Cognitive appraisals, objectivity and coping in ambulance workers: a pilot study.

OBJECTIVES: Ambulance workers are regularly exposed to call-outs, which are potentially psychologically traumatic. The ability to remain objective and make adaptive appraisals during call-outs may be beneficial to this at-risk population. This pilot study investigated the links between cognitive appraisals, objectivity and coping in ambulance workers. METHODS: Forty-five ambulance workers from the London Ambulance Service, UK, were studied. Trauma exposure, post-traumatic stress disorder and depression symptoms were assessed using self-report measures. Positive and negative appraisals were measured in relation to two previous call-outs: one during which they coped well and one during which they did not. RESULTS: Enhanced coping was associated with making more positive appraisals during the call-out. Better coping was also related to greater levels of objectivity during these call-outs. Coping less well was associated with the use of more negative appraisals during the call-out. CONCLUSIONS: Ambulance workers may benefit from psychological interventions, which focus on cognitive reappraisal and enhancing objectivity to improve coping and resilience.

Frequency of cardiotoxicity following intramuscular administration of epinephrine in emergency department patients with anaphylaxis.

Objectives: Epinephrine can be a life-saving treatment for patients with anaphylaxis. Potential cardiovascular side effects of epinephrine may contribute to clinician hesitancy to use it. However, the frequency of cardiotoxicity resulting from epinephrine treatment for anaphylaxis is not well described. We sought to describe the frequency of cardiotoxicity following intramuscular (IM) administration of epinephrine in adult emergency department (ED) patients with anaphylaxis. Methods: We conducted a retrospective observational study at a single, quaternary care academic ED in Tennessee. We identified consecutive ED visits with the diagnosis of anaphylaxis from 2017 to 2021 who received at least one intramuscular (IM) dose of epinephrine in the ED. Analysis was primarily descriptive. The primary outcome was cardiotoxicity, the occurrence of any of the following after epinephrine administration: ischemic electrocardiogram changes, systolic blood pressure >200 mmHg, or cardiac arrest ≤4 h; elevated troponin ≤12 h; or percutaneous coronary intervention or depressed ejection fraction ≤72 h. Results: Among 338 included patients, 16 (4.7%; 95%CI: 2.8-7.6%) experienced cardiotoxicity. Cardiotoxic events included eight (2.4%) ischemic electrocardiogram changes, six (1.8%) episodes of elevated troponin, five (1.5%) atrial arrhythmias, one (0.3%) ventricular arrythmia, and one (0.3%) depressed ejection fraction. Patients with cardiotoxicity were significantly older, had more comorbidities, and were more likely to have received multiple doses of epinephrine or an epinephrine infusion compared with a single IM dose of epinephrine. Conclusions: Among 338 consecutive adult ED patients who received IM epinephrine for anaphylaxis during a recent 4-year period, cardiotoxic side effects were observed in approximately 5% of patients.

Immunodiagnostic Detection of Angiostrongylus cantonensis Exposure on Hawaii Island Using Isogeographic 31-kDa Antigen.

Angiostrongylus cantonensis is the leading cause of neuroangiostrongyliasis worldwide, and east Hawaii Island is a hotspot for the disease in the United States. A combination of glycoproteins with molecular weight of 31 kDa has been used as antigen to evaluate antibody response in human serum samples in Thailand with high specificity and sensitivity. In a previous pilot study, the Thailand-isolated 31-kDa proteins showed efficacy in dot-blot tests using serum samples from 435 human volunteers on Hawaii Island. However, we hypothesized that native antigen isolated from Hawaii A. cantonensis may exhibit higher specificity than the Thailand-isolated 31-kDa antigen due to potential minor variation in epitopes between isolates. In this study, 31-kDa glycoproteins were isolated by sodium dodecyl-sulfate polyacrylamide gel electrophoresis from adult A. cantonensis nematodes collected from rats captured on east Hawaii Island. The resultant proteins were purified by electroelution, pooled, bioanalyzed, and quantified. A subset of 148 samples from human participants of the original cohort of 435 was consented for this study, including 12 of the original 15 clinically diagnosed participants. Results of ELISA using the Hawaii-isolated 31-kDa antigen were compared with results of the same serum samples previously tested with both crude Hawaii antigen ELISA and Thailand 31-kDa antigen dot blot. This study shows a seroprevalence in the general population of East Hawaii Island of 25.0%, similar to previous findings of 23.8% seroprevalence in this cohort using crude antigen from Hawaii A. cantonensis and 26.5% using Thailand 31-kDa antigen.

Positive outcomes for operatively managed self-harm burns.

Within healthcare generally, patients who self-harm can experience stigma and inequitable medical care. Previous studies have suggested that patients with small self-harm burn injuries may not be treated equally in comparison to non-intentional injuries. Furthermore, there is an absence of literature related to surgical outcomes for self-harm burn injuries. A retrospective cohort study of an adult burns service's outpatient attendances over a four-year period was completed. Self-harm burn injuries were identified and hospital medical records were used to extract demographic, burn injury, treatment and outcome information. 94 self-harm burn injuries in 58 patients presented over the study period. Of those who presented with self-harm burn injuries, 29 % (n = 17) of patients presented on more than one occasion, 54 % (n = 50) of wounds were managed surgically and 80 % (n = 36) of full thickness injuries were managed surgically. The post-operative course and healing time was similar to what would be expected after non-intentional burn injuries. In 93 % (n = 54) of all patients presenting with self-harm burn injuries, there was no reported tampering or non-compliance. There was no tampering or non-compliance in 94 % (n = 47) of those with self-harm burn injuries when wounds were treated surgically. The findings support the view that self-harm burn injuries should be treated in the same way as non-intentional burn injuries and that similar outcomes from treatment can be expected. However, further research is needed to explore this systematically.

Experiences of medical tattooing in women following burn injuries: An interpretative phenomenological analysis.

INTRODUCTION: Physical changes to appearance caused by burn injuries can have significant psychological consequences. Medical tattooing is an intervention aimed at restoring appearance but little is known about the experiences of patients or the psychological impact of medical tattooing following burns. This study aimed to explore burn patients' psychological experiences of medical tattooing. METHOD: In-depth interviews were conducted with eight adult women who had experienced a burn injury and subsequently undergone medical tattooing. RESULTS: Using interpretative phenomenological analysis (IPA) to analyse the verbatim transcripts of interviews, two subordinate themes ('Management of Hope' and 'The Medical Tattooing Process') and one superordinate theme ('Impact of Medical Tattooing: 'Normal-ish is Fantastic'') emerged, which were set within a broader context of another superordinate theme: 'Inner Conflict about Acceptability of Perceived Need'. The findings suggested that medical tattooing is experienced positively, may have positive psychological consequences, and may allow women to regain a sense of normality and an improved sense of being acceptable in society following burn injuries. Findings additionally highlighted a conflicting narrative of a pressure to conform to certain expectations of appearance, alongside a sense that a desire to meet these expectations may also not be viewed as important, acceptable or legitimate. CONCLUSIONS: Medical tattooing may be a potentially valuable intervention psychologically, although support and information seem important and further research is required.

Improving service provision for patients who are prescribed continence products.

It is estimated that 14 million people experience problems with bladder control and 6.5 million people have a bowel control problem (Bladder and Bowel Foundation, 2008). Many will rely on continence products to manage their problem and as such require products which ensure user dignity and discretion is maintained. Locally, an ever-increasing spend on prescribed continence products promoted a review of current service delivery. The combined results of a clinical audit and patient satisfaction survey highlighted areas in which service delivery needed immediate improvement. Significant service re-design has been undertaken with prescribing responsibility for continence-related products being transferred from GP practices to specialist nurses working within the continence service. Improvements in clinical care have been achieved and cost savings have been re-invested in the service.

Acceptance and commitment therapy for appearance anxiety: three case studies.

INTRODUCTION: Due to scarring, appearance anxiety is a common psychological difficulty in patients accessing burns services. Appearance anxiety can significantly impact upon social functioning and quality of life; thus, the availability of effective psychological therapies is vital. Acceptance and Commitment Therapy (ACT) is considered useful for treating distress associated with other health conditions and may lend itself well to appearance anxiety. However, no published research is currently available. METHODS: Three single case studies (two male burns patients; one female necrotising fasciitis patient) are presented where appearance anxiety was treated using ACT. A treatment protocol was followed and evaluated: the Derriford Appearance Scale measured appearance anxiety; the Work and Social Adjustment Scale measured impairment in functioning; the Acceptance and Action Questionnaire measured acceptance (willingness to open up to distressing internal experiences); and the Committed Action Questionnaire measured engagement in meaningful and valued life activities. Measures were given at every treatment session and patient feedback was obtained. One-month follow-up data were available for two cases. RESULTS: After the intervention, all patients had reduced functional impairment and were living more valued and meaningful lives. No negative effects were found. DISCUSSION: These case studies suggest that ACT may be a useful psychological therapy for appearance anxiety. The uncontrolled nature of the intervention limits the conclusions that can be drawn. CONCLUSION: A pilot feasibility study to evaluate the effectiveness of ACT for appearance anxiety is warranted. LAY SUMMARY: Many patients with scars can feel distressed about their appearance. This is known as appearance anxiety and can include patients accessing burns services. Appearance anxiety can stop patients from enjoying a good quality of life and impact upon important areas of daily functioning. It is therefore important that psychological therapies are effective. However, research investigating the effectiveness of psychological therapies is limited. This paper describes the psychological therapy of three patients who were distressed about scarring. A psychological therapy called Acceptance and Commitment Therapy (ACT) was used as part of standard care and evaluated using questionnaires and patient feedback. After the course of ACT, all patients were less impacted day-to-day by their appearance anxiety and were living more valued and meaningful lives. No negative effects were found. These case studies suggest that ACT may be a useful psychological therapy for appearance anxiety and further research evaluating it should be completed.

Recording therapy sessions: an evaluation of patient and therapist reported behaviours, attitudes and preferences.

BACKGROUND: Audio recording of cognitive behavioural therapy (CBT) sessions has been recommended but not yet widely adopted. It is believed to have positive effects on later recall and reflection by the patient and on supervisory quality and accuracy for therapists. AIMS: To evaluate self-reported attitudes and behaviour regarding audio recording of therapy sessions in both patients and therapists in a setting where such recording is routinely carried out. METHOD: In a centre specializing in CBT for anxiety disorders, 72 patients completed a questionnaire at the start of therapy and 31 patients completed a questionnaire at the end of therapy. Fifteen therapists also completed a similar questionnaire. RESULTS: Ninety percent of patients reported listening to recordings between therapy sessions to some extent. The majority reported discussing the recordings with their therapist. Patients typically planned to keep the recordings after therapy ended. Most patients and therapists endorsed positive attitudes towards the use of recordings. Similar advantages (e.g. improving memory for sessions) and disadvantages (e.g. practical issues and feeling self-conscious) of recordings were generated by patients and therapists. Therapists were more likely than patients to express concern about recordings being distressing for patients to listen to. Both patients and therapists regarded the use of recordings for therapist peer supervision purposes favourably. CONCLUSION: The use of audio recording of sessions as an adjunct to therapy (where patients listen to recordings between sessions) and for therapist supervision is rated as both highly acceptable and useful by both therapists and patients.

Quantitative and thematic analysis of burns surgeons' attitudes, beliefs and surgical decision-making in self-harm burn injuries: The use of a questionnaire and hypothetical cases.

BACKGROUND: Self-harm injuries represent a significant minority of attendances within burns services. However, there is minimal research exploring burns surgeons' attitudes and beliefs about self-harm and how treatment decisions are made. METHOD: Burns surgeons (n=37) completed a questionnaire which measured attitudes and beliefs about self-harm. Surgical decision-making was also explored by prompting surgeons to make treatment decisions for hypothetical case scenarios, and describe their rationale behind their decisions. RESULTS: The majority of surgeons reported positive attitudes about self-harm. However, around one in ten judged patients who self-harm more negatively, around a fifth offer surgery less frequently and almost a quarter believed that surgery should only be offered a limited number of times in repeated self-harm. Unhelpful or inaccurate beliefs (e.g. self-harm is 'attention seeking,' surgery would reinforce the self-harm, and that patients who self-harm tamper with skin grafts) were evident in some surgeons. Thematic analysis of qualitative data describing surgical decisions identified five themes: Equal Access to Care; Multidisciplinary Working; Old or Unhelpful Stories; Concerns about Tampering; and Repeated vs. First Time Self-Harm Episodes. More experienced surgeons were less judgmental, more likely to offer surgical interventions, and less likely to hold unhelpful or inaccurate beliefs compared to junior surgeons. CONCLUSIONS: Some surgeons are not acting in line with UK guidance on the management of self-harm injuries. Education on the topic of self-harm is essential in burns services and this may be particularly important early on during surgical careers. Prospective research regarding surgical treatments and outcomes following self-harm is required.

The role of psychological flexibility in appearance anxiety in people who have experienced a visible burn injury.

BACKGROUND: Individuals with visible differences can experience appearance anxiety that is distressing and disruptive to daily functioning. Understanding psychological factors that maintain appearance anxiety related to scarring is important in developing theoretical understanding of adjustment to injury, and in identifying targets for psychological therapies. This study aimed to investigate whether psychological flexibility, a key element underpinning acceptance and commitment therapy (ACT), was associated with appearance anxiety. It was hypothesised that reduced psychological flexibility (lower acceptance, cognitive defusion, mindfulness, and committed action) would be related to increased appearance anxiety. The role of psychological flexibility in the maintenance of appearance anxiety was investigated using a cross-sectional quantitative questionnaire study. METHOD: Seventy-eight burns patients (47 female, 31 male; M age=45.2years) completed the Derriford Appearance Scale (DAS-24), the Acceptance and Action Questionnaire (AAQ-II), the Cognitive Fusion Questionnaire (CFQ), the Five Facet Mindfulness Questionnaire (FFMQ), and the Committed Action Questionnaire (CAQ-8). RESULTS: As hypothesised, increased appearance anxiety was related to reduced acceptance (rs(76)=0.80, p<0.001, one-tailed) and cognitive defusion (rs(76)=0.76, p<0.001). Reduced levels of mindfully describing (r(72)=-0.39, p<0.001), acting with awareness (r(72)=-0.57, p<0.001), non-judging (r(72)=-0.61, p<0.001) and non-reactivity (r(72)=-0.28, p<0.01) as well as reduced committed action (r(72)=-0.57, p<0.001) were also related to increased appearance anxiety. CONCLUSIONS: Individuals experiencing appearance anxiety associated with a burn injury may struggle with accepting difficult emotions, stepping back from distressing thoughts, being mindful and engaging in valued action. These findings suggest that ACT may be useful in treating appearance related anxiety and concerns associated with conditions causing a visible difference.

IMPLSE course: a near-peer simulation course.

Background: Near-peer teaching is recognised for its benefit to both students and facilitators when used as an adjunct to traditional teaching. Simulation is an effective tool for teaching acute management. There are currently no published long-term objective data of the efficacy of near-peer simulation teaching. Methods: We designed the 'Immediate Management: Peer Led Simulated Emergencies' course, a near-peer simulation course for medical students run by junior doctors covering common medical and surgical emergencies. Participants and teachers were objectively tested before and after sessions, and participant confidence in various areas was self-assessed. Participants were followed up at 18 months with both repeat testing and analysis of finals examination results. Results: Participants' mean test scores improved significantly postcourse and remained significantly higher than baseline at 18-month follow-up. There was no difference between participants' and non-participants' final examination performance. Participant confidence increased in all areas immediately and at 18-month follow-up. Junior doctor facilitator test scores significantly improved after teaching on the course. Conclusions: Near-peer simulation courses can be effectively designed and run by junior doctors and our results suggest that they result in long-term improvement in test scores. Larger studies with randomised control groups are required to confirm the efficacy of such teaching.

Audit of healthcare professionals' attitudes towards patients who self-harm and adherence to national guidance in a UK burns and plastic surgery department.

BACKGROUND: Rates of self-harm injuries are considered to be increasing. The attitudes of healthcare staff towards patients who self-harm may be negative and a small amount of research specifically investigating burns and plastic surgery healthcare professionals has recently been conducted exploring this issue. This study aimed to determine attitudes towards and adherence to national guidance by healthcare professionals in a UK burns and plastic surgery department with respect to patients who self-harm. METHOD: An audit questionnaire, completed in a designated Burns Unit and plastic surgery department, within a UK hospital with a major trauma centre. RESULTS: Data were obtained from 59 healthcare professionals. The majority of responders held positive attitudes towards those who had self-harmed. However, a significant minority held negative attitudes, stating that they found it difficult to be compassionate (10%; n = 6) and believing that patients usually self-harm to get attention (9%; n = 5). One-fifth (n = 12) agreed that, on a departmental level, conservative management (as opposed to surgery) was offered more frequently for self-harm injuries compared with accidental injuries, contrary to national guidance. Awareness of national guidance in relation to self-harm injuries was markedly lacking, in only 12% (n = 7/59) and the frequency of completing relevant training was low (34%, n = 20/59). CONCLUSION: Education among healthcare professionals is important, to ensure adherence to best practice. The findings of this study strongly suggest that many healthcare professionals do not know the current best practice. As a result, these highly vulnerable patients may be receiving sub-optimal care, with consequentially poor outcomes.

A comparison of two psychological screening methods currently used for inpatients in a UK burns service.

Various types of psychological screening are currently used in the UK to identify burn patients who are experiencing psychological distress and may need additional support and intervention during their hospital admission. This audit compared two types of psychological screening in 40 burn inpatients. One screening method was an unpublished questionnaire designed to explore multiple areas of potential distress for those who have experienced burns. The other method was an indirect psychological screen via discussions within multi-disciplinary team (MDT) meetings where a Clinical Psychologist was present to guide and prompt psychological discussions. Data was collected between November 2012 and September 2016. Results suggested that both screening methods were similar in identifying patients who benefit from more formal psychological assessment. Indeed, statistical analysis reported no difference between the two screening methods (N=40, p=.424, two-tailed). In conclusion, measuring distress in burns inpatients using a burns-specific questionnaire and psychological discussions within MDT meetings are similar in their ability to identify patients in need of more thorough psychological assessment. However, both screening methods identified patients who were in need of psychological input when the other did not. This suggests that psychological screening of burns inpatients, and the psychological difficulties that they can present with, is complex. The advantages and disadvantages of both methods of screening are discussed.

Posttraumatic stress symptomatology and appearance distress following burn injury: An interpretative phenomenological analysis.

OBJECTIVES: Although many traumatic incidents result in changes to appearance, little research has examined the experience of individuals distressed by such changes in connection with psychological processes involved in posttraumatic stress disorder (PTSD). This study aimed to examine how PTSD and appearance concern associated with burn injury are experienced when both difficulties co-occur. METHOD: The qualitative method of interpretative phenomenological analysis (IPA) was used to provide a framework for building nuanced accounts of individual experience. In-depth analysis was conducted with interview data obtained from 8 women, who were purposively selected on the basis of being distressed in relation to burn scarring, and having symptoms of PTSD. RESULTS: Participants described how changes in appearance were experienced as maintaining a sense of threat through social stigma, and acting as a trigger for re-experiencing the traumatic incident that had caused the burn injury. As such, appearance concern and PTSD symptomatology appeared intertwined within the participants' accounts of their postburn injury recovery. CONCLUSIONS: This is the first study to consider some of the processes through which PTSD and appearance concern might be mutually maintained. The results suggest that psychosocial interventions need to be tailored to simultaneously address processes related to concerns about change in appearance and also with traumatic re-experiencing. (PsycINFO Database Record

A pilot study exploring the relationship between trauma symptoms and appearance concerns following burns.

Individuals who have experienced burns often have to adjust to distressing changes to their appearance. Trauma symptoms are another common psychological difficulty in the burn-injured population. However, there has been a lack of research exploring the possible relationship between trauma symptoms and appearance concerns in populations where incidents have led to appearance changes, including burns. The aim of this pilot study was to investigate the relationship between trauma symptoms and appearance concerns in the burn-injured population. Burn-injured patients (n=33) referred to a Burns Clinical Psychology service completed measures of trauma symptom severity, appearance concerns and changes in outlook. Analyses revealed a statistically significant positive relationship between trauma symptoms and appearance concerns (r=0.41, p<0.01, one-tailed). Participants with higher trauma symptoms had more appearance concerns. Furthermore, negative changes in outlook following the burns were positively related to trauma symptoms (r=0.69, p<0.001, two-tailed) and appearance concerns (r=0.50, p<0.01, two-tailed). Age was negatively related to appearance concerns (r=-0.41, p<0.05, two-tailed) but not trauma symptoms. Gender was not statistically related to trauma symptoms or appearance concerns. Burn injury factors (% TBSA, primary location of the injury, cause of the injury and time since the injury) were not related to trauma symptoms or appearance concerns. In conclusion, trauma symptoms and appearance concerns following burns may be positively related and further research in this area is needed. Theoretical and clinical implications are discussed.

The effects of flying: processes, consequences and prevention.

The dangers of flying have recently been highlighted in the media; however, the available literature is contradictory, as are current recommendations for travellers. The purpose of this article is to provide an account of the research that has been undertaken to investigate the possible consequences of air travel. It will examine the effect that flying has on the body, especially the respiratory and circulatory systems, by studying the theoretical and empirical literature. The aim is to provide nurses with a sound insight into the effects of long-distance flying on the body, and the potential adverse effects/complications, such as deep vein thrombosis and pulmonary embolism, that may occur as a result. In addition, it provides information on the treatment options available and should enable nurses to give sound prophylactic advice after discharge. By encouraging passengers to take precautions, the number of people affected by flight could be reduced.

Emotion regulation, physiological arousal and PTSD symptoms in trauma-exposed individuals.

OBJECTIVES: Retrospective studies suggest a link between PTSD and difficulty regulating negative emotions. This study investigated the relationship between PTSD symptoms and the ability to regulate negative emotions in real-time using a computerised task to assess emotion regulation. METHOD: Trauma-exposed ambulance workers (N = 45) completed self-report measures of trauma exposure, PTSD symptoms and depression. Participants then completed a computer task requiring them to enhance, decrease or maintain their negative emotions in response to unpleasant images. Skin conductance responses (SCR) were recorded and participants also made ratings of emotion intensity. Immediately after the computer task, participants were asked to describe the strategies they had used to regulate their negative emotions during the task and recorded spontaneous intrusions for the unpleasant images they had seen throughout the following week. RESULTS: PTSD symptoms were associated with difficulty regulating (specifically, enhancing) negative emotions, greater use of response modulation (i.e., suppression) and less use of cognitive change (i.e., reappraisal) strategies to down-regulate their negative emotions during the task. More intrusions developed in participants who had greater reductions in physiological arousal whilst decreasing their negative emotions. LIMITATIONS: PTSD was measured by self-report rather than by a clinician administered interview. The results suggest a relationship between emotion regulation ability and PTSD symptoms rather than emotion regulation and PTSD. CONCLUSIONS: Difficulty regulating negative emotions may be a feature of trauma-exposed individuals with PTSD symptoms, which may be linked to the types of strategies they employ to regulate negative emotions.