Should I stay or should I go? An exploration of the decision-making behavior of acute cardiac patients during the COVID-19 pandemic.

BACKGROUND: During the SARS-COV-2 (COVID-19) pandemic efforts to reduce virus transmission resulted in non-emergency patients being deterred from seeking help. The number of patients presenting with acute cardiac conditions reduced, significantly OBJECTIVES: To explore the decision-making process, and influential factors in that process, of patients and their family during an acute cardiac event. METHODS: A qualitative research design was employed using purposive sampling of patients who experienced an acute cardiac event during the social containment mandates. Semi-structured interviews were conducted, with thematic analysis of interview transcripts. RESULTS: Twenty-five participants were recruited from three UK hospitals. Themes identified were reliance on informal support network, lack of awareness of cardiac symptoms leading to delayed help-seeking, and an indirect COVID-19 effect (e.g. avoiding treatment). CONCLUSIONS: These results highlight the need for informed public health messages, targeting patients and their support networks, that allow those in need of treatment to access care.

Continuous bupivacaine infusion post-iliac crest bone graft harvesting in pediatric cleft surgery: role and comparison with ketorolac.

OBJECTIVE: To investigate the use of intravenous ketorolac and iliac crest bupivacaine infusion in the management of iliac crest donor-site pain in the pediatric cleft population. The null hypothesis was there is no difference with respect to pain scores between ketorolac and iliac crest bupivacaine infusion as analgesic adjuncts to intravenous opioids. METHODS: A total of 54 children and adolescents (27 boys, 27 girls) undergoing alveolar cleft repair or Le Fort I osteotomy were assigned randomly in a prospective, single-blinded fashion to one of three groups: intravenous ketorolac plus iliac crest normal saline infusion, intravenous ketorolac plus iliac crest bupivacaine infusion, or iliac crest bupivacaine infusion alone. Iliac crest infusions and ketorolac were administered for 48 hours or until discharge, whichever occurred first. All patients received morphine via a patient-controlled analgesia device. MAIN OUTCOME MEASURE(S): Primary outcome was pain score, and secondary outcomes were morphine consumption and satisfaction scores. RESULTS: Pain scores, morphine consumption, and satisfaction scores were not significantly different among groups. Estimated costs were significantly higher for bupivacaine infusion than intravenous ketorolac. CONCLUSIONS: Iliac crest donor-site pain is well managed in this patient population. Intravenous ketorolac and iliac crest bupivacaine infusion provide comparable analgesia for iliac crest bone graft donor-site pain in children and adolescents.

Recurrent pulmonary embolism and pulmonary hypertension in chronic tetraplegia.

STUDY DESIGN: Case report. OBJECTIVE: To describe an unusual case of progressive pulmonary hypertension due to recurrent pulmonary embolism in a chronically paralyzed spinal cord injury patient. SETTING: Veterans Administration Hospital, West Roxbury, MA, USA. SUBJECT: A 57-year-old man, tetraplegic, sensory incomplete and motor complete for 30 years due to a diving accident, complained of lightheadedness and shortness of breath intermittently for 7 years. Examination during the latest episode revealed anxiety, confusion, respirations 28 per min, blood pressure 80/60 mmHg, and arterial pH 7.41, P(CO2) 28 mmHg, P(O2) 95 mmHg on 2 l of oxygen. A chest film 2 weeks earlier had revealed a right-sided cutoff of pulmonary vasculature; the current film showed right-sided pleural effusion. Review of EKGs showed a trend of increasing right axis deviation with recovery and recurrences during the previous 9 years and a current incomplete right bundle branch block with clockwise rotation and inverted T waves in V1-4. Computerized tomography with contrast material revealed small pulmonary emboli, but only in retrospect. The patient died shortly after scanning. AUTOPSY: The pulmonary arteries were free of thromboemboli on gross examination but medium and small-sized arteries were constricted or obliterated with thrombotic material microscopically. The estimated ages of the thromboemboli ranged from days to years. The right ventricle was hypertrophied; the coronary arteries were patent. CONCLUSION: Recurrent pulmonary emboli resulted in chronic pulmonary hypertension and eventual death in a patient with chronic tetraplegia.

Clinical implications of research on countertransference: science informing practice.

This article presents a clinically oriented synthesis of research findings pertaining to countertransference (CT). Findings are organized around five therapy-relevant questions concerning the origins, triggers, manifestations, management, and effects of CT. To date, research has focused primarily on impediments posed by therapists' CT reactions and mechanisms for managing them. It is argued that future research needs to be directed toward better understanding how therapists can use CT to enhance their work with clients.

Outcome measures for adult critical care: a systematic review.

OBJECTIVES: 1. To identify generic and disease specific measures of impairment, functional status and health-related quality of life that have been used in adult critical care (intensive and high-dependency care) survivors. 2. To review the validity, reliability and responsiveness of the measures in adult critical care survivors. 3. To consider the implications for future policy and to make recommendations for further methodological research. 4. To review what is currently known of the outcome of adult critical care. DATA SOURCES: Searches of electronic databases (MEDLINE, EMBASE, CINAHL, PsycLIT, The Cochrane Library and SIGLE) from 1970 to August 1998. Manual searches of five journals (1985-98) not indexed in electronic databases and relevant conference proceedings (1993-98). Reference lists of six existing reviews, plus snowballing from reference lists of all relevant articles identified. STUDY SELECTION: Randomised trials, non-randomised trials (cohort studies) and case series that included data on outcomes after discharge from adult (16 years and over) critical care. DATA EXTRACTION AND SYNTHESIS: If reported, the following data were extracted from each paper: patient characteristics (age, gender, severity of illness, diagnostic category) number of patients eligible for study, follow-up period, number of deaths before follow-up, number and proportion of survivors included in follow-up method of presentation of outcome data - proportion normal as defined by reference values, or aggregate value (e.g. mean or median), or aggregate values plus an indication of variance (e.g. standard deviation or inter-quartile range). Evidence for three measurement properties was sought for each outcome measure that had been used in at least two studies - their validity, reliability and responsiveness in adult critical care. If the authors did not report these aspects explicitly, an attempt was made to use the data provided to provide these measurement properties. For measures that were used in at least ten studies, information on actual reported outcomes were also extracted. RESULTS: MEASURES USED IN CRITICAL CARE: Measures of impairment were largely confined to the respiratory system so are almost certainly not appropriate for many critical care survivors. They can be categorised as respiratory volumes (e.g. vital capacity), gas flow within the respiratory system (e.g. forced expiratory volume in 1 second (FEV1)), pulmonary diffusing capacity (e.g. carbon monoxide diffusing capacity) and visualisation of the upper airway (e.g. bronchoscopy). Multiple tests are often performed. Eight measures of physical functional status were used, five generic and three disease-specific. The most frequently used generic measures were multi-item scales. Two single-item global measures attempted to capture a person's overall activity level or functional status. Five multi-item measures of mental functional status were used, four generic and one specific to trauma patients. The generic measures were either confined to assessing depressive symptoms or also encompassed a measure of anxiety. Measures of neuropsychological functioning relate to a person's cognition, attention, ability to process information and memory. Apart from one single-item measure, which focused on communication level, six multi-item measures were used with critical care survivors. Such measures are particularly appropriate for use with survivors of head injury or other neurological insult and, in that sense, they are disease-specific rather than generic measures. Single item measures of recovery were frequently used but researchers often invented their own, so there was little consistency in the wording. These measures had five principal foci - return to work, return to own home, degree of recovery, productivity and chronic health status. One multi-item scale was also used. (ABSTRACT TRUNCATED)

The use of time step simulations and difference equations (TSSADEQ) in modeling heparin pharmacokinetics.

A model in which the clearance of heparin requires the binding of heparin to a finite and regenerated pool of binding was constructed using time step simulations and difference equations (TSSADEQ). A simulation of a heparin i.v. bolus demonstrated a dose-dependent, triphasic pharmacokinetic curve with (1) an initial log-linear phase representing first-order association of heparin with binding sites, (2) an intermediate plateau phase representing constant regeneration of heparin binding sites, and (3) a terminal log-linear phase occurring when the quantity of regenerated sites exceeded the remaining heparin. Sensitivity analysis based on the literature produced estimates of the k at 1.39 to 2.77 h-1, the pool of binding sites of 50 units/kg, and the regeneration rate of 15 to 20 unit/kg/h--virtually identical to the empirically derived guidelines for the bolus size and infusion rate for unfractionated heparin. A pilot study of bolus dosing of unfractionated heparin in normal volunteers confirmed the model.

The mediating role of cutaneous sensitivity within neonatal psychoneuroimmunology.

Preliminary results of this study have been presented at the ICIS Conferences held in Atlanta, 1998; a Summary of results has been quoted in Adamson-Macedo (1997; 1998). OBJECTIVES: Despite knowledge that preterm infants in intensive care are in distress and need to be provided with appropriate intervention, studies with ventilated babies are still rare particularly during their first weeks of life. This study tested the hypothesis that cutaneous stimulation in the form of TAC-TIC therapy, involving only light stroking and NOT massage or kinesthetic massage, has a mediating role in eliciting beneficial psychoneuroimmunological coactions in the ventilated preterm during the first week of post-natal life. METHODS: A repeated measure, counterbalanced design, was used to collect data twice daily for three consecutive days. This intervention was compared with a control condition consisting of a period of spontaneous activity during which the same infants lay alone with no intervention taking place. For the first time, monitoring facilities were made available for immunological, physiological and behavioral responses to be assessed simultaneously before and after intervention and before and after spontaneous activities. RESULTS. A one tailed t-test indicated that the cutaneous intervention resulted in significantly more episodes of beneficial coactions than matched sessions of spontaneous activity. CONCLUSION: It is suggested that the sensory nerves endings in the skin receive the stimulation from the stroking actions; consequently impulses are being sent via afferent nerve fibers to the limbic system where the sensation is interpreted, by 68% of the neonates, as being comforting or not distressing.

The nature of attachment in a neonatal intensive care unit.

Attachment is defined as the formation of a relationship between a mother and her newborn infant. The concept of attachment has been inadequately defined and often confused with feelings associated with love, instinct, engrossment, and being connected to others. Prematurity and associated maternal-infant separation at birth can affect the attachment process. In this article, a research project, using Leninger's ethnonursing approach is described. Leninger's method was chosen to study the phenomenon of attachment in a neonatal intensive care unit (NICU). Ethnonursing has been found to be a suitable approach for the study of complex situations. Ethnonursing is based on an observation, participation in care, and reflection model. Qualitative data for this study were collected by observation, participation in care, and interviews of mothers (N = 25) in a tertiary NICU. Data were analyzed by comparison of narratives from field notes and transcripts. Findings from the analysis indicate the process of attachment was not automatic. Attachment should be considered as an individualized process. Two dichotomies associated with attachment were identified through the research. These were overt and covert attachment processes and may be dependent on the health status of the infant and the mother, environmental circumstances, and on the quality of care the infant receives.

The integration of complementary therapies in North and South Thames Regional Health Authorities' critical care units.

Subsequent to the rising interest in complementary therapies, a survey was conducted to determine the extent of integration of complementary therapies in critical care units in the North and South Thames Regional Health Authorities in the Greater London area. In total, 45 critical care units were surveyed at random. The results of the survey indicated Neonatal Intensive Care Units showed the greatest interest and provision (75%) of complementary therapies. This was primarily in the application of baby massage. In contrast, only 10% of Coronary Care Units surveyed provided complementary therapies. Results further indicated that of 51.1% of critical care units which claimed to provide complementary therapies, only 7% provided interventions on a routine, systematic basis.

Liverpool Seizure Severity Scale revisited.

The purpose of the study was to examine the psychometric properties of the revised Liverpool Seizure Severity Scale. The scale has been adapted to increase its content validity and its potential for detecting change attributable to antiepileptic drug treatment. Ninety-seven patients completed the revised scale of which 32 completed it for both major and minor seizures. Reliability of the revised scale was conducted using assessment of internal consistency and test-retest. T-tests were conducted to assess the ability of patients to differentiate between major and minor seizures on scores of the seizure-severity scale. The psychometric properties of the scale were not adversely affected by either the increase in the number of items or the additional response scores. Patients completing the two scales of major and minor seizures were able to reliably differentiate between the two. We have attempted to improve the Liverpool Seizure Severity Scale in order to enhance its reliability, validity and sensitivity to change. The amendments we have made have not adversely affected its psychometric properties and we hope that it will make it more acceptable for use in clinical trials of new antiepileptic drug treatment. The revised scale is currently being applied to a number of clinical trials.

TAC-TIC therapy: a non-pharmacological stroking intervention for premature infants.

This paper describes a non-pharmacological stroking intervention which has been used with premature infants. This intervention is referred to as Touching and Caressing, Tender in Caring (TAC-TIC) therapy. Some of the beneficial outcomes resulting from TAC-TIC in healthy preterms are outlined, along with some of the initial findings from research using the therapy with the high-risk ventilated premature neonate. Current research has been conducted using a psychoneuroimmunological framework and preliminary findings have indicated stabilized cardiovascular responses, enhanced secretory immunity and increased frequency of occurrence of comfort behaviours as a result of TAC-TIC therapy.

Localization of alpha1(I) collagen mRNA in myocardium from the spontaneously hypertensive rat during the transition from compensated hypertrophy to failure.

Spontaneously hypertensive rats (SHR) commonly develop impairment of myocardial function between ages 18-24 months. Isolated muscle studies demonstrate depressed myocardial contractility and increased passive stiffness. Studies of the extracellular matrix in SHR with failure (SHR-F) demonstrate an increased expression of genes encoding extracellular matrix components (ECM), hydroxyproline concentration and fibrosis relative to age-matched non-failing animals. In the present study, tissue sections of hearts from SHR-F, non-failing SHR (SHR-NF) and non-hypertensive Wistar Kyoto rats (WKY) were hybridized with a cDNA probe for alpha1(I) collagen mRNA, which was found by Northern blot analysis to be elevated in SHR-F relative to hearts from control animals. In situ hybridization studies demonstrate increased perivascular and interstitial collagen alpha1(I) gene expression in myocardium from the SHR relative to WKY. In addition, failing hearts from the SHR demonstrate focal alpha1(I) collagen mRNA accumulation in the endocardium and at sites of degenerating single myocardial cells.

Effect of chronic colchicine administration on the myocardium of the aging spontaneously hypertensive rat.

Colchicine has been demonstrated to suppress the release of fibroblast growth factors, retard collagen formation and augment collagenase activity. Trials with colchicine in patients with hepatic fibrosis have suggested clinical benefit. The development of impaired myocardial function in the spontaneously hypertensive rat (SHR) is associated with a marked increase in myocardial fibrosis. The present study was carried out to test the hypothesis that chronic colchicine administration to the SHR would prevent the development of fibrosis and impaired myocardial performance. Colchicine (1 mg/l drinking water) was administered to male SHR and WKY rats from at age 13 months until 24 months or until evidence of heart failure was observed. Age-matched untreated SHR and colchicine treated and untreated WKY served as controls. At study, active and passive properties of isolated left ventricular muscle preparations were determined. Myocardial fibrosis was assessed by measuring hydroxyproline and histologic determination of interstitial cross-sectional area. Increases in LV hydroxyproline and interstitial area were found in untreated SHR relative to WKY; passive myocardial stiffness was increased and active muscle properties were depressed. In comparing colchicine treated vs untreated SHR, no differences in hydroxyproline, interstitial area or intrinsic myocardial function were found. In the WKY, colchicine increased myocardial interstitium and passive stiffness without changing hydroxyproline. Active myocardial function was not depressed. Thus, chronic colchicine administration neither attenuated the development of interstitial fibrosis nor prevented impaired myocardial function in the SHR. Colchicine treatment was associated with increased interstitium in WKY with increased passive myocardial stiffness.

Salivary lysozyme: a noninvasive marker for the study of the effects of stress of natural immunity.

Salivary lysozyme levels were measured to determine the effect of stress on innate mucosal immunity. In the first study perceived stress levels of 39 participants were using a stress/arousal checklist questionnaire. Salivary lysozyme levels were found to show a negative correlation (r = -.477, p < .01) with the perceived stress level. In a second study, salivary lysozyme concentrations were measured during periods of high and low stress in the form of an actual stressor--final year examinations. The concentration of lysozyme was found to be significantly (p < .05) lower in the sample taken before the examination when the students were awaiting entry into the examination hall compared to the levels after completion of all examinations. These results indicate that salivary lysozyme concentrations are sensitive to psychological stress and could be utilized as a potential marker in studies looking at the effects of stress on immunity. Because the usefulness of sIgA as a marker has been questioned, the use of salivary lysozyme as a noninvasive index of mucosal immunity warrants further investigation.

Reducing anxiety: the employment of Therapeutic Touch as a nursing intervention.

Patient anxiety is frequently associated with admission and treatment in Critical Care Units. In Critical Care, one aim is the promotion of comfort so that anxiety experienced by patients can be reduced. In this article, a quasi-experimental design which attempted to determine the effectiveness of Therapeutic Touch as a nursing intervention is described. It was hypothesized that Therapeutic Touch would promote comfort and reduce anxiety. Before implementation of the project, a semi-structured interview was conducted amongst nurses (n = 18) from an Intensive Care Unit in a District General Hospital in East London. Interviews were conducted in order to determine the nurses' perceptions of the effectiveness of Therapeutic Touch as a complementary therapy. Initial findings of nurse interviews, a nurse's personal experiences of administering Therapeutic Touch and a case study indicate there may be a place for Therapeutic Touch as an intervention for promoting comfort and reducing anxiety in Critical Care.

Interobserver variability in the diagnosis of high-grade prostatic intraepithelial neoplasia and adenocarcinoma.

High-grade prostatic intraepithelial neoplasia (PIN) is a strong predictor of carcinoma when identified in small-needle biopsy specimens. However, the diagnostic variability of PIN is unknown. Eight pathologists reviewed 321 prostatic biopsy specimens to assess the variability of the diagnosis of high-grade PIN and carcinoma. All of the specimens were classified as negative, high-grade PIN, suspicious for high-grade PIN, carcinoma, or suspicious for carcinoma, more than one diagnosis was permitted, except for negative. We compared diagnoses made by two observers by pairing them for negative versus high-grade PIN, negative versus carcinoma, high-grade PIN versus carcinoma, and all diagnostic categories together. Mean kappa coefficient values for 28 interobserver combinations were 0.451, 0.845, 0.669, and 0.482, respectively, for each of the four comparison combinations considered. Our results indicate a high level of agreement, "almost perfect" (kappa = 0.81-1.0) for carcinoma, "moderate" (kappa = 0.41-0.60) for high-grade PIN, and "substantial" (kappa = 0.61-0.81) for high-grade PIN versus carcinoma. We found that variability was related to the level of interest in prostatic pathology, the conditions of the study, the subjective application of diagnostic criteria, and the influence of peers and clinical colleagues.

Countertransference in group psychotherapy: waking a sleeping dog.

This paper reviews and critiques the literature on countertransference (CT) in group psychotherapy. The literature review is organized within a framework that calls attention to the origins, triggers, manifestations, and effects of CT in groups, as well as CT management factors. An overriding critique is that the present literature lacks a research foundation of any kind. An argument is made for beginning research in this domain, and guidelines for doing so are presented.