"Like fighting a fire with a water pistol": A qualitative study of the work experiences of critical care nurses during the COVID-19 pandemic.

AIM: To understand the experience of critical care nurses during the COVID-19 pandemic, through the application of the Job-Demand-Resource model of occupational stress. DESIGN: Qualitative interview study. METHODS: Twenty-eight critical care nurses (CCN) working in ICU in the UK NHS during the COVID-19 pandemic took part in semi-structured interviews between May 2021 and May 2022. Interviews were guided by the constructs of the Job-Demand Resource model. Data were analysed using framework analysis. RESULTS: The most difficult job demands were the pace and amount, complexity, physical and emotional effort of their work. Prolonged high demands led to CCN experiencing emotional and physical exhaustion, burnout, post-traumatic stress symptoms and impaired sleep. Support from colleagues and supervisors was a core job resource. Sustained demands and impaired physical and psychological well-being had negative organizational consequences with CCN expressing increased intention to leave their role. CONCLUSIONS: The combination of high demands and reduced resources had negative impacts on the psychological well-being of nurses which is translating into increased consideration of leaving their profession. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The full impacts of the pandemic on the mental health of CCN are unlikely to resolve without appropriate interventions. IMPACT: Managers of healthcare systems should use these findings to inform: (i) the structure and organization of critical care workplaces so that they support staff to be well, and (ii) supportive interventions for staff who are carrying significant psychological distress as a result of working during and after the pandemic. These changes are required to improve staff recruitment and retention. REPORTING METHOD: We used the COREQ guidelines for reporting qualitative studies. PATIENT AND PUBLIC CONTRIBUTION: Six CCN provided input to survey content and interview schedule. Two authors and members of the study team (T.S. and S.C.) worked in critical care during the pandemic.

The Environmental Footprint of Neurosurgery Operations: An Assessment of Waste Streams and the Carbon Footprint.

Healthcare in England generates 24.9 million tonnes of carbon dioxide equivalents (CO2e), equating to approximately 4% of the total national output of greenhouse gases (GHG), and of this, 10% is from the manufacturing of medical equipment. Operating theatres are a major contributor of biomedical waste, especially consumables, and are three-to-six times more energy intensive than the rest of the hospital. This study seeks to quantify and evaluate the carbon cost, or footprint, of neurosurgery at a single institution in England. A single neurosurgical operation generates, on average, 8.91 kg of waste per case, equivalent to 24.5 CO2e kg per case, mostly from single-use equipment. Per annum, 1300 neurosurgical operative cases are performed with total waste generation of 11,584.4 kg/year and a carbon footprint of 31,859 (kg) CO2e. The challenge of achieving net zero GHG presents an opportunity to catalyse innovation and sustainability in neurosurgery, from how care is delivered, through to equipment use and surgical methodologies. This should improve the quality of healthcare provision to patients and yield potential cost savings.

On day admissions in neurosurgery: a comparative cohort study.

Day of admission neurosurgery is a viable method to reduce health care associated costs, complications and length of stay. Within the national health service in England the picture is very mixed with some neurosurgery centres universally admitting patients the day before and others admitting on the day of surgery.We altered our admissions policy during a 4 month time period from 'day-before' surgery to 'day-of' surgery for elective neurosurgery. A number of patients still continued to be admitted the day before surgery due to consultant choice. We conducted a comparative cohort study of these two patient groups to see if there were any differences in surgical cancellation rates, the reasons for these cancellations and the implied cost savings.In total 199 patients underwent neurosurgery during this time period, 87 patients were admitted on the 'day-of' and 112 patients on the 'day-before' surgery. The overall cancellation rate was 18%. The cancellation rate in patients admitted on the 'day-of' surgery was 12.6% (11/87). The rate of cancellation in patients admitted the 'day-before' surgery was 22.3% (25/112). This difference was not significant (p = 0.1). Day of surgery admission resulted in a cost saving of almost £30,000 in this group of patients over a 4 month period. If extrapolated for all patients over the course of a year it would result in cost savings in the region of £150,000.In summary, admitting elective neurosurgery patients on the day of surgery does not affect cancellation rates, prevents unnecessary overnight hospital admission and results in significant cost saving.

Women in neurosurgery in the United Kingdom: past, present and future.

Whilst a growing number of women in the United Kingdom (UK) are making a success of a career in medicine as a whole, a considerable gender imbalance persists in neurosurgery. The extent of this disparity and the factors that perpetuate it are difficult to assess. Furthermore, over the 70 years since the first female neurosurgeon in the UK commenced her postgraduate training, it is difficult to gauge the progress that has been made. In this article we present a snapshot of women who have played, and who are playing, a key role in UK neurosurgery, highlighting their diverse career paths. We also present the current training distribution and subspecialties of women in UK neurosurgery. We use these data to reflect upon the possible barriers to completion of neurosurgical training, obtaining a substantive consultant position, and reaching positions of academic and clinical leadership. We discuss potential interventions that may overcome these. Highlighting the role women play in UK neurosurgery's past, present and future should inspire more female neurosurgeons to become leaders in the coming years.

Seizure Outcome After Surgery for Insular High-Grade Glioma.

BACKGROUND: The insular cortex is an eloquent island of mesocortex surrounded by vital structures making this region relatively challenging to neurosurgeons. Historically, lesions in this region were considered too high risk to approach given the strong chance of poor surgical outcome. Advances in recent decades have meant that surgeons can more safely access this eloquent region. Seizure outcome after excision of insular low-grade gliomas is well reported, but little is known about seizure outcomes after excision of insular high-grade gliomas. METHODS: A retrospective analysis was performed of all patients presenting with new-onset seizures during 2015-2019 who underwent excision of an insular high-grade glioma at 3 regional neurosurgical centers in the United Kingdom. RESULTS: We identified 38 patients with a mean (SD) age of 45.7 (15.3) years with median follow-up of 21 months. At long-term follow-up, of 38 patients, 23 were seizure-free (Engel class I), 2 had improved seizures (Engel class II), 6 had poor seizure control (Engel class III/IV), and 7 died. CONCLUSIONS: Excision of insular high-grade gliomas is safe and results in excellent postoperative seizure control.

Work-related stress: the impact of COVID-19 on critical care and redeployed nurses: a mixed-methods study.

INTRODUCTION: We need to understand the impact of COVID-19 on critical care nurses (CCNs) and redeployed nurses and National Health Service (NHS) organisations. METHODS AND ANALYSIS: This is a mixed-methods study (QUANT-QUAL), underpinned by a theoretical model of occupational stress, the Job Demand-Resources Model (JD-R). Participants are critical care and redeployed nurses from Scottish and three large English units.Phase 1 is a cross-sectional survey in part replicating a pre-COVID-19 study and results will be compared with this data. Linear and logistic regression analysis will examine the relationship between antecedent, demographic and professional variables on health impairment (burnout syndrome, mental health, post-traumatic stress symptoms), motivation (work engagement, commitment) and organisational outcomes (intention to remain in critical care nursing and quality of care). We will also assess the usefulness of a range of resources provided by the NHS and professional organisations.To allow in-depth exploration of individual experiences, phase 2 will be one-to-one semistructured interviews with 25 CCNs and 10 redeployed nurses. The JD-R model will provide the initial coding framework to which the interview data will be mapped. The remaining content will be analysed inductively to identify and chart content that is not captured by the model. In this way, the adequacy of the JD-R model is examined robustly and its expression in this context will be detailed. ETHICS AND DISSEMINATION: Ethics approval was granted from the University of Aberdeen CERB2020101993. We plan to disseminate findings at stakeholder events, publish in peer-reviewed journals and at present at national and international conferences.

Biographies of international women leaders in neurosurgery.

We received so many biographies of women neurosurgery leaders for this issue that only a selection could be condensed here. In all of them, the essence of a leader shines through. Many are included as "first" of their country or color or other achievement. All of them are included as outstanding-in clinical, academic, and organized neurosurgery. Two defining features are tenacity and service. When faced with shocking discrimination, or numbing indifference, they ignored it or fought valiantly. When choosing their life's work, they chose service, often of the most neglected-those with pain, trauma, and disability. These women inspire and point the way to a time when the term "women leaders" as an exception is unnecessary.-Katharine J. Drummond, MD, on behalf of this month's topic editors.

Traumatic Events Exposure and Psychological Trauma in Children Victims of War in the Gaza Strip.

The present article studies war-related trauma and its effects on children living in the Gaza Strip, 6 months after the attack launched by the Israeli army on July 8, 2014, which lasted for 51 days. The objective was twofold: (a) to identify the prevalence of exposure to traumatic events and (b) to examine the symptoms of traumatic stress in children as described by their parents or tutors using the Harvard Trauma Questionnaire (HTQ). Data from 1,850 male and female children aged between 6 and 15 years living in the Gaza Strip were collected throughout the months of February and April 2015, that is 6 months after the attack. Results showed that the majority of the children were exposed to bombardments and residential area destruction (83.51%), were confined at home unable to go outside (72.92%), were witness to the profanation of mosques (70.38%), were exposed to combat situations (66.65%), and saw corpses (59.95%). A sample of 275 males (28.3%) and 232 females (26.5%) showed diagnoses of posttraumatic stress disorder (PTSD). Gender and age were independent of PTSD. The presence of this pathology was positively related to the number of trauma events experienced. The type of traumatic experience was hardly related to age and gender. A greater protection on behalf of the families against exposure to traumatic events could explain these differences.

Pathophysiology of cerebral oedema in acute liver failure.

Cerebral oedema is a devastating consequence of acute liver failure (ALF) and may be associated with the development of intracranial hypertension and death. In ALF, some patients may develop cerebral oedema and increased intracranial pressure but progression to life-threatening intracranial hypertension is less frequent than previously described, complicating less than one third of cases who have proceeded to coma since the advent of improved clinical care. The rapid onset of encephalopathy may be dramatic with the development of asterixis, delirium, seizures and coma. Cytotoxic and vasogenic oedema mechanisms have been implicated with a preponderance of experimental data favouring a cytotoxic mechanism. Astrocyte swelling is the most consistent neuropathological finding in humans with ALF and ammonia plays a definitive role in the development of cytotoxic brain oedema. The mechanism(s) by which ammonia induces astrocyte swelling remains unclear but glutamine accumulation within astrocytes has led to the osmolyte hypothesis. Current evidence also supports an alternate 'Trojan horse' hypothesis, with glutamine as a carrier of ammonia into mitochondria, where its accumulation results in oxidative stress, energy failure and ultimately astrocyte swelling. Although a complete breakdown of the blood-brain barrier is not evident in human ALF, increased permeation to water and other small molecules such as ammonia has been demonstrated resulting from subtle alterations in the protein composition of paracellular tight junctions. At present, there is no fully efficacious therapy for cerebral oedema other than liver transplantation and this reflects our incomplete knowledge of the precise mechanisms underlying this process which remain largely unknown.

Differences in the profile of neonatal abstinence syndrome signs in methadone- versus buprenorphine-exposed neonates.

AIMS: To compare the profile of signs of neonatal abstinence syndrome (NAS) in methadone- versus buprenorphine-exposed infants. DESIGN, SETTING AND PARTICIPANTS: Secondary analysis of NAS data from a multi-site, double-blind, double-dummy, flexible-dosing, randomized clinical trial. Data from a total of 129 neonates born to opioid-dependent women who had been assigned to receive methadone or buprenorphine treatment during pregnancy were examined. MEASUREMENTS: For 10 days after delivery, neonates (methadone = 72, buprenorphine = 57) were assessed regularly using a 19-item modified Finnegan scale. Data from neonates who required pharmacological treatment (methadone = 41, buprenorphine = 27) were included up to the time treatment was initiated. The incidence and mean severity of the total NAS score and each individual sign of NAS were calculated and compared between medication conditions, as was the median time until morphine treatment initiation among treated infants in each condition. FINDINGS: Two NAS signs (undisturbed tremors and hyperactive Moro reflex) were observed significantly more frequently in methadone-exposed neonates and three (nasal stuffiness, sneezing, loose stools) were observed more frequently in buprenorphine-exposed neonates. Mean severity scores on the total NAS score and five individual signs (disturbed and undisturbed tremors, hyperactive Moro reflex, excessive irritability, failure to thrive) were significantly higher among methadone-exposed neonates, while sneezing was higher among buprenorphine-exposed neonates. Among treated neonates, methadone-exposed infants required treatment significantly earlier than buprenorphine-exposed infants (36 versus 59 hours postnatal, respectively). CONCLUSIONS: The profile of neonatal abstinence syndrome differs in methadone- versus buprenorphine-exposed neonates, with significant differences in incidence, severity and treatment initiation time. Overall, methadone-exposed neonates have a more severe neonatal abstinence syndrome.

Caregiver and self-report of mental health symptoms in 9-year old children with prenatal cocaine exposure.

OBJECTIVE: To assess the effect of prenatal cocaine exposure on mental health symptoms in 9-year old children controlling for potential confounders. METHODS: 332 children (170 prenatally cocaine-exposed (PCE), 162 non cocaine-exposed (NCE) were assessed using self (Dominic Interactive; DI) and caregiver report (Child Behavior Checklist; CBCL). RESULTS: Higher levels of PCE were associated with caregiver report of clinically elevated aggressive and delinquent behavior. With each increased unit of PCE, children were 1.3 times more likely to be rated as aggressive (OR=1.30, 95% CI: 1.02-1.67, p<0.04). For each increased unit of PCE, girls were 2 times more likely to be rated as having delinquent behavior (OR=2.08, 95% CI: 1.46-2.96, p<0.0001). PCE status was also associated with increased odds of delinquent behavior (OR=2.41; 95% CI: 1.16-4.97, p=0.02), primarily due to the increased risk among girls with PCE. While girls with PCE status were 7 times more likely than NCE girls to have delinquent behaviors (OR=7.42; 95% CI: 2.03-27.11, p<0.002) boys with PCE did not demonstrate increased risk (OR=0.98; 95% CI: 0.36-2.65, p>0.97). Foster or adoptive parents were more likely to rate their PCE children as having more thought problems, inattention, delinquent behavior, aggression, externalizing and overall problems (p<0.05) than biologic mothers or relative caregivers. Higher 2nd trimester tobacco exposure was associated with increased odds of caregiver reported anxiety (OR=1.73; 95% CI 1.06-2.81, p<0.03) and marijuana exposure increased the odds of thought problems (OR=1.68; 95% CI 1.01-2.79, p<0.05). Children with PCE self-reported fewer symptoms of oppositional defiant disorder (ODD) compared to NCE children (OR=0.44, 95% CI: 0.21-0.92, p<0.03). Greater tobacco exposure was associated with increased odds of child reported ODD (OR=1.24; 95% CI 1.03-1.78, p<0.03). CONCLUSION: Higher PCE was associated with disruptive behaviors including aggression and delinquent behavior among girls by caregiver report, but not child report. These findings highlight the need for early behavioral assessment using multiple informants in multi-risk children.

Acute febrile myalgia in Vietnam due to trichinellosis following the consumption of raw pork.

Trichinellosis outbreaks occur occasionally in Vietnam following the consumption of undercooked pork. Diagnosing trichinella can be problematic because fever and myalgia are nonspecific, and diagnosis may be delayed. We describe 5 Vietnamese patients in whom trichinellosis was diagnosed after several weeks of illness.

An overview of principles of effective treatment of substance use disorders and their potential application to pregnant cigarette smokers.

Cigarette smoking remains a leading preventable cause of poor pregnancy outcomes and infant morbidity and mortality. Despite three decades of research encompassing more than 60 trials and 20,000 pregnant women, cessation rates produced by existing interventions are often low (<20%), especially among socioeconomically disadvantaged women. This has led to a call for the development and testing of novel interventions. One strategy for identifying novel interventions for pregnant smokers is to examine efficacious interventions for other types of substance use disorders (SUDs). Pregnant smokers share many sociodemographic similarities with other sub-populations of individuals with SUDs, suggesting that interventions efficacious with the latter may also benefit the former. The National Institute on Drug Abuse's guide, "Principles of Drug Addiction Treatment: A Research-based Guide", presents empirically validated principles of effective treatments for other SUDs. The present report enumerates these principles, briefly describes some of the empirical evidence supporting them, and explores their potential application to the treatment of smoking during pregnancy. Overall, the results of this exercise suggest much promise for enhancing treatment outcomes for pregnant smokers by borrowing from and extending what has been learned with other populations with SUDs.

Depressive symptoms predict smoking status among pregnant women.

The current study assessed self-reported psychopathology in women who spontaneously quit or continued smoking after learning that they are pregnant and examined whether any potential differences remained after control for confounding variables. All participants (77 smokers and 50 spontaneous quitters) completed 3 assessments of psychological functioning prior to enrollment in either smoking cessation or relapse prevention studies. Assessments included the Brief Symptom Inventory (BSI); the Beck Depression Inventory (BDI); and the Adult Self-Report (ASR). Smokers and spontaneous quitters differed on sociodemographic and smoking characteristics. In terms of psychological functioning, smokers reported significantly more depression/anxiety symptoms and withdrawn behavior than spontaneous quitters on the BSI and the ASR. Higher depression scores on the BSI were associated with increased odds of continued smoking, even after controlling for sociodemographic and smoking variables in multivariate analyses. These results suggest that depressive symptoms may be an independent contributor to the problem of continued smoking during pregnancy, which may have implications for smoking-cessation interventions among pregnant women.

Psychometric properties of the Dominic interactive assessment: a computerized self-report for children.

The reliability and validity of the Dominic Interactive (DI) assessment were evaluated. The DI is a computerized self-report measure for children, which assesses symptom presence for seven DSM-IV diagnoses. The participants were 322 children (169 cocaine exposed, 153 non-cocaine exposed) who were recruited at birth for a prospective longitudinal study. At 6 years of age, measures of self-report, parent report, and observational data were collected. Moderate to excellent internal consistencies on the DI were found for the total sample as well as for subsamples based on cocaine status and gender. Concurrent validity correlations between DI scales and the Child Behavior Checklist, Affect in Play Scale, a modified Conners's Teachers Rating Scale, and the Parenting Stress Index were examined. Significant relationships among scales were more apt to be among comparisons that assessed externalizing behaviors. Overall, low correlations were obtained, which are comparable to other studies that evaluate agreement between child and parent report of behaviors.

Mesenchymal stem cells.

It has become clear that adult mammalian bone marrow contains not one but two ostensibly discrete populations of adult stem cells. The first and by far the most fully characterized are the hematopoietic stem cells responsible for maintaining lifelong production of blood cells. The biological characteristics and properties of the second marrow resident population of stem cells, variously termed bone marrow stromal cells or mesenchymal stem cells, are in contrast much less well understood. In vitro, cultures established from single-cell suspensions of bone marrow from a wide range of mammalian species generate colonies of adherent marrow stromal cells, each derived from a single precursor cell termed a colony-forming unit-fibroblast (CFU-F). Culture conditions have been developed to expand marrow stromal cells in vitro while maintaining the capacity of these cells to differentiate into bone, fat, and cartilage. A significant portion of our current knowledge of this population of cells is based on analysis of the properties of these culture expanded cells, not on the primary colony-initiating cells. In this article, we will focus on methodologies to prospectively isolate stromal progenitors from mouse and human bone marrow and will review current data that suggest stromal progenitors in the bone marrow in situ are associated with the outer surfaces of blood vessels and may share identity with vascular pericytes.