Exploring healthcare workers' experiences of a simple intervention to reduce their intrusive memories of psychological trauma: an interpretative phenomenological analysis.

ABSTRACTBackground: Many healthcare workers (HCWs) endured psychologically traumatic events at work during the coronavirus disease 2019 (COVID-19) pandemic. For some, these events are re-experienced as unwanted, recurrent, and distressing intrusive memories. Simple psychological support measures are needed to reduce such symptoms of post-traumatic stress in this population. A novel intervention to target intrusive memories, called an imagery-competing task intervention (ICTI), has been developed from the laboratory. The intervention includes a brief memory reminder cue, then a visuospatial task (Tetris® gameplay using mental rotation instructions for approximately 20 min) thought to interfere with the traumatic memory image and reduce its intrusiveness. The intervention has been adapted and evaluated in a randomized controlled trial (RCT) with Swedish HCWs (ClinicalTrials.gov identifier: NCT04460014).Objective: We aimed to explore how HCWs who worked during the COVID-19 pandemic experienced the use of a brief intervention to reduce their intrusive memories of work-related trauma.Method: Interpretative phenomenological analysis was used for in-depth understanding of the lived experiences of HCWs who used the intervention. Seven participants from the RCT were interviewed by an independent researcher without prior knowledge of the intervention. Interviews were conducted via telephone and transcribed verbatim.Results: Four general themes were generated: 'Triggers and troublesome images', 'Five Ws regarding support - what, when, why, by/with who, for whom', 'Receiving it, believing it, and doing it' and 'The intervention - a different kind of help'; the last two included two subthemes each. The results reflect participants' similarities and differences in their lived experiences of intrusive memories, support measures, and intervention impressions and effects.Conclusion: HCWs' experiences of the novel ICTI reflect a promising appraisal of the intervention as a potential help measure for reducing intrusive memories after trauma, and gives us a detailed understanding of HCWs' needs, with suggestions for its adaption for future implementation.Trial registration: ClinicalTrials.gov identifier: NCT04460014.

Many healthcare workers experience images or 'flashbacks' of traumatic experiences from their work during the COVID-19 pandemic.To ensure that individual needs are met, there is a need to tailor and refine current psychological support measures and their use for healthcare workers.The imagery-competing task intervention was perceived as acceptable, indicating its potential utility as a help measure to reduce intrusive memories after trauma.

Family member's experiences with and evaluation of an ICU Liaison Nurse Service: A qualitative study.

BACKGROUND: Family members of critically ill patients often experience anxiety when their relatives are transferred from ICU to another level of care. ICU liaison nurse (ICULN) visits have been associated with improved support for patients, their families and nursing staff but has not been extensively studied in the non-English speaking setting. Yet, cross-country variations such as how hospital care is delivered and by who means that innovations such as the ICULN may not be able to be simply transferred to other contexts and may not have similar outcomes. AIM: The aim of this study was to investigate family member's experiences with and evaluation of ICULN support service in one Swedish ICU. STUDY DESIGN: A qualitative evaluation study was undertaken, recruiting family members of former ICU patients. Audio-taped in-depth interviews were conducted. Data were analysed by content analysis. FINDINGS: Fifteen family members were interviewed. Two categories: Minds the gap between intensive care and the next care level and providing stability in an uncertain situation were identified. The ICULN supported the family members both directly, when the ICULNs listened to their questions and met their needs, and indirectly, when the ICULNs took responsibility for the patients and their physical and psychological conditions and wellbeing. CONCLUSION: Families valued and were satisfied with the ICULN service but also gave suggestions to improve the service in this particular hospital context. RELEVANCE TO CLINICAL PRACTICE: The study showed that an ICULN support service met several needs of family members and therefore was a beneficial way to support patients and family members in the transition from the ICU to the ward.

Patient experiences of an intensive care Liaison Nurse support service.

OBJECTIVES: To illuminate patients' experiences of being a part of an liaison nurse support service focused on supporting recently transferred intensive care unit patients. RESEARCH METHODOLOGY/DESIGN: A qualitative inductive descriptive design including in-depth interviews was chosen. SETTING: A project including an liaison nurse support service-intervention was undertaken during a 16-week period at a University hospital in Sweden. The liaison nurse support service was available Monday-Friday 10 am - 6 pm and nurses visited the patient 1-4 times after transfer to the ward. MAIN OUTCOME MEASURES: Of the 109 patients who were visited by the liaison nurse support service, 14 agreed to be interviewed about their experiences of the transfer. Data was analysed by inductive content analysis. FINDINGS: One overall theme, An advocate in a vulnerable situation emerged from the data. Four subthemes were identified: Ensures transfer of information between the intensive care unit and the general ward, Makes the circumstances understandable and coordinates between the care levels and Offers emotional support and stability in an uncertain situation. CONCLUSION: The liaison nurse support service contributed to ensuring accurate transfer of information, solved problems when the patient themselves did not have control or strength and provided emotional support.

Simplified Postoperative Care After Spring-assisted Strip Craniotomy for Sagittal Synostosis: A Prospective Before-and-After Study.

ABSTRACT: Since the development of spring-assisted techniques for corrective craniofacial surgery, routine postoperative admission to intensive care units (ICUs) has been questioned. However, close monitoring is necessary if the continuous infusion of morphine is used as recommended for better pain relief. In this study, the authors evaluated a simplified postoperative protocol without continuous morphine infusion and no indwelling urinary catheter following spring-assisted surgery (SAS) for sagittal synostosis. Ten children were cared for according to a standard protocol with postoperative intravenous (i.v.) infusion of morphine and an indwelling urinary catheter, and 11 consecutive children were treated according to a simplified protocol with pain relief based on intermittent injections of morphine and clonidine [according to Face, Legs, Activity, Cry, Consolability (FLACC) scores >4] without the indwelling catheter. A Mann-Whitney U test was used for comparison of distributions between the two groups. The results revealed no differences between groups regarding the proportion of FLACC scores >4, total amount of administered i.v. morphine and clonidine, total volume of buffered glucose infused, time to first feeding on breast milk or substitute, or the length of stay. Despite the inherent limitations of our small observational study, the authors concluded that at our institution, it was possible to exclude a standard continuous i.v. infusion of morphine and an indwelling urinary catheter from our postoperative care protocol without decreasing the quality of pain relief in children submitted to SAS for sagittal synostosis. This finding supports downgrading the level of care from the ICU to a regular ward after limited immediate postoperative observation.

An intervention targeting social, communication and daily activity skills in children and adolescents with Down syndrome and autism: a pilot study.

PURPOSE: To evaluate whether an intervention, targeting deficits in social communication, interaction and restricted activities in children and adolescents with Down syndrome and autism could lead to enhanced participation in family and school activities. METHODS: The intervention included education for parents and school staff about autism, and workshops to identify social-communication and daily living activities that would be meaningful for the child to practice at home and at school. Thereafter, a three-month period of training for the child followed. Outcome measures comprised evaluation of goal achievement for each child, the "Family Strain Index" questionnaire and a visual scale pertaining to the parents' general opinion about the intervention. RESULTS: On average, more than 90% of the goals were (to some extent or completely) achieved at home and at school. The mean scores of the "Family Strain Index" were almost identical at the follow-up to those before intervention. The evaluation supported that the use of strategies, intended to facilitate activities and communication, remained largely 18 months after start of the intervention. CONCLUSION: Despite the group involved in this study being composed of older children and adolescents, most of whom had severe and profound intellectual disability, the goal achievements and parents' views on the intervention were encouraging.

Variability in alignment of central venous pressure transducer to physiologic reference point in the intensive care unit-A descriptive and correlational study.

BACKGROUND: The phlebostatic axis is the most commonly used anatomical external reference point for central venous pressure measurements. Deviation in the central venous pressure transducer alignment from the phlebostatic axis causes inadequate pressure readings, which may affect treatment decisions for critically ill patients in intensive care units. AIM: The primary aim of the study was to assess the variability in central venous pressure transducer levelling in the intensive care unit. We also assessed whether patient characteristics impacted on central venous pressure transducer alignment deviation. METHODS: A sample of 61 critical care nurses was recruited and asked to place a transducer at the appropriate level for central venous pressure measurement. The measurements were performed in the intensive care unit on critically ill patients in supine and Fowler's positions. The variability among the participants using eyeball levelling and a laser levelling device was calculated in both sessions and adjusted for patient characteristics. RESULTS: A significant variation was found among critical care nurses in the horizontal levelling of the pressure transducer placement when measuring central venous pressure in the intensive care unit. Using a laser levelling device did not reduce the deviation from the phlebostatic axis. Patient characteristics had little impact on the deviation in the measurements. CONCLUSION: The anatomical external landmark for the phlebostatic axis varied between critical care nurses, as the variation in the central venous pressure transducer placement was not reduced with a laser levelling device. Standardisation of a zero-level for vascular pressures should be considered to reduce the variability in vascular pressure readings in the intensive care unit to improve patient treatment decisions. Further studies are needed to evaluate critical care nurses' knowledge and use of central venous pressure monitoring and whether assistive tools and/or routines can improve the accuracy in vascular pressure measurements in intensive care units.

Evaluation of a sound environment intervention in an ICU: A feasibility study.

BACKGROUND: Currently, it is well known that the sound environment in intensive care units (ICU) is substandard. Therefore, there is a need of interventions investigating possible improvements. Unfortunately, there are many challenges to consider in the design and performance of clinical intervention studies including sound measurements and clinical outcomes. OBJECTIVES: (1) explore whether it is possible to implement a full-scale intervention study in the ICU concerning sound levels and their impact on the development of ICU delirium; (2) discuss methodological challenges and solutions for the forthcoming study; (3) conduct an analysis of the presence of ICU delirium in the study group; and (4) describe the sound pattern in the intervention rooms. METHODS: A quasi-randomized clinical trial design was chosen. The intervention consisted of a refurbished two-bed ICU patient room (experimental) with a new suspended wall-to-wall ceiling and a low frequency absorber. An identical two-bed room (control) remained unchanged. INCLUSION CRITERIA: Patients >18 years old with ICU lengths of stay (LoS) >48h. The final study group consisted of 31 patients: six from the rebuilt experimental room and 25 from the control room. Methodological problems and possible solutions were continuously identified and documented. RESULTS: Undertaking a full-scale intervention study with continuous measurements of acoustic data in an ICU is possible. However, this feasibility study demonstrated some aspects to consider before start. The randomization process and the sound measurement procedure must be developed. Furthermore, proper education and training are needed for determining ICU delirium. CONCLUSION: This study raises a number of points that may be helpful for future complex interventions in an ICU. For a full-scale study to be completed a continuously updated cost calculation is necessary. Furthermore, representatives from the clinic need to be involved in all stages during the project.

Noise in the ICU patient room - Staff knowledge and clinical improvements.

INTRODUCTION: The acoustic environment in the intensive care unit patient room, with high sound levels and unpredictable sounds, is known to be poor and stressful. Therefore, the present study had two aims: to investigate staff knowledge concerning noise in the intensive care unit and: to identify staff suggestions for improving the sound environment in the intensive care unit patient room. METHOD: A web-based knowledge questionnaire including 10 questions was distributed to 1047 staff members at nine intensive care unit. Moreover, 20 physicians, nurses and enrolled nurses were interviewed and asked to give suggestions for improvement. RESULTS: None of the respondents answered the whole questionnaire correctly; mean value was four correct answers. In the interview part, three categories emerged: improving staff's own care actions and behaviour; improving strategies requiring staff interaction; and improving physical space and technical design. CONCLUSION: The results from the questionnaire showed that the staff had low theoretical knowledge concerning sound and noise in the intensive care unit. However, the staff suggested many improvement measures, but also described difficulties and barriers. The results from this study can be used in the design of future interventions to reduce noise in the intensive care unit as well as in other settings.

Lighting, sleep and circadian rhythm: An intervention study in the intensive care unit.

Patients in an intensive care unit (ICU) may risk disruption of their circadian rhythm. In an intervention research project a cycled lighting system was set up in an ICU room to support patients' circadian rhythm. Part I aimed to compare experiences of the lighting environment in two rooms with different lighting environments by lighting experiences questionnaire. The results indicated differences in advantage for the patients in the intervention room (n=48), in perception of daytime brightness (p=0.004). In nighttime, greater lighting variation (p=0.005) was found in the ordinary room (n=52). Part II aimed to describe experiences of lighting in the room equipped with the cycled lighting environment. Patients (n=19) were interviewed and the results were presented in categories: "A dynamic lighting environment", "Impact of lighting on patients' sleep", "The impact of lighting/lights on circadian rhythm" and "The lighting calms". Most had experiences from sleep disorders and half had nightmares/sights and circadian rhythm disruption. Nearly all were pleased with the cycled lighting environment, which together with daylight supported their circadian rhythm. In night's actual lighting levels helped patients and staff to connect which engendered feelings of calm.

Meanings of being critically ill in a sound-intensive ICU patient room - a phenomenological hermeneutical study.

UNLABELLED: The aim of this study was to illuminate the meanings of being critically ill in a sound-intensive ICU patient room, as disclosed through patients' narratives. Patient rooms in ICUs are filled with loud activity and studies have revealed sound levels comparable to those of a busy road above the patient's head. There is a risk that the sound or noise is disturbing and at worst a major problem for the patient, but there is a lack of knowledge concerning the patients' own experiences. Thirteen patients were asked to narrate their experiences of the sound environment in ICU patient rooms. The interviews were analyzed using a phenomenological- hermeneutical method inspired by the philosophy of Ricoeur. Six themes emerged from the analysis. CONCLUSION: The meanings of being a patient in a sound- intensive environment were interpreted as never knowing what to expect next regarding noise, but also of being situated in the middle of an uncontrollable barrage of noise, unable to take cover or disappear. This condition is not to be seen as static; for some patients there is movement and change over time. The meanings indicate that the unpredictable shifts between silence and disturbing sounds stress the critically ill patient and impede sleep and recovery. Our findings indicate the need to reduce disturbing and unexpected sounds and noise around critically ill patients in high-tech environments in order to facilitate wellbeing, sleep and recovery. Nurses have a vital role in developing such an environment.

The sound environment in an ICU patient room--a content analysis of sound levels and patient experiences.

This study had two aims: first to describe, using both descriptive statistics and quantitative content analysis, the noise environment in an ICU patient room over one day, a patient's physical status during the same day and early signs of ICU delirium; second, to describe, using qualitative content analysis, patients' recall of the noise environment in the ICU patient room. The final study group comprised 13 patients. General patient health status data, ICU delirium observations and sound-level data were collected for each patient over a 24-hour period. Finally, interviews were conducted following discharge from the ICU. The sound levels in the patient room were higher than desirable and the LAF max levels exceed 55dB 70-90% of the time. Most patients remembered some sounds from their stay in the ICU and whilst many were aware of the sounds they were not disturbing to them. However, some also experienced feelings of fear related to sounds emanating from treatments and investigations of the patient beside them. In this small sample, no statistical connection between early signs of ICU delirium and high sound levels was seen, but more research will be needed to clarify whether or not a correlation does exist between these two factors.

Low-dose/dose-rate γ radiation depresses neural differentiation and alters protein expression profiles in neuroblastoma SH-SY5Y cells and C17.2 neural stem cells.

The effects of low doses of ionizing radiation on cellular development in the nervous system are presently unclear. The focus of the present study was to examine low-dose γ-radiation-induced effects on the differentiation of neuronal cells and on the development of neural stem cells to glial cells. Human neuroblastoma SH-SY5Y cells were exposed to (137)Cs γ rays at different stages of retinoic acid-induced neuronal differentiation, and neurite formation was determined 6 days after exposure. When SH-SY5Y cells were exposed to low-dose-rate γ rays at the onset of differentiation, the number of neurites formed per cell was significantly less after exposure to either 10, 30 or 100 mGy compared to control cells. Exposure to 10 and 30 mGy attenuated differentiation of immature C17.2 mouse-derived neural stem cells to glial cells, as verified by the diminished expression of glial fibrillary acidic protein. Proteomic analysis of the neuroblastoma cells by 2D-PAGE after 30 mGy irradiation showed that proteins involved in neuronal development were downregulated. Proteins involved in cell cycle and proliferation were altered in both cell lines after exposure to 30 mGy; however, the rate of cell proliferation was not affected in the low-dose range. The radiation-induced attenuation of differentiation and the persistent changes in protein expression is indicative of an epigenetic rather than a cytotoxic mechanism.

Outcome after injury: memories, health-related quality of life, anxiety, and symptoms of depression after intensive care.

BACKGROUND: To examine the relationship between delusional memories from the Intensive Care Unit (ICU) stay, health related quality of life (HRQoL), anxiety, and symptoms of depression in patients with physical trauma, 6 months to 18 months after their ICU stay. METHODS: Multicenter study in five combined medical and surgical ICUs (n = 239). A questionnaire comprising the Medical outcome Short Form 36, the Hospital Anxiety and Depression scale, and the Intensive Care Unit Memory tool was sent to the patients with trauma 6 months to 18 months after their discharge from the ICU. Clinical data were drawn from patient records in retrospect. A matched reference sample (n = 159) was randomly drawn from the Swedish Short Form 36 norm database (n = 8,930). RESULTS: Patients with trauma had significantly lower HRQoL than the reference sample. One or more delusional memories such as hallucinations, nightmares, dreams, or sensations of people trying to hurt them in the ICU were experienced by 26%. These patients were significantly younger, had a longer ICU stay, relied more on mechanical ventilation, and had higher Injury Severity Score and Sequential Organ Failure Assessment scores. They also reported a significantly poorer HRQoL and a higher probability of experiencing anxiety (51% vs. 29%) and symptoms of depression (48% vs. 26%) compared with patients without such memories. CONCLUSIONS: Our results highlight the importance of treating the delusional memories experienced by ICU patients with a trauma diagnosis as a postinjury factor with a potential to create anxiety and symptoms of depression and which may affect HRQoL after discharge.

Memories following physical trauma in patients treated in the ICU: does gender and head injury make a difference?

The aim of this study was to explore differences between male and female survivors and describe the relation between head injury and memories in men and women. This multi-centre study included 239 trauma patients who answered a self-administered questionnaire (ICUM tool) 6-18 months after discharge from the ICU. Few gender differences were found regarding their memories before, during and after the ICU stay. The univariate and multivariate analyses showed that more women than men reported memories from the time in hospital before being admitted to the ICU. Women also recalled a significantly higher number of memories of feelings than men. Furthermore, patients without head injury had more memories from the time before and during their stay in the ICU than patients with head injury but did not report more memories from the time after the ICU. The ISS mean score was higher for men than for women, more men than women had renal failure and more men than women received opioid treatment. The conclusion is that gender is of less importance concerning memories from the time before, during and after the stay in the ICU.

Observations of nonadherence to recombinant human growth hormone therapy in clinical practice.

BACKGROUND: The effectiveness of all prescribed treatments is contingent on patient adherence. The reported levels of adherence to recombinant human growth hormone (r-hGH) therapy are highly variable, but it has been suggested that nonadherence might be as high as 36% to 49%. OBJECTIVES: This commentary discusses the factors that affect long-term adherence to injection treatment, of which r-hGH therapy is a particular challenge. It also explores potential strategies to improve adherence to injection treatments in clinical practice. METHODS: The opinion of the authors was validated and supported by published literature. A PubMed literature search was conducted in November 2006, identifying English-language articles containing key terms growth hormone, adherence, and compliance. RESULTS: This study found that factors associated with poor adherence to injection treatments include patients' lack of understanding of their disease, patient age, chronicity of the disease, complex treatment regimens, and insufficient information on the implications of nonadherence. Strengthening the patient-physician relationship by providing the patient with a clear understanding of his/her disease and the benefits of adherence, making improvements in injection devices, and eliminating subjective illness concepts, might increase adherence to SC injection treatments, thereby reducing increasing health care costs associated with nonadherence. CONCLUSIONS: Poor adherence to r-hGH therapy has a dual effect, in that it leads to reduced efficacy out-comes and increased health care costs. Implementing strategies to improve adherence with injection treatment might be of particular clinical benefit to patients undergoing r-hGH therapy.

Delusional memories from the intensive care unit--experienced by patients with physical trauma.

During and after intensive care unit (ICU) stays some patients report unreal experiences or so called delusional memories, which can be a source of distress. The aims of this study were: to describe trauma patients' memories of their stay in the ICU, factors that may influence delusional memories, problems experienced after discharge from the ICU and the patients' return to work. In this multi-centre study, 239 trauma patients filled in a self-administered questionnaire (ICUM tool) 6-18 months after their ICU stay. Clinical data were obtained from patient records. Fifteen percent of the respondents had no memory whatsoever of the ICU. Factual memories such as visits by family members were recalled by 83%. Delusional memories were reported by 26%, nightmares being the most common. These patients' also had more memories of pain, fear and panic. Significant factors associated with delusional memories were age <50 year, ICU stay >or=3 days, temperature >or=38 degrees C, S-Haemaglobin

A transcriptional inhibitor targeted by the atypical orphan nuclear receptor SHP.

SHP (short heterodimer partner, NROB2) is an atypical orphan member of the mammalian nuclear receptor family that consists only of a putative ligand-binding domain and thus cannot bind DNA. Instead, SHP acts as a transcriptional coregulator by inhibiting the activity of various nuclear receptors (downstream targets) via occupation of the coactivator-binding surface and active repression. However, repression mechanisms have remained elusive and may involve coinhibitory factors (upstream targets) distinct from known nuclear receptor corepressors. Here, we describe the isolation of mouse E1A-like inhibitor of differentiation 1 (EID1) as a candidate coinhibitor for SHP. We characterize the interactions between SHP and EID1 and identify two repression-defective SHP mutations that have lost the ability to bind EID1. We suggest histone acetyltransferases and histones as targets for EID1 action and propose that SHP inhibition of transcription involves EID1 antagonism of CBP/p300-dependent coactivator functions.