Can equity in care be achieved for stigmatized patients? Discourses of ideological dilemmas in perioperative care.

BACKGROUND: In the perioperative care of individuals with obesity, it is imperative to consider the presence of risk factors that may predispose them to complications. Providing optimal care in such cases proves to be a multifaceted challenge, significantly distinct from the care required for non-obese patients. However, patients with morbidities regarded as self-inflicted, such as obesity, described feelings of being judged and discriminated in healthcare. At the same time, healthcare personnel express difficulties in acting in an appropriate and non-insulting way. In this study, the aim was to analyse how registered nurse anaesthetists positioned themselves regarding obese patients in perioperative care. METHODS: We used discursive psychology to analyse how registered nurse anaesthetists positioned themselves toward obese patients in perioperative care, while striving to provide equitable care. The empirical material was drawn from interviews with 15 registered nurse anaesthetists working in a hospital in northern Sweden. RESULTS: Obese patients were described as "untypical", and more "resource-demanding" than for the "normal" patient in perioperative care. This created conflicting feelings, and generated frustration directed toward the patients when the care demanded extra work that had not been accounted for in the schedules created by the organization and managers. CONCLUSIONS: Although the intention of these registered nurse anaesthetists was to offer all patients equitable care, the organization did not always provide the necessary resources. This contributed to the registered nurse anaesthetists either consciously or unconsciously blaming patients who deviated from the "norm".

Association of depressive disorders and dementia with mortality among older people with hip fracture.

BACKGROUND: Hip fracture (HF) is a significant cause of mortality among older people. Almost half of the patients with HF have dementia, which increases the mortality risk further. Cognitive impairment is associated with depressive disorders (DDs) and both dementia and DDs are independent risk factors for poor outcome after HF. However, most studies that evaluate mortality risk after HF separate these conditions. AIMS: To investigate whether dementia with depressive disorders (DDwD) affects the mortality risk at 12, 24, and 36 months after HF among older people. METHODS: Patients with acute HF (n = 404) were included in this retrospective analysis of two randomized controlled trials performed in orthopedic and geriatric departments. Depressive symptoms were assessed using the Geriatric Depression Scale and cognitive function was assessed using the Mini-Mental State Examination. A consultant geriatrician made final depressive disorder and dementia diagnoses using the Diagnostic and Statistical Manual of Mental Disorders criteria, with support from assessments and medical records. The 12-, 24- and 36-month mortality after HF was analyzed using logistic regression models adjusted for covariates. RESULTS: In analyses adjusted for age, sex, comorbidity, pre-fracture walking ability, and fracture type, patients with DDwD had increased mortality risks at 12 [odds ratio (OR) 4.67, 95% confidence interval (CI) 1.75-12.51], 24 (OR 3.61, 95% CI 1.71-7.60), and 36 (OR 4.53, 95% CI 2.24-9.14) months. Similar results were obtained for patients with dementia, but not depressive disorders, alone. CONCLUSION: DDwD is an important risk factor for increased mortality at 12, 24, and 36 months after HF among older people. Routinely assessments after HF for cognitive- and depressive disorders could identify patients at risk for increased mortality, and enable early interventions. TRIAL REGISTRATION: RCT2: International Standard Randomized Controlled Trial Number Register, trial registration number: ISRCTN15738119.

Health effects related to exposure of static magnetic fields and acoustic noise-comparison between MR and CT radiographers.

OBJECTIVES: We explored the prevalence of health complaints subjectively associated with static magnetic field (SMF) and acoustic noise exposure among MR radiographers in Sweden, using CT radiographers as a control group. Additionally, we explored radiographers' use of strategies to mitigate adverse health effects. METHODS: A cross-sectional survey was sent to all hospitals with MR units in Sweden. MR and/or CT personnel reported prevalence and attribution of symptoms (vertigo/dizziness, nausea, metallic taste, illusion of movement, ringing sensations/tinnitus, headache, unusual drowsiness/tiredness, forgetfulness, difficulties concentrating, and difficulties sleeping) within the last year. We used logistic regression to test associations between sex, age, stress, SMF strength, working hours, and symptom prevalence. Data regarding hearing function, work-environmental noise, and strategies to mitigate adverse symptoms were also analysed. RESULTS: In total, 529 out of 546 respondents from 86 hospitals were eligible for participation. A ≥ 20 working hours/week/modality cut-off rendered 342 participants grouped into CT (n = 75), MR (n = 121), or mixed personnel (n = 146). No significant differences in symptom prevalence were seen between groups. Working at ≥ 3T increased SMF-associated symptoms as compared with working at ≤ 1.5T (OR: 2.03, CI95: 1.05-3.93). Stress was a significant confounder. Work-related noise was rated as more troublesome by CT than MR personnel (p < 0.01). MR personnel tended to use more strategies to mitigate adverse symptoms. CONCLUSION: No significant differences in symptom prevalence were seen between MR and CT radiographers. However, working at 3T increased the risk of SMF symptoms, and stress increased adverse health effects. Noise nuisance was considered more problematic by CT than MR personnel. KEY POINTS: • No significant differences in symptom prevalence were seen between MR and CT radiographers. • Working at ≥ 3 T doubled the odds of experiencing SMF symptoms (vertigo/dizziness, nausea, metallic taste, and/or illusion of movement) as compared to working exclusively at ≤ 1.5 T. • Work-related acoustic noise was less well mitigated and was rated as more troublesome by CT personnel than by MR personnel.

Maintaining Image Quality While Reducing Acoustic Noise and Switched Gradient Field Exposure During Lumbar MRI.

BACKGROUND: MR-generated acoustic noise can contribute to patient discomfort and potentially be harmful. One way to reduce this noise is by altering the gradient output and/or waveform using software optimization. Such modifications might influence image quality and switched gradient field exposure, and different techniques appear to affect sound pressure levels (SPLs) to various degrees. PURPOSE: To evaluate SPLs, image quality, switched gradient field exposure, and participants' perceived noise levels during two different acoustic noise reduction (ANR) techniques, Quiet Suite (QS) and Whisper Mode (WM), and to compare them with conventional T2-weighted turbo spin echo (T2W TSE) of the lumbar spine. DESIGN: Prospective. SUBJECTS: Forty adults referred for lumbar MRI. FIELD STRENGTH/SEQUENCE: Conventional T2W TSE, T2W TSE with QS, and T2W TSE with WM were acquired at 1.5 T. ASSESSMENT: Peak SPL (A-weighted decibels, dBA), perceived noise levels (Borg CR10®-scale), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), three radiologists' qualitative assessments in image quality on an ordinal scale 1-4, switched gradient field exposure (% general public), and gradient currents were measured. Interobserver reliability was reported as percentage agreement. STATISTICAL TESTS: Repeated measures ANOVA, Friedman's ANOVA, and Wilcoxon's Signed-Rank Test for acoustic noise measurements and image quality assessments. RESULTS: Mean peak SPLs were 89.9 dBA, 74.3 dBA, and 78.8 dBA for conventional, QS, and WM, respectively (P < 0.05). Participants perceived QS as the quietest and conventional as the loudest sequence (P < 0.05). No qualitative differences in image quality were seen (P > 0.05), although QS showed significantly improved SNR and CNR (P < 0.05). Switched gradient field exposure was reduced by 66% and 48% for QS and WM, respectively. DATA CONCLUSION: Without degrading image quality, both QS and WM are viable ANR techniques in lumbar T2W TSE. QS provided the lowest SPL, the lowest gradient field exposure and was perceived as the most silent among the three sequences. LEVEL OF EVIDENCE: 1 TECHNICAL EFFICACY STAGE: 5.

Longitudinal Evidence for Smaller Hippocampus Volume as a Vulnerability Factor for Perceived Stress.

Hippocampal volume has been found to be smaller in individuals with stress-related disorders, but it remains unclear whether smaller volume is a consequence of stress or rather a vulnerability factor. Here, we examined this issue by relating stress levels to hippocampal volumes in healthy participants examined every 5 years in a longitudinal population-based study. Based on scores of 25- to 60-year-old participants on the perceived stress questionnaire, we defined moderately to high (n = 35) and low (n = 76) stress groups. The groups were re-examined after 5 years (at the 6th study wave). Historical data on subjective stress were available up to 10 years prior to Wave 5. At the first MRI session, the moderately to high stress group had a significantly smaller hippocampal volume, as measured by FreeSurfer (version 5.3), compared with the low-stress group. At follow-up, group differences in stress levels and hippocampal volume remained unchanged. In retrospective analyses of subjective stress, the observed group difference in stress was found to be stable. The long-term stability of group differences in perceived stress and hippocampal volume suggests that a small hippocampal volume may be a vulnerability factor for stress-related disorders.

Does touch massage facilitate recovery after stroke? A study protocol of a randomized controlled trial.

BACKGROUND: Despite high quality stroke care, decreased sensorimotor function, anxiety and pain often remain one year after stroke which can lead to impaired health and dependence, as well as higher healthcare costs. Touch massage (TM) has been proven to decrease anxiety and pain, and improve quality of health in other conditions of reduced health, where reduced anxiety seems to be the most pronounced benefit. Thus there are reasons to believe that TM may also reduce anxiety and pain, and improve quality of life after stroke. Further, several studies indicate that somatosensory stimulation can increase sensorimotor function, and it seems feasible to believe that TM could increase independence after stroke. In this study we will evaluate effects of TM after stroke compared to sham treatment. METHODS: This is a prospective randomized open-labelled control trial with blinded evaluation (PROBE-design). Fifty patients with stroke admitted to stroke units will be randomized (1:1) to either a TM intervention or a non-active transcutaneous electrical nerve stimulation (non-TENS) control group. Ten sessions of 30 min treatments (TM or control) will be administered during two weeks. Assessment of status according to the International Classification of Functioning, Disability and Health (ICF), including body function, activity, and participation. Assessment of body function will include anxiety, pain, and stress response (heart rate variability and salivary cortisol), where anxiety is the primary outcome. Activity will be assessed by means of sensorimotor function and disability, and participation by means of health-related quality of life. Assessments will be made at baseline, after one week of treatment, after two weeks of treatment, and finally a follow-up after two months. The trial has been approved by the Regional Ethical Review Board. DISCUSSION: TM seems to decrease anxiety and pain, increase health-related quality of life, and improve sensorimotor functions after stroke, but the field is largely unexplored. Considering the documented pleasant effects of massage in general, absence of reported adverse effects, and potential effects in relation to stroke, it is essential to evaluate effects of TM during the sub-acute phase after stroke. The results of this project will hopefully provide important knowledge for evidence-based care. TRIAL REGISTRATION: ClinicalTrials.gov: NTC01883947.

Touch massage: a pilot study of a complex intervention.

OBJECTIVES: To report and evaluate a complex touch massage intervention according to the British Medical Research Council framework. This study aimed to evaluate the effects of touch massage on levels of anxiety and physiological stress in patients scheduled for elective aortic surgery. BACKGROUND: The use of touch massage has increased during the past decade but no systematic studies have been implemented to investigate the effectiveness of such treatment. It is important to conduct multidisciplinary investigations into the effects of complex interventions such as touch massage. For this, the British Medical Research Council has provided a useful framework to guide the development, piloting, evaluation and reporting of complex intervention studies. METHOD: A pilot study with a randomized controlled design including 20 patients (10 + 10) scheduled for elective aortic surgery. Selected outcome parameters included; self-reported anxiety, measured by the State-Trait Anxiety Inventory Form Y instrument, and physiological stress, measured by heart rate variability, blood pressure, respiratory frequency, oxygen saturation and concentrations of cortisol, insulin and glucose in serum. RESULTS: There were significant differences in self-reported anxiety levels before and after touch massage (p = 0.007), this was not observed in the control group (p = 0.833). There was a significant difference in self-reported anxiety levels between the touch massage group and the control group after touch massage and rest (p = 0.001). There were no significant differences in physiological stress-related outcome parameters between patients who received touch massage and controls. CONCLUSION: In our study, touch massage decreased anxiety levels in patients scheduled for elective aortic surgery, and the British Medical Research Council framework was a useful guideline for the development, evaluation and reporting of a touch massage intervention. RELEVANCE TO CLINICAL PRACTICE: Touch massage can reduce patients' anxiety levels and is thus an important nursing intervention in intensive and post-operative care.

The effect of COVID-19 pandemic on perioperative factors: data from the Swedish Perioperative Register.

BACKGROUND: The COVID-19 pandemic has affected healthcare organizations in many areas. The aim of this study was to describe surgical interventions, anesthesia, and postoperative outcomes in adult patients during the first wave and 1 year into the COVID-19 pandemic in Sweden, and to compare these outcomes with outcomes during the same period the year before the pandemic. METHODS: Data were collected from the Swedish PeriOperative Register, and included 417, 233 perioperative registration of patients ≥ 18 years old between period 1 (March-June 2019), period 2 (March-June 2020), and period 3 (March-June 2021). RESULTS: Compared with pre-pandemic (period 1), the number of surgical interventions decreased by 28% in the first wave (period 2); 1 year into the pandemic (period 3), the number of interventions was still 7.5% lower than pre-pandemic. The largest drops between periods 1 and 2 were noted in the specialties of ear, nose, and larynx surgery, - 55.6%; teeth, jaws, mouth, and pharynx surgery, - 45.0%; endocrine system surgery, - 38.8%. The number of acute surgeries remained stable during all three periods. Volatiles were more frequently used for the maintenance of general anesthesia in period 2 than in either period 1 or 3 (p < 0.001). Minor differences were noted throughout the periods in postoperative nausea and vomiting as well as postoperative pain. CONCLUSIONS: The COVID-19 pandemic has had an impact on perioperative care in Sweden. During the first wave of the pandemic, the number of surgical interventions decreased, but the number of acute surgeries remained stable compared with pre-pandemic numbers. Perioperative organizations have had and will continue to have challenges handling the increased number of patients needing perioperative care.

Pleasant human touch is represented in pregenual anterior cingulate cortex.

Touch massage (TM) is a form of pleasant touch stimulation used as treatment in clinical settings and found to improve well-being and decrease anxiety, stress, and pain. Emotional responses reported during and after TM have been studied, but the underlying mechanisms are still largely unexplored. In this study, we used functional magnetic resonance (fMRI) to test the hypothesis that the combination of human touch (i.e. skin-to-skin contact) with movement is eliciting a specific response in brain areas coding for pleasant sensations. The design included four different touch conditions; human touch with or without movement and rubber glove with or without movement. Force (2.5 N) and velocity (1.5 cm/s) were held constant across conditions. The pleasantness of the four different touch stimulations was rated on a visual analog scale (VAS-scale) and human touch was rated as most pleasant, particularly in combination with movement. The fMRI results revealed that TM stimulation most strongly activated the pregenual anterior cingulate cortex (pgACC). These results are consistent with findings showing pgACC activation during various rewarding pleasant stimulations. This area is also known to be activated by both opioid analgesia and placebo. Together with these prior results, our finding furthers the understanding of the basis for positive TM treatment effects.

Preserved somatosensory conduction in complete spinal cord injury: Discomplete SCI.

OBJECTIVE: Spinal cord injury (SCI) disrupts the communication between brain and body parts innervated from below-injury spinal segments, but rarely results in complete anatomical transection of the spinal cord. The aim of this study was to investigate residual somatosensory conduction in clinically complete SCI, to corroborate the concept of sensory discomplete SCI. METHODS: We used fMRI with a somatosensory protocol in which blinded and randomized tactile and nociceptive stimulation was applied on both legs (below-injury level) and one arm (above-injury level) in eleven participants with chronic complete SCI. The experimental design accounts for possible confounding mechanical (e.g. vibration) and cortico-cortical top-down mechanisms (e.g. attention/expectation). RESULTS: Somatosensory stimulation on below-level insensate body regions activated the somatotopically corresponding part of the contralateral primary somatosensory cortex in six out of eleven participants. CONCLUSIONS: Our results represent afferent-driven cortical activation through preserved somatosensory connections to the brain in a subgroup of participants with clinically complete SCI, i.e. sensory discomplete SCI. SIGNIFICANCE: Identifying patients with residual somatosensory connections might open the door for new rehabilitative and restorative strategies as well as inform research on SCI-related conditions such as neuropathic pain and spasticity.

Interpersonal touch interventions for patients in intensive care: A design-oriented realist review.

AIM: To develop a theoretical framework to inform the design of interpersonal touch interventions intended to reduce stress in adult intensive care unit patients. DESIGN: Realist review with an intervention design-oriented approach. METHODS: We searched CINAHL, MEDLINE, EMBASE, CENTRAL, Web of Science and grey literature sources without date restrictions. Subject experts suggested additional articles. Evidence synthesis drew on diverse sources of literature and was conducted iteratively with theory testing. We consulted stakeholders to focus the review. We performed systematic searches to corroborate our developing theoretical framework. RESULTS: We present a theoretical framework based around six intervention construction principles. Theory testing provided some evidence in favour of treatment repetition, dynamic over static touch and lightening sedation. A lack of empirical evidence was identified for construction principles relating to intensity and positive/negative evaluation of emotional experience, moderate pressure touch for sedated patients and intervention delivery by relatives versus healthcare practitioners.

Endocannabinoids and related lipids in blood plasma following touch massage: a randomised, crossover study.

BACKGROUND: The endocannabinoid system is involved in the regulation of stress and anxiety. In a recent study, it was reported that short-term changes in mood produced by a pleasant ambience were correlated with changes in the levels of plasma endocannabinoids and related N-acylethanolamines (Schrieks et al. PLoS One 10: e0126421, 2015). In the present study, we investigated whether stress reduction by touch massage (TM) affects blood plasma levels of endocannabinoids and related N-acylethanolamines. RESULTS: A randomized two-session crossover design for 20 healthy participants was utilised, with one condition that consisted of TM and a rest condition as control. TM increased the perceived pleasantness rating of the participants, and both TM and rest reduced the basal anxiety level as assessed by the State scale of the STAI-Y inventory. However, there were no significant effects of either time (pre- vs. post-treatment measures) as main effect or the interaction time x treatment for the plasma levels of the endocannabinoids anandamide and 2-arachidonoylglycerol or for eight other related lipids. Four lipids showed acceptable relative reliabilities, and for two of these (linoleoyl ethanolamide and palmitoleoyl ethanolamide) a significant correlation was seen between the TM-related change in levels, calculated as (post-TM value minus pre-TM value) - (post-rest value minus pre-rest value), and the corresponding TM-related change in perceived pleasantness. CONCLUSIONS: It is concluded that in the participants studied here, there are no overt effects of TM upon plasma endocannabinoid levels. Possible associations of related N-acylethanolamines with the perceived pleasantness should be investigated further.

Preserved somatosensory conduction in a patient with complete cervical spinal cord injury.

OBJECTIVE: Neurophysiological investigation has shown that patients with clinically complete spinal cord injury can have residual motor sparing ("motor discomplete"). In the current study somatosensory conduction was assessed in a patient with clinically complete spinal cord injury and a novel methodology for assessing such preservation is described, in this case indicating "sensory discomplete" spinal cord injury. METHODS: Blood oxygenation level-dependent functional magnetic resonance imaging (BOLD fMRI) was used to examine the somatosensory system in a healthy subject and in a subject with a clinically complete cervical spinal cord injury, by applying tactile stimulation above and below the level of spinal cord injury, with and without visual feedback. RESULTS: In the participant with spinal cord injury, somatosensory stimulation below the neurological level of the lesion gave rise to BOLD signal changes in the corresponding areas of the somatosensory cortex. Visual feedback of the stimulation strongly modulated the somatosensory BOLD signal, implying that cortico-cortical rather than spino-cortical connections can drive activity in the somatosensory cortex. Critically, BOLD signal change was also evident when the visual feedback of the stimulation was removed, thus demonstrating sensory discomplete spinal cord injury. CONCLUSION: Given the existence of sensory discomplete spinal cord injury, preserved but hitherto undetected somatosensory conduction might contribute to the unexplained variability related to, for example, the propensity to develop decubitus ulcers and neuropathic pain among patients with clinically complete spinal cord injury.

The efficacy of P6 acupressure with sea-band in reducing postoperative nausea and vomiting in patients undergoing craniotomy: a randomized, double-blinded, placebo-controlled study.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a multifactorial problem after general anesthesia. Despite antiemetic prophylaxis and improved anesthetic techniques, PONV still occurs frequently after craniotomies. P6 stimulation is described as an alternative method for preventing PONV. The primary aim of this study was to determine whether P6 acupressure with Sea-Band could reduce postoperative nausea after elective craniotomy. Secondary aims were to investigate whether the frequency of vomiting and the need for antiemetics could be reduced. METHODS: In this randomized, double-blinded, placebo-controlled study, patients were randomized into either a P6 acupressure group (n=43) or a sham group (n=52). Bands were applied unilaterally at the end of surgery, and all patients were administered prophylactic ondansetron. Postoperative nausea was evaluated with a Numerical Rating Scale, 0 to10, and the frequency of vomiting was recorded for 48 hours. RESULTS: We found no significant effect from P6 acupressure with Sea-Band on postoperative nausea or vomiting in patients undergoing craniotomy. Nor was there any difference in the need for rescue antiemetics. Altogether, 67% experienced PONV, and this was especially an issue at >24 hours in patients recovering from infratentorial surgery compared with supratentorial surgery (55% vs. 26%; P=0.014). CONCLUSIONS: Unilateral P6 acupressure with Sea-Band applied at the end of surgery together with prophylactic ondansetron did not significantly reduce PONV or the need for rescue antiemetics in patients undergoing craniotomy. Our study confirmed that PONV is a common issue after craniotomy, especially after infratentorial surgery.

Touch massage, a rewarding experience.

This study aims to describe and analyze healthy individuals' expressed experiences of touch massage (TM). Fifteen healthy participants received whole body touch massage during 60 minutes for two separate occasions. Interviews were analyzed by narrative analysis. Four identifiable storyline was found, Touch massage as an essential need, in this storyline the participants talked about a desire and need for human touch and TM. Another storyline was about, Touch massage as a pleasurable experience and the participants talked about the pleasure of having had TM. In the third storyline Touch massage as a dynamic experience, the informants talked about things that could modulate the experience of receiving TM. In the last storyline, Touch massage influences self-awareness, the participants described how TM affected some of their psychological and physical experiences. Experiences of touch massage was in general described as pleasant sensations and the different storylines could be seen in the light of rewarding experiences.