID-19.

BACKGROUND: Millions of Americans have tested positive for COVID-19. The illness has a range of clinical symptoms with varying degrees of symptom severity; there is limited research about the lived experience of having COVID-19. OBJECTIVE: The study aim was to understand the lived experience of having COVID-19, provide detail on the length and severity of symptoms as well as coping mechanisms of those with the illness, and identify issues individuals face when accessing healthcare. METHODS: This phenomenological qualitative study included semistructured interviews of 45 people ages 18 years and older living in the United States who tested positive for COVID-19. Inductive content analysis was employed for subjective interpretation of the text through a systematic coding classification to identify themes for analysis and conclusions. RESULTS: This study details a variety of symptom presentations of individuals who tested positive for COVID-19 as well as mental health concerns related to fear and living with COVID-19. DISCUSSION: Individuals expressed varying emotions when finding they tested positive for COVID-19. Many conveyed fear of having COVID-19 and indicated it was a traumatic experience. This fear is an important clinical finding that policymakers and providers should consider when treating acute and chronic COVID-19 patients. Finally, many participants, commonly referred to as "long haulers," experienced ongoing and lingering symptoms highlighting an area in need of further research.

Ventricular assist device for Fontan: who, when and why?

PURPOSE OF REVIEW: Since the advent of the Fontan palliation, survival of patients with univentricular congenital heart disease has increased significantly. These patients will, however, ultimately develop heart failure requiring advanced therapies such as heart transplantation. As wait times are long, mechanical circulatory support (MCS) is an attractive therapy, both for bridge to transplantation and destination therapy in patients not suitable for transplantation. This review aims to summarize current thinking about how to determine which patients would benefit from a ventricular assist device (VAD), the optimal time for implantation and which device should be considered. RECENT FINDINGS: VAD implantation in end-stage Fontan is still in its infancy; however, case reports and research interest have increased extensively in the past few years. Mortality is significantly higher than in noncongenital heart disease patients. Implantation in patients with primarily systolic dysfunction is indicated, whereas patients with increased transpulmonary gradient may not benefit from a single-VAD solution. When possible, implantation should occur prior to clinical decompensation with evidence of end-organ damage, as outcomes at this point are worse. SUMMARY: Fontan patients demonstrating signs of heart failure should be evaluated early and often for feasibility and optimal timing of VAD implantation. The frequency of this procedure will likely increase significantly in the future.

Home before Hospital: a whole of system re-design project to improve rates of home-based dialysis therapy: Experience and outcomes over 8 years.

BACKGROUND: Despite evidence that clinical outcomes for patients treated with peritoneal dialysis (PD) or home haemodialysis are better than for patients treated with conventional satellite or hospital-based haemodialysis, rates of home-based dialysis therapies world-wide remain low. Home-based dialysis care is also cost-effective and indeed the favoured dialysis option for many patients. METHODS & OBJECTIVES: Using a lean-thinking framework and established change management methodology, a project embracing a system-wide approach at making a change where a 'Home before Hospital' philosophy underpinned all approaches to dialysis care was undertaken. Three multidisciplinary working groups (pathway, outreach and hybrid) were established for re-design and implementation. The primary aim was to improve home-based dialysis therapy prevalence rates from a baseline of 14.8% by ≥2.5%/year to meet a target of 35%, whilst not only maintaining but improving the quality of care provided to patients requiring maintenance dialysis. A 'future' state pathway was developed after review of the 'current' state (Pathway Working Group) and formed the basis on which a nurse-led outreach service (Outreach Working Group) was established. With the support of the multidisciplinary team, the outreach service model focussed on early, consistent, and frequent education, patient support in decision-making, and clinician engagement. RESULTS: A target prevalence of >30% for home-based therapies (mainly achieved with PD) was achieved within 2 years. This prevalence rate reached 35% within 3 years and was maintained at 8 years. In addition, selected patients already on maintenance satellite-based haemodialysis (Hybrid Working Group) were educated to achieve high levels of proficiencies in self-care. CONCLUSION: Having the system-wide approach to a Quality Improvement Process and using established principles and change management processes, the successful implementation of a new sustainable model of care focussed on home-based dialysis therapy was achieved. A key feature of the model (through outreach) was early nurse-led education and support of patients in decision-making and ongoing support through multidisciplinary care.

Anaesthesia for minimally invasive cardiac procedures in the catheterization lab.

PURPOSE OF REVIEW: The share of cardiac procedures performed in settings involving nonoperating room anaesthesia (NORA) continues to grow rapidly, and the number of publications related to anaesthetic techniques in cardiac catheterization laboratories is substantial. We aim to summarize the most recent evidence about outcomes related to type of anaesthetic in minimally invasive cardiac procedures. RECENT FINDINGS: The latest studies, primarily focused on transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve repair (TMVr), demonstrate the need for reliable monitoring and appropriate training of the interdisciplinary teams involved in this high-risk NORA setting. SUMMARY: Inappropriate sedation and concurrent inadequate oxygenation are main risk factors for claims involving NORA care. Current evidence deriving from TAVR shows that monitored anaesthesia care (MAC) is associated with shorter length of stay and lower mortality.

Role of Bivalirudin for Anticoagulation in Adult Perioperative Cardiothoracic Practice.

Bivalirudin, a direct thrombin inhibitor with a fast onset of action and short half-life, is often referred to as an alternative anticoagulant to a heparin/protamine regimen. Bivalirudin demonstrated promising results as an anticoagulant in cardiac surgery with and without cardiopulmonary bypass, postcardiotomy extracorporeal membrane oxygenation, interventional cardiology and endovascular procedures, and particularly in the treatment of patients with heparin-induced thrombocytopenia undergoing high-risk cardiac surgery. Currently, bivalirudin in cardiac surgery with cardiopulmonary bypass has a limited clinical spectrum, likely because the still obvious advantages of its competitor, heparin, outweigh it in terms of medical costs, established point-of-care monitoring systems, and availability of protamine as a reversal agent. The unique pharmacology of the drug also requires adjustment of surgical and perfusion strategy. In contrast, in off-pump coronary artery surgery, established protocols from interventional cardiology can be easily translated into the operating room. In this setting bivalirudin has the potential for a more important role in the future. Through a triple mechanism of action-inhibition of plasma thrombin, clot bound thrombin, and collagen-induced platelet activation-bivalirudin may perform better than heparin by attenuating the immediate postoperative prothrombotic state and thus positively impacting the early coronary graft patency after off-pump coronary artery bypass grafting. Further studies are necessary to better evaluate this niche field and discover further applications for this unique anticoagulant.

Lessons Learnt From the Narratives of Women Who Self-Harm in Prison.

Background: In England and Wales, women in prison make up a minority (<5%) of the total custodial population, yet acts of self-harm are around five times more common among incarcerated women. While there has been a multiagency effort to improve how acts of self-harm are documented across prisons, the patterns and functions of self-harm for women in prison have not yet been fully addressed. Aims: We aimed to determine the patterns, prevalence, and functions of self-harm among women in prison through a mixed-methods study. Method: A total of 108 women with a history of self-harm were interviewed across three female prisons. Participants completed a structured questionnaire detailing their experiences of self-harm across prison and community settings. Results: We found that women in prison who frequently self-harmed disclosed high levels of trauma: past experiences of domestic violence (81.5%), childhood sexual abuse (66.7%), and adult sexual abuse (60.2%). Prevalent methods of recent in-prison acts of self-harm involved cutting, followed by ligaturing. Limitations: The study used a cross-sectional design, self-reported data, and featured a subset of women identified as being at high-risk of self-harm. Conclusion: Motivations behind acts of self-harm by women in prison are complex. Triggers appear to be past trauma, deteriorating mental health, and separation from children or family.

Frontal fibrosing alopecia associated with generalized hair loss.

We present six cases of frontal fibrosing alopecia, in which generalized hair loss is a feature. Although this variant of lichen planopilaris has been reported clinically in a number of patients, there is very little histological evidence that the condition exists in peripheral sites. We believe this pattern of involvement may be more common than is reported, and have provided histological evidence of lichen planopilaris being present at sites beyond the scalp and eyebrows.

Nursing impact on chronic disease Medicaid health home patients: A qualitative study.

BACKGROUND: Managing individuals with chronic health conditions in the primary care setting continues to be a significant challenge in the US health care system. This issue is further compounded for low-income individuals with both mental health and physical health chronic conditions. The Affordable Care Act provides opportunities to launch chronic disease Medicaid health homes (MHH) to address the existing health care gaps. Within a multidisciplinary team, the nurse serves an integral role as the main care manager and coordinator aimed to improve patient experiences, health outcomes, and lowering health care costs. AIMS: The aim of this qualitative study is to assess the nurse's perception of their MHH role and how they may impact patient health care utilization patterns. MATERIALS & METHODS: The qualitative study included a focus group of eleven nurses and individual interviews with seven nurses. RESULTS: Six themes were identified that focus on how nurses can use a wide range of effective communication strategies and interpersonal skills to establish and maintain a nurse-patient relationship. DISCUSSION: The six themes provided insight as to nurses' perceived role in an MHH and how they impact patient health outcomes. The overarching message addressed connecting with the patient and taking the time to find out what was important to them. CONCLUSION: Nurses were able to impact patient health care utilization patterns.

Diagnosis of type I cryoglobulinaemia made through identifying crystals in the blood smear.

We report a case of type I cryoglobulinaemia in a 52-year-old man who presented with widespread cutaneous necrosis. The diagnosis could not be established early on, as repeated testing for cryoglobulin was negative despite a careful collection method. The diagnosis was made 1 year later, on an incidental full blood smear that revealed crystals, which is an uncommon way to diagnose this condition. We discuss the difficulties we faced in establishing the diagnosis and emphasise the need for repeat cryoglobulin testing in this clinical setting. In such cases, examination of a blood smear should be considered.

Community-based home support agencies: comparing the quality of care of cooperative and non-profit organizations.

In the province of Québec, services focusing on the instrumental activities of daily living are delivered to seniors by a combination of non-profit organizations and cooperatives. But do these organizations perform differently? This study asks whether home support cooperatives deliver higher-quality care than non-profit home support agencies. The specific effects of consumer and worker participation on the board of directors are also tested. Data were collected in 2006 and 2007 from 831 individuals receiving home support services from nine cooperatives and nine non-profits. Two consumer-centered measures of quality were used: a summated, 39-point satisfaction score and a 4-point overall quality score. Data were analyzed using ordered logistic regression. Results show that although organizational type was not a predictor of the two quality outcomes, worker involvement in governance was positively associated with the satisfaction score, while consumer involvement was positively associated with the overall quality score.

Prospective study of patch testing in patients with vulval pruritus.

Forty-three patients with the primary complaint of vulval pruritus were recruited to take part in this prospective patch-testing study. A detailed questionnaire was administered to each and patch testing to an extended battery of allergens was undertaken. This included the European standard series, preservatives, corticosteroids and a battery of common over-the-counter topical vulval treatments. Analysis of demographic data and prior treatments used, and various other parameters, were studied in the context of patch-test results. This prospective study reports a very high rate of contact sensitivity in patients presenting with vulval pruritus, with 81.4% of those tested having at least one contact allergen detected. One or more clinically relevant allergens were found in 44% of the subjects patch tested. The variables found to predict a greater likelihood of a contact allergy were a biopsy diagnosis of vulval dermatitis, the use of multiple topical treatments, sexual inactivity and patients with severe pruritus on a self-reported scale. Most importantly, many clinically relevant allergens these patients reacted to were outside the European standard series. This highlights the need for an extended series in this patient population.

A Qualitative Study of Good-Bye Letters in Prison Therapy.

BACKGROUND: Self-harm rates among imprisoned women in the UK are extremely high and there are limited psychological therapies available to support them in prison. This paper presents women's subjective accounts of receiving good-bye letters at the end of brief psychodynamic interpersonal therapy (PIT) and how these letters positively impacted on their incidents of self-harm. AIMS: This study presents the accounts of 13 imprisoned women who self-harmed and received letters following completion of a minimum of four sessions of brief PIT in prison. METHOD: A semi-structured interview covered several aspects of their experience, which included details of self-harm since completing brief therapy as well as usage of a good-bye letter and its impact. The interviews were analyzed using thematic analysis. RESULTS: Three themes emerged from the analysis: connecting with the therapist: receiving the letter; connecting to self: understanding and awareness; and connecting to others: sharing the good-bye letter. CONCLUSION: Findings show the positive impact the letters had for the women following therapy. The preliminary impressions suggest that letters may be a helpful tool enhancing the benefits of brief PIT therapy with imprisoned women who self-harm.

[Nle4-D-Phe7]-alpha-melanocyte-stimulating hormone significantly increased pigmentation and decreased UV damage in fair-skinned Caucasian volunteers.

Epidermal melanin reduces some effects of UV radiation, the major cause of skin cancer. To examine whether induced melanin can provide protection from sunburn injury, 65 subjects completed a trial with the potent synthetic melanotropin, [Nle4-D-Phe7]-alpha-melanocyte-stimulating hormone ([Nle4-D-Phe7]-alpha-MSH) delivered by subcutaneous injection into the abdomen at 0.16 mg/kg for three 10-day cycles over 3 months. Melanin density, measured by reflectance spectroscopy, increased significantly in all [Nle4-D-Phe7]-alpha-MSH-treated subjects. The highest increases were in volunteers with lowest baseline skin melanin levels. In subjects with low minimal erythemal dose (MED) skin type, melanin increased by an average of 41% (from 2.55 to 3.59, P < 0.0001 vs placebo) over eight separate skin sites compared with only 12% (from 4.18 to 4.70, P < 0.0001 vs placebo) in subjects with a high-MED skin type. Epidermal sunburn cells resulting from exposure to 3 MED of UV radiation were reduced by more than 50% after [Nle4-D-Phe7]-alpha-MSH treatment in the volunteers with low baseline MED. Thymine dimer formation was also shown to be reduced by 59% (P = 0.002) in the epidermal basal layer. This study has shown for the first time the potential ability of a synthetic hormone that augments melanin production to provide photoprotection to people who normally burn in direct sunlight.

The successful double cryopreservation of rabbit (Oryctolagus cuniculus) semen in large volume using the directional freezing technique with reduced concentration of cryoprotectant.

Using directional freezing, our objective was to cryopreserve rabbit semen and achieve fertility that was equal or higher than that achieved with conventional freezing. The working hypothesis was that controlling the ice-front propagation would allow reduction of DMSO concentration to <1M, in addition to the capability to freeze large volumes (2-10 mL). Moreover, single and double freezing of semen were used to demonstrate the abbreviated mechanical stress imparted by directional freezing. Single-cryopreserved semen from 15 males extended with 0% egg yolk/1.75 M DMSO, 15.3% egg yolk/0.88 M DMSO and 20% egg yolk/0M DMSO resulted in lower (P<0.05) mean+/-S.E.M. post-thaw motility (3.6+/-1.1, 28.5+/-2.8 and 36.3+/-1.8%, respectively) compared to fresh semen (73.3+/-1.2%). Semen from seven of these males, subject to double freezing using only egg yolk based extenders, resulted in post-thaw motilities of 18.1+/-2.2 and 16.4+/-3.3%. Despite the reduced functional parameters of cryopreserved semen, fertility and kindling rates of 73.9 and 56.5% for single frozen-thawed, and 28.6 and 35.7% for double frozen-thawed semen were achieved (with insemination of 98 females). There was no significant difference in fertility rate between fresh semen (87.5%) and semen that was single frozen-thawed with the 15.3% egg yolk/0.88 M DMSO extender (73.9%). In conclusion, cryopreservation of rabbit semen in large volumes using directional freezing achieved fertility rates similar to those achieved with fresh semen. Furthermore, acceptable fertility rates with double frozen-thawed semen could facilitate the future use of sex-sorted semen in rabbits.

The effect of long non-reproductive periods on the genital health in captive female white rhinoceroses (Ceratotherium simum simum, C.s. cottoni).

White rhinoceroses suffer from a low reproductive rate in captivity. Intensive efforts to propagate specifically the northern white rhinoceros have been very limited. The dismal outlook for this subspecies in the wild makes successful ex situ breeding programs paramount. In this context, this study examined 48 southern and 6 northern white rhinoceroses using ultrasound and faecal hormone analysis to elucidate causes for female reproductive failure and to determine whether long non-reproductive periods have a detrimental impact on genital health. Results showed that 76% of the nulliparous females had intact hymenal membrane indicating these females had never been bred, at an age when their wild counterparts have delivered multiple offspring. Fifty-six percent of the studied population had various reproductive pathology. Cystic endometrial hyperplasia; leiomyomas of the cervix, uterus and ovary, adenoma; para-ovarian cysts and hydromucometra represent the scope of lesions identified. The stages of the lesions in nulliparous females correlated with age (r = 0.4, P < 0.05). Due to the severity of the lesions, 28% of the study population was considered post-reproductive. Therefore, the reproductive life span in some individuals was 10-20 years shorter than expected. However, in parous females the incidence of pathological lesions was significantly lower (P < 0.0001). Seventy-eight percent females studied had erratic or absent luteal activity. The hormone data corresponded with two ultrasonographic levels of ovarian activity, active and inactive, occurring within an age range of 3-19 years and 15-38 years, respectively. This suggests the lack of ovarian activity by reproductive mid-life in non-reproducing females. The accuracy of the ultrasound findings was validated by necropsy in nine animals showing a strong positive correlation (r2 = 0.9, p < 0.001). Our data suggests that the development of reproductive pathology and ovarian inactivity in white rhinoceros is an age-related consequence of long non-reproductive periods. This asymmetric ageing process of the genital organs can be prevented with the achievement of at least one pregnancy.

An exploration of issues of management and intention to stay: allied health professionals in South West Victoria, Australia.

Management of allied health staff and services often has implications for staff stability and retention. A survey of allied health staff in South West Victoria was conducted in 2003 to explore issues relating to recruitment and retention. Findings relating to management and retention of staff in their current job are addressed in this report. A total of 138 staff returned their questionnaires. Results were related to Maslow's hierarchy of needs, level of belonging, with professional needs identified as feeling supported, orientation to the position, clear job description, and able to recommend the position to others. Qualitative data showed that recommending the position was associated with job satisfaction, autonomy, flexibility, and variety of work. The immediate management structure was significantly related to retention. Reasons given for intending to leave were related to management categories. These were management structure, lack of career structure, and lack of professional support. Reasons given by respondents for not recommending their current position were as follows: not for long-term career, risk of deskilling if staying too long, and financially unrewarding. These reasons were also related to management. Positive reasons for staying, which were related to management, included flexible work conditions, variety of clinical and management experience, good working environment, good support, and autonomy. Recommendations are given for organizational development and training for managers.