Occupational therapist-guided cognitive interventions in critically ill patients: a feasibility randomized controlled trial.

PURPOSE: Intensive care unit (ICU) delirium is a common complication of critical illness requiring a multimodal approach to management. We assessed the feasibility of a novel occupational therapist (OT)-guided cognitive intervention protocol, titrated according to sedation level, in critically ill patients. METHODS: Patients aged ≥ 18 yr admitted to a medical/surgical ICU were randomized to the standard delirium prevention protocol or to the OT-guided cognitive intervention protocol in addition to standard of care. The target enrolment number was N = 112. Due to the COVID-19 pandemic, the study enrolment period was truncated. The primary outcome was feasibility of the intervention as measured by the proportion of eligible cognitive interventions delivered by the OT. Secondary outcomes included feasibility of goal session length (20 min), participant clinical outcomes (delirium prevalence and duration, cognitive status, functional status, quality of life, and ICU length of stay), and a description of methodological challenges and solutions for future research. RESULTS: Seventy patients were enrolled and 69 patients were included in the final analysis. The majority of OT-guided sessions (110/137; 80%) were completed. The mean (standard deviation [SD]) number of sessions per patient was 4.1 (3.8). The goal session length was achieved (mean [SD], 19.8 [3.1] min), with few sessions (8/110; 7%) terminated early per patient request. CONCLUSION: This novel OT-guided cognitive intervention protocol is feasible in medical/surgical ICU patients. A larger randomized controlled trial is required to determine the impact of such a protocol on delirium prevalence or duration. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT03604809); registered 18 June 2018.

RéSUMé: OBJECTIF: Le délirium est une complication courante à l'unité des soins intensifs et requiert une prise en charge multimodale. Nous avons évalué la faisabilité d'un nouveau protocole d'intervention cognitive dirigé par l'ergothérapeute, titré en fonction du niveau de sédation, chez des patients gravement malades. MéTHODE: Les patients âgés ≥ 18 ans admis dans une USI médico-chirurgicale ont été randomisés à suivre le protocole standard de prévention du délirium ou le protocole d'intervention cognitive dirigé par l'ergothérapeute, en plus du standard de soins. La cible de recrutement était N = 112. En raison de la pandémie de COVID-19, la période de recrutement de l'étude a été raccourcie. Le critère d'évaluation principal était la faisabilité de l'intervention telle que mesurée par la proportion d'interventions cognitives admissibles prodiguées par l'ergothérapeute. Les critères d'évaluation secondaires comprenaient la faisabilité de la durée cible de la séance (20 min), les issues cliniques des participants (prévalence et durée du délirium, état cognitif, état fonctionnel, qualité de vie et durée de séjour à l'USI), ainsi qu'une description des défis méthodologiques et des solutions pour les recherches futures. RéSULTATS: Soixante-dix patients ont été recrutés et 69 patients ont été inclus dans l'analyse finale. La majorité des séances dirigées par l'ergothérapie (110/137; 80 %) ont été complétées. Le nombre moyen (écart type [ET]) de séances par patient était de 4,1 (3,8). L'objectif de durée de la séance a été atteint (moyenne [ET], 19,8 [3,1] min), avec quelques séances (8/110; 7 %) interrompues prématurément à la demande du patient. CONCLUSION: Ce nouveau protocole d'intervention cognitive dirigé par l'ergothérapie est réalisable chez les patients en soins intensifs médicaux et chirurgicaux. Une étude randomisée contrôlée plus vaste est nécessaire afin de déterminer l'impact d'un tel protocole sur la prévalence ou la durée du délirium. ENREGISTREMENT DE L'éTUDE: www.ClinicalTrials.gov (NCT03604809); enregistrée le 18 juin 2018.

Thinking about Social Determinants of Health through the Relationality of Work and Drug Use.

Public health often frames drug use and addiction as destructive and antithetical to productive citizenship, particularly formal employment. Anthropologists show how drug use emerges in specific institutional, social, and political economic contexts. This attention to context suggests that the relationship between drug use and work may not be as stable as epidemiology models it. There is a multiplicity to the relationality of work and drug use. These results are based on in-depth interviews conducted in 2018 and 2019 with 16 individuals undergoing addiction treatment at a residential facility in northern Arizona. In some cases, drug and alcohol use led to losing work. In other cases, drug and alcohol use made work more possible. The entanglements between work and drug use fluctuated through time. Social determinants of health are relationally brought into being, part of larger assemblages, and dynamic.

Toward an ethics of global health (de)funding: Thoughts from a maternity hospital project in Kabul, Afghanistan.

Funding and defunding decisions in global health are often not subject to ethical scrutiny although they carry the potential for iatrogenic violence. The funding and defunding of a maternal health project in Kabul, Afghanistan during the 2000s reveals the post 9/11 science-politics dynamics that resulted in the emergence of maternal mortality in Afghanistan as a humanitarian object. Despite concerns raised by the Afghan Ministry of Public Health, U.S. Department of Health and Human Services subcontractors renovated one of four public maternity hospitals in Kabul, doubling the number of births per year and increasing the rate of caesarean sections. Project defunding in 2011 was due to a confluence of primarily political factors. Project actors - Afghan and internationals - expressed ethical concerns about the abrupt defunding and the particular risks to women undergoing emergency caesarean sections at the hospital. The analysis presented here has wider relevance for the global surgery movement and concerns about fluctuations in donor funding in global health. There is a need for an ethics of global health funding and defunding decisions that encompasses policies, relationships, stronger local public health systems and civic participation. Global health (de)funding must be made more of an object of ethical deliberation and negotiation.

Toward an anthropology of loneliness.

Loneliness, which is increasingly recognized as a public health concern, is not just a matter of individual psychology or cognition, but inherently social, cultural, and relational. It is an affective, subjective, and intersubjective reality, distinct from the physical reality of social isolation. This introduction to the thematic issues of Transcultural Psychiatry argues that the social and cultural nature of loneliness is an important area of study that requires interdisciplinary approaches and can particularly benefit from ethnography. Contributors explore concepts and expressions of loneliness in Japan, Kenya, Mexico, North Africa, Palestine, Russia, and the US. Cross-cutting themes include the importance of cultural expectations, practice, place, and recognition in the experience of loneliness. Loneliness is a culturally shaped experience that is problematized and medicalized across cultures, but it may also be fundamental to the human condition.

Effect of early cognitive interventions on delirium in critically ill patients: a systematic review.

PURPOSE: A systematic review of the literature was conducted to determine the effects of early cognitive interventions on delirium outcomes in critically ill patients. SOURCE: Search strategies were developed for MEDLINE, EMBASE, Joanna Briggs Institute, Cochrane, Scopus, and CINAHL databases. Eligible studies described the application of early cognitive interventions for delirium prevention or treatment within any intensive care setting. Study designs included randomized-controlled trials, quasi-experimental trials, and pre/post interventional trials. Two reviewers independently extracted data and assessed risk of bias using Cochrane methodology. PRINCIPAL FINDINGS: Four hundred and four citations were found. Seven full-text articles were included in the final review. Six of the included studies had an overall serious, high, or critical risk of bias. After application of cognitive intervention protocols, a significant reduction in delirium incidence, duration, occurrence, and development was found in four studies. Feasibility of cognitive interventions was measured in three studies. Cognitive stimulation techniques were described in the majority of studies. CONCLUSION: The study of early cognitive interventions in critically ill patients was identified in a small number of studies with limited sample sizes. An overall high risk of bias and variability within protocols limit the utility of the findings for widespread practice implications. This review may help to promote future large, multi-centre trials studying the addition of cognitive interventions to current delirium prevention practices. The need for robust data is essential to support the implementation of early cognitive interventions protocols.

RéSUMé: OBJECTIF : Une revue systématique de la littérature a été réalisée afin de déterminer les effets des interventions cognitives précoces sur l'évolution du delirium chez les patients en état critique. SOURCE: Des stratégies de recherche ont été mises au point pour explorer les bases de données MEDLINE, EMBASE, Joanna Briggs Institute, Cochrane, Scopus et CINAHL. Les études éligibles devaient décrire l'application d'interventions cognitives précoces pour la prévention ou le traitement du delirium dans un contexte de soins intensifs. Les types d'études retenues incluaient des études randomisées contrôlées, des études quasi expérimentales et des études pré-/post-interventionnelles. En se fondant sur la méthodologie Cochrane, deux réviseurs ont extrait les données et évalué le risque de biais de manière indépendante. CONSTATATIONS PRINCIPALES: Quatre cent quatre citations ont été extraites. Sept articles ont été retenus pour le compte rendu final. Six des études incluses présentaient un risque global de biais majeur, élevé ou critique. Après l'application des protocoles d'interventions cognitives, quatre études ont noté une réduction significative de l'incidence, de la durée, de la survenue et de l'apparition de delirium. Trois études ont mesuré la faisabilité des interventions cognitives. La majorité des études décrivaient les techniques de stimulation cognitive. CONCLUSION: Nous sommes parvenus à identifier quelques études ayant des tailles d'échantillon limitées décrivant des interventions cognitives précoces chez les patients en état critique. Un risque global élevé de biais et de variabilité au sein des protocoles limite toutefois l'utilité de ces observations pour leurs applications dans la pratique. Ce compte rendu pourrait susciter l'intérêt de chercheurs pour réaliser des études d'envergure et multicentriques examinant l'ajout d'interventions cognitives aux pratiques actuelles de prévention du delirium. Le besoin de données robustes est crucial pour soutenir la mise en œuvre de protocoles précoces d'interventions cognitives.

Being unneeded in post-Soviet Russia: Lessons for an anthropology of loneliness.

The problem of loneliness is receiving increasing attention in the popular media and among social scientists. Despite anthropology's rich engagement with emotions and experience, the anthropology of loneliness is still scant. In psychology, loneliness has been defined as relational lack. In this article, I reconsider one culturally specific form of relational lack-being unneeded among post-Soviet Muscovites. I draw on the anthropological literature on emotion, exchange, and morality to suggest that being unneeded is an ethical commentary on a lack of recognition. During Soviet times, recognition was secured through informal social exchange practices. Being unneeded among middle-aged and elderly post-Soviet Muscovites is therefore connected to a constricted ability to give and experience recognition. One avenue of analysis for an anthropology of loneliness is to consider social exchange practices and how these connect with societal and moral dimensions of loneliness.

The US Mortality Crisis: An Examination of Non-Hispanic White Mortality and Morbidity in Yavapai County, Arizona.

Midlife non-Hispanic white mortality in the United States is rising, particularly in small metro and rural counties. This article responds to calls for county-level studies. We examine social determinants of morbidity and mortality among adult non-Hispanic whites in Yavapai County, Arizona, as part of an integrative study. We report overall mortality trends in Yavapai County using CDC Wonder data and then examine social determinants of reported physical health and mental distress in Yavapai County data using 6 years (2011-2016) of the Arizona Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS includes 1,024 non-Hispanic white respondents aged 25-64. We also present data from the recently established Yavapai County Overdose Fatality Review Board (YCOFRB). Mortality trends indicate that suicide and drug and alcohol-related mortality have all increased since 1999. These increases affect all 5-year age groups from 25 to 64 and both men and women. BRFSS data show that low education and unemployment, but not number of children or home ownership, are significantly associated with worse reported health and frequent mental distress in multivariate analyses. The YCOFRB point to the importance of homelessness and mental health. The mortality crisis in Yavapai County is not restricted to midlife or to drug-related deaths. The unemployed and those with low levels of education are particularly at risk. There is a need for integrative approaches that use local data to elucidate social determinants of morbidity and mortality and to reveal structural determinants.

A Global Perinatal Health Indicator Falters in Afghanistan.

Through the life of a global health project in a maternity hospital in Kabul, Afghanistan one indicator-intrapartum mortality-was taken to represent the quality of emergency obstetric care and was at the center of a struggle over project management. The indicator was also contested by Afghan clinicians, and so was adapted, in which process the relationship between the indicator and women's lives outside the hospital was made clear. As the indicator faltered, new possibilities for intervention emerged, although these were not fully realized. Global health governance and financing must be flexible enough to respond when indicators falter.

Factors Associated with the Duration of Moderate-to-Severe Diarrhea among Children in Rural Western Kenya Enrolled in the Global Enteric Multicenter Study, 2008-2012.

Diarrheal disease is a leading cause of death among young children worldwide. As rates of acute diarrhea (AD; 1-6 days duration) have decreased, persistent diarrhea (PD; > 14 days duration) accounts for a greater proportion of the diarrheal disease burden. We describe factors associated with the duration of moderate-to-severe diarrhea in Kenyan children < 5 years old enrolled in the Global Enteric Multicenter Study. We found 587 (58%) children experienced AD, 360 (35%) had prolonged acute diarrhea (ProAD; 7-13 days duration), and 73 (7%) had PD. We constructed a Cox proportional hazards model to identify factors associated with diarrheal duration. Risk factors independently associated with longer diarrheal duration included infection with Cryptosporidium (hazard ratio [HR]: 0.868, P = 0.035), using an unimproved drinking water source (HR: 0.87, P = 0.035), and being stunted at enrollment (HR: 0.026, P < 0.0001). Diarrheal illness of extended duration appears to be multifactorial; given its association with adverse health and development outcomes, effective strategies should be implemented to reduce the duration and severity of diarrheal illness. Effective treatments for Cryptosporidium should be identified, interventions to improve drinking water are imperative, and nutrition should be improved through exclusive breastfeeding in infants ≤ 6 months and appropriate continued feeding practices for ill children.

Guardian of the furnace: mitochondria, TRAP1, ROS and stem cell maintenance.

Mitochondria are key to eukaryotic cell survival and their activity is linked to generation of reactive oxygen species (ROS) which in turn acts as both an intracellular signal and an effective executioner of cells with regards to cellular senescence. The mitochondrial molecular chaperone tumor necrosis factor receptor associated protein 1 (TRAP1) is often termed the cytoprotective chaperone for its role in cancer cell survival and protection from apoptosis. Here, we hypothesize that TRAP1 serves to modulate mitochondrial activity in stem cell maintenance, survival and differentiation.

Gender and HIV testing in Burkina Faso: an exploratory study.

This study investigated the utilization of services around HIV testing in Burkina Faso through a survey that combined quantitative and qualitative data from 14 selected sites and 299 questionnaires. While some attitudes and behaviors towards HIV testing were similar for women and men, we found lower use of services by men, greater concerns about testing and disclosure on the part of women, and differences between men and women in motivations to test, and the experience of testing and its consequences. The results are discussed in the context of Burkina Faso and in terms of their implications for efforts to improve access to services around HIV.

Basal and angiopoietin-1-mediated endothelial permeability is regulated by sphingosine kinase-1.

Endothelial cells (ECs) regulate the barrier function of blood vessels. Here we show that basal and angiopoietin-1 (Ang-1)-regulated control of EC permeability is mediated by 2 different functional states of sphingosine kinase-1 (SK-1). Mice depleted of SK-1 have increased vascular leakiness, whereas mice transgenic for SK-1 in ECs show attenuation of leakiness. Furthermore, Ang-1 rapidly and transiently stimulates SK-1 activity and phosphorylation, and induces an increase in intracellular sphingosine-1-phosphate (S1P) concentration. Overexpression of SK-1 resulted in inhibition of permeability similar to that seen for Ang-1, whereas knockdown of SK-1 by small interfering RNA blocked Ang-1-mediated inhibition of permeability. Transfection with SKS225A, a nonphosphorylatable mutant of SK-1, inhibited basal leakiness, and both SKS225A and a dominant-negative SK-1 mutant removed the capacity of Ang-1 to inhibit permeability. These effects were independent of extracellular S1P as knockdown or inhibition of S1P1, S1P2, or S1P3, did not affect the Ang-1 response. Thus, SK-1 levels in ECs powerfully regulate basal permeability in vitro and in vivo. In addition, the Ang-1-induced inhibition of leakiness is mediated through activation of SK-1, defining a new signaling pathway in the Ang-1 regulation of permeability.

Women's midlife health across cultures: DAMES comparative analysis.

OBJECTIVE: The Decisions At Menopause Study (DAMES) investigates the experience of menopause in four countries. This article explores self-reported health. DESIGN: Women aged 45 to 55 years were interviewed in Lebanon (n=298), Morocco (n=299), Spain (n=300), and the United States (n=293). The survey instrument included closed- and open-ended questions. Statistical analyses were used to assess the determinants of reporting poor health, and textual analyses were used to highlight themes related to perceptions of health. RESULTS: In Lebanon and Morocco, 22% and 28%, respectively, of the women sampled indicated that their health was not good. In Spain and the United States, 15% and 11% of the women sampled reported their health as fair or poor. We explored significant predictors of poorer reported health across sites. Responses to the open-ended questions "How is your health?" and "How do you compare your health to other women your own age?" revealed common concerns of aches and pains, tiredness, work/responsibilities, and family across all four sites. Unique themes included the war in Lebanon, poverty in Morocco, and social activity in Spain. Menopausal symptoms may in many cases be overshadowed by other health concerns of middle-aged women. Nonspecific symptoms such as tiredness and aches and pains serve to link bodily health with social circumstances. Family and work responsibilities are common concerns of middle-aged women. CONCLUSIONS: Research on midlife health and menopause needs to be systematic enough to enable cross-cultural comparisons. At the same time, it must be flexible enough to identify population-specific symptoms, social context, and lifestyle concerns.

Role of protein kinase Czeta in thrombin-induced endothelial permeability changes: inhibition by angiopoietin-1.

Endothelial cell leakiness is regulated by mediators such as thrombin, which promotes endothelial permeability, and anti-inflammatory agents, such as angiopoietin-1. Here we define a new pathway involved in thrombin-induced permeability that involves the atypical protein kinase C isoform, PKCzeta. Chemical inhibitor studies implicated the involvement of an atypical PKC isoform in thrombin-induced permeability changes in human umbilical vein endothelial cells. Thrombin stimulation resulted in PKCzeta, but not the other atypical PKC isoform, PKClambda, translocating to the membrane, an event known to be critical to enzyme activation. The involvement of PKCzeta was confirmed by overexpression of constitutively active PKCzeta, resulting in enhanced basal permeability. Dominant-negative PKCzeta prevented the thrombin-mediated effects on endothelial cell permeability and inhibited thrombin-induced activation of PKCzeta. Rho activation does not appear to play a role, either upstream or downstream of PKCzeta, as C3 transferase does not block thrombin-induced PKCzeta activation and dominant-negative PKCzeta does not block thrombin-induced Rho activation. Finally, we show that angiopoietin-1 inhibits thrombin-induced PKCzeta activation, Rho activation, and Ca(++) flux, thus demonstrating that the powerful antipermeability action of angiopoietin-1 is mediated by its action on a number of signaling pathways induced by thrombin and implicated in permeability changes.