Experiences of Student Circus Arts Performers Undertaking a Shoulder Rehabilitation Program Via Telehealth Consultation During the COVID-19 Pandemic.

OBJECTIVE: To explore the subjective experiences of student circus arts performers with atraumatic shoulder instability undertaking a 12-week shoulder rehabilitation program during the COVID-19 pandemic lockdown, in Melbourne, Australia. METHODS: Using a qualitative design, 14 circus arts students from the National Institute of Circus Arts (Australia) were individually interviewed via teleconsultation. All interviews were recorded, transcribed, and analysed using inductive thematic analysis. RESULTS: Five overarching themes were identified: (i) impact (physical and mental), (ii) opportunity, (iii) developing routine, (iv) client-therapist relationship, and (v) transformation. All participants reported positive physical changes to their shoulder including increases in strength, stability, range of motion, less pain, "clicking" and "clunking," improved posture, muscle memory, as well as carry-over to functional circus activities. The pandemic's mental impact varied across the cohort, with positive and negative experiences described in relation to cognitive, social, and affective factors. Most performers felt the pandemic provided an opportunity to focus on rehabilitation of their shoulder. The program effects were also underpinned by positive client-therapist relationships and a progressive transformation of learning where students gained knowledge of their condition, developed tools to manage their current shoulder impairment, and learned how to apply this new knowledge to future management of their condition. CONCLUSION: A shoulder exercise intervention delivered via teleconsultation during the COVID-19 pandemic resulted in subjective reports of positive physical changes to the participants' shoulder health complaint. This was facilitated through client-physiotherapist relationships, providing structure during uncertain times, and by providing education to help in understanding their condition and its future management.

Psychological mediators of psychological distress and quality of life in inflammatory bowel disease.

BACKGROUND AND AIMS: Using the Common Sense Model (CSM), this study aimed to examine the extent to which illness beliefs, coping styles, self-efficacy, and mindfulness mediate this relationship. METHODS: Two hundred and sixty-one adults (198 females; 169 with Crohn's Disease) with IBD participated in this cross-sectional study. Measures used in this study were the short Crohn's Disease Activity Index, Ulcerative Colitis Lichtiger Index, Inflammatory Bowel Disease Questionnaire, New General Self-Efficacy Scale, Carver Brief COPE scale, Mindful Attention Awareness Scale, Brief Illness Perceptions Questionnaire, and the Depression and Anxiety Stress Scales. RESULTS: Using structural equation modelling, the final model indicated IBD symptoms had a significant direct influence only on illness perceptions (ß = 0.66, p < .001). In turn, illness perceptions had a significant direct influence on depression and anxiety (ß = 0.34, p < .001) and QoL (ß = -0.67, p < .001), and was also linked to higher maladaptive coping (ß = 0.28, p < .001) and lower self-efficacy (ß = -0.49, p < .001), but not with mindfulness or adaptive coping (p > .05). Maladaptive coping (ß = 0.46, p < .001) and mindfulness (ß = 0.23, p < .001) were linked with increased distress. QoL was influenced by distress (ß = -0.40, p < .001). CONCLUSIONS: Consistent with the predictions of the CSM, the relationships between IBD symptoms and depression and anxiety, and between IBD symptoms and quality of life, are statistically mediated via psychological variables including illness perceptions and maladaptive coping.

Food knowledge and psychological state predict adherence to a gluten-free diet in a survey of 5310 Australians and New Zealanders with coeliac disease.

BACKGROUND: A gluten-free diet treats coeliac disease, but its efficacy depends on strict adherence. A variety of patient factors may influence adherence but have not been well described at a population level. AIM: To comprehensively assess the patient factors that influence gluten-free diet adherence in patients with coeliac disease. METHODS: Patients with coeliac disease completed an online survey comprising the validated Celiac Dietary Adherence Test in addition to data on demographics, details of diagnosis and management and assessment of diet knowledge, quality of life and psychological distress. Survey data were analysed for predictors of adherence and quality of life. RESULTS: Of 7393 responses, 5310 completed the Celiac Dietary Adherence Test and 3230 (61%) were adherent to a gluten-free diet. Multivariate regression showed older age, being male, symptoms after gluten ingestion, better food knowledge and lower risk of psychological distress were independent predictors of adherence (each P ≤ 0.008). Additionally, dietary adherence was associated with better quality of life (P < 0.001; multiple regression). Respondents who considered themselves to have poor food knowledge were more likely to incorrectly identify gluten-free foods, but could still recognise gluten-containing foods, suggesting that poor knowledge may lead to over-restriction of diet. CONCLUSIONS: Poor knowledge of a gluten-free diet and psychological wellbeing were independent modifiable risk factors for inadequate adherence to a gluten-free diet in patients with coeliac disease. Involvement of both a dietitian and mental health care professional, in the presence of psychological distress, is likely to be necessary to improve adherence and health outcomes.

Relationship between health status, illness perceptions, coping strategies and psychological morbidity: a preliminary study with IBD stoma patients.

BACKGROUND AND AIMS: Individuals living with IBD and a stoma are at an increased risk of anxiety and depression and it is likely that several factors mediate these relationships, including illness perceptions and coping strategies. Using the Common Sense Model (CSM), this study aimed to characterize the mediators of anxiety and depression in an IBD stoma cohort. METHODS: Eighty-three adults (23 males) with a stoma (25 ileostomy, 58 colostomy; 26 emergency, 57 planned, 55 permanent, 28 temporary) completed an online survey. Health status was measured with the Health Orientation Scale (HOS), coping styles assessed with the Carver Brief COPE scale, illness perceptions explored with the Brief Illness Perceptions Questionnaire (BIPQ), and anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS). RESULTS: Combining the questionnaire data using structural equation modeling resulted in a final model with an excellent fit (χ(2) (11)=12.86, p=0.30, χ(2)/N=1.17, SRMR<0.05, RMSEA<0.05, GFI>0.96, CFI>0.99). Consistent with the CSM, health status directly influenced illness perceptions, which in turn, influenced coping (emotion-focused and maladaptive coping). Interestingly, months since surgery was found to influence illness perceptions and emotion-focused coping directly, but not health status. While depression was influenced by illness perceptions, emotion-focused coping and maladaptive coping, anxiety was only influenced by illness perceptions and maladaptive coping. CONCLUSIONS: The preliminary results provide further evidence for the complex interplay between psychological processes. In terms of directions for psychological interventions, a focus on identifying and working with illness perceptions is important.

Illness perceptions in IBD influence psychological status, sexual health and satisfaction, body image and relational functioning: A preliminary exploration using Structural Equation Modeling.

BACKGROUND AND AIMS: This study aimed to characterize the relationships between illness perceptions, body image and self-consciousness, sexual health (sexual problems and sexual satisfaction), anxiety and depression, and marital and family functioning in patients with IBD. METHODS: Seventy-four IBD patients (44 CD, 13 males, 61 females, mean age 38 years) completed an online questionnaire. Illness perceptions explored with the Brief Illness Perceptions Questionnaire, and anxiety and depression measured using the Hospital Anxiety and Depression Scale, Sexual Problems Scale, Sexual Satisfaction Scale, Marital Functioning Scale, Family Functioning Scale, and Body Image and Self-Consciousness During Intimacy Scale. RESULTS: Exploratory Structural Equation Modeling (SEM) provided a final model with an excellent fit (χ(2) (25)=27.84, p=.32, χ(2)/N=1.11, CFI>0.99, RMSEA<0.04, SRMR<0.07, GFI>0.93). Illness perceptions had a significant direct influence on depression (ß=0.49, p<0.001), anxiety (ß=0.55, p<0.001), and family functioning (ß=-0.17, p<0.001). Several mediating pathways were also found involving sexual problems, sexual satisfaction, and body image and self-consciousness during intimacy. Being female was associated with increased sexual problems but increased sexual satisfaction. CONCLUSIONS: The findings provide further evidence for the adverse impact of patient IBD-related illness perceptions on anxiety and depression. The findings also provide the preliminary evidence for the impact of illness perceptions and psychological comorbidity in relation to sexual health and relationship and family functioning. These aspects of psychological processing provide a framework and direction for further research into the nature of IBD and its influence on the patient and their family.

Preliminary examination of the relations between disease activity, illness perceptions, coping strategies, and psychological morbidity in Crohn's disease guided by the common sense model of illness.

BACKGROUND: An individual's psychological adjustment to illness is influenced by disease severity, illness perceptions, and coping strategies. A more precise understanding of the contribution of each of these factors to a patient's well-being may influence the kind of psychological support required by patients. This study therefore aimed to characterize the contributors to psychological well-being in patients with Crohn's disease (CD). The design was a cross-sectional questionnaire-based study. METHODS: Ninety-six CD patients (34 males, 62 females, mean age 38 years) attending a tertiary hospital inflammatory bowel disease outpatient clinic were studied. Disease severity was evaluated according to the Crohn's Disease Activity Index (CDAI), coping styles assessed with the Carver Brief COPE scale, illness perceptions explored with the Brief Illness Perceptions Questionnaire (BIPQ), and anxiety and depression measured using the Hospital Anxiety and Depression Scale (HADS). RESULTS: Combining the questionnaire data using structural equation modeling resulted in a final model with an excellent fit (χ(2) (7) = 10.42, P = 0.17, χ(2) /N = 1.49, root mean square error of approximation (RMSEA) < 0.07, comparative fit index (CFI) > 0.97, Goodness-of-fit index (GFI) > 0.97). Disease activity had a significant direct influence on illness perceptions (ß = 51, P < 0.001). In turn, illness perceptions had a significant direct influence on depression and anxiety (ß = 41, P < 0.001, ß = 0.40, P < 0.001, respectively). Use of emotional coping strategies was associated significantly (P < 0.001) with the presence of anxiety and depression. CONCLUSIONS: There is an interrelationship between disease activity, illness perceptions, coping strategies, and depression and anxiety. These aspects of psychological processing provide a framework and direction for the psychological support that patients with CD require.

Review of studies that have used the Standard Shiftwork Index: evidence for the underlying model of shiftwork and health.

The Standard Shiftwork Index (SSI) provides shiftwork researchers with a standardised battery for assessing the impact of shiftwork on psychological and physiological well-being. We review the published SSI literature and evaluate the extent to which the results of these publications support the model underpinning the SSI. A total of 70 SSI publications were identified, of which 41 were selected. The 41 studies were published between 1993 and 2006 and had a combined total of 21,420 respondents. The analysis indicated support for parts of the SSI model, particularly in relation to the impact of shift systems design on individual well-being, as well as the role of individual factors (e.g., personality, coping style). However, evidential support for the model as a whole is incomplete. The findings of the reviewed studies are summarised and methodological limitations are discussed.

Reporting of fatal adverse drug reactions.

OBJECTIVES: To review the reports of fatal adverse drug reactions (ADRs) submitted to the Ontario Medical Association Adverse Drug Reactions Monitoring Program between 1990 and 1994; to identify drugs associated with fatal outcomes; and to assess the causative role of the drug in these events and the completeness of the data in these reports. METHODS: Drug(s) identified on each ADR report as being responsible for the reaction were considered. Agents were classified by the Anatomical Therapeutic and Chemical classification system. The causality of each ADR report was evaluated by using an algorithmic rating scale. RESULTS: From the Ontario Medical Association database, 97 cases of ADRs that resulted in death were reviewed. One hundred fourteen medications were implicated as "suspect" drugs in the 97 deaths. The most commonly implicated drug classes were musculoskeletal agents, blood and blood-forming organ agents, and nervous system agents. Patients over 65 years of age comprised 60% of this series. After independent assessment as to causality, 13% of the cases were rated as probable, 86% were rated as possible and 1% were rated as doubtful. Seventy per cent of reports did not include information regarding medical history. Forty-two per cent of cases failed to provide adequate information to evaluate the feasibility of the time to onset of the ADR. The use of concomitant drugs was not reported in 12% of cases. CONCLUSIONS: The drugs most frequently implicated in fatal ADRs were consistent with those reported in other studies. Algorithmic causality assessments were of limited value in these reports. The completeness of the reports and adequacy of the information were poor. The type of reporting forms and information provided were not homogenous. There is a need to improve quality of reporting and harmonize reporting forms between monitoring bodies. The feasibility of unique data collection forms and obligatory reporting for fatal ADRs should be considered.

Idiosyncratic drug reactions: the reactive metabolite syndromes.

Idiosyncratic drug reactions are unpredictable reactions that can result in significant morbidity and mortality. Severe reactions are often characterised by fever and internal organ involvement. Despite progress in the identification of reactive metabolites believed to be the cause of idiosyncratic reactions, the basic mechanisms remain elusive. Furthermore, because of the lack of consensus regarding definition of these syndromes, reporting, and therefore epidemiological data, are often unreliable. Research is needed to explore further the pathophysiology of these reactions, so that better diagnostic tests and treatment methods can be developed.

Cost-effectiveness analysis of six strategies for cardiovascular surgery prophylaxis in patients labeled penicillin allergic.

The cost-effectiveness of different approaches to antimicrobial prophylaxis for cardiovascular surgery patients labeled penicillin allergic was studied. A decision-analytic model was used to examine the cost-effectiveness of six strategies for antimicrobial prophylaxis in cardiovascular surgery patients at a tertiary care hospital. The strategies consisted of (1) giving vancomycin to all patients labeled penicillin allergic, (2) giving cefazolin to all patients labeled penicillin allergic, (3) giving vancomycin to all patients with a history suggesting an immunoglobulin E (IgE)-mediated reaction to penicillin and cefazolin to patients without such a history, (4) administering a penicillin skin test to patients with a history suggesting an IgE-mediated reaction to penicillin and giving vancomycin to patients with positive results and cefazolin to all others, (5) skin testing all patients labeled penicillin allergic and giving vancomycin to those with positive results and cefazolin to those with negative results, regardless of history, and (6) skin testing all patients and giving vancomycin to those with positive results or a history suggesting an IgE-mediated reaction to penicillin and cefazolin to all others. Giving cefazolin to all patients labeled penicillin allergic was the least expensive strategy but was associated with the highest rate of both anaphylactic and non-life-threatening serious reactions. Selective use of vancomycin in patients with a history suggesting an IgE-mediated reaction to penicillin was associated with an added cost and a slightly lower rate of anaphylaxis. Although skin-testing strategies may decrease both non-life-threatening and anaphylactic reactions, the incremental cost was high. When vancomycin was given to all patients labeled penicillin allergic, the incremental cost was very high. A decision-analytic model indicated that selective use of vancomycin is more cost-effective than indiscriminate use of vancomycin for surgical prophylaxis in cardiovascular surgery patients labeled penicillin allergic.

Anticonvulsant hypersensitivity syndrome: incidence, prevention and management.

Although the anticonvulsant hypersensitivity syndrome was first described in 1950, confusion still abounds regarding the syndrome. The triad of fever, rash and internal organ involvement occurring 1 to 8 weeks after exposure to an anticonvulsant heralds this rare (1 in 1,000 to 10,000 exposures) but serious reaction. Aromatic anticonvulsants [phenytoin, phenobarbital (phenobarbitone) and carbamazepine] are the most frequently involved drugs; however, there have also been several cases of anticonvulsant hypersensitivity syndrome associated with lamotrigine. Fever, in conjunction with malaise and pharyngitis, is often the first sign. This is followed by a rash which can range from a simple exanthem to toxic epidermal necrolysis. Internal organ involvement usually involves the liver, although other organs such as the kidney, CNS or lungs may be involved. Hypothyroidism may be a complication in these patients approximately 2 months after occurrence of symptoms. The aromatic anticonvulsants are metabolised to hydroxylated aromatic compounds, such as arene oxides. If detoxification of this toxic metabolite is insufficient, the toxic metabolite may bind to cellular macromolecules causing cell necrosis or a secondary immunological response. Cross-reactivity among the aromatic anticonvulsants may be as high as 75%. In addition, there is a familial tendency to hypersensitivity to anticonvulsants. Discontinuation of the anticonvulsant is essential in patients who develop symptoms compatible with anticonvulsant hypersensitivity syndrome. A minimum battery of laboratory tests, such as liver transaminases, complete blood count and urinalysis and serum creatinine, should be performed. Corticosteroids are usually administered if symptoms are severe. Patients with anticonvulsant hypersensitivity syndrome should avoid all aromatic anticonvulsants; benzodiazepines, valproic acid (sodium valproate) or one of the newer anticonvulsants can be used for seizure control. However, valproic acid should be used very cautiously in the presence of hepatitis. There is no evidence that lamotrigine cross-reacts with aromatic anticonvulsants. In addition, family counselling is a vital component of patient management.

Adverse effects of antiepileptics.

When choosing an anticonvulsant drug, factors such as efficacy, pharmacokinetics, cost, teratogenic effects and potential adverse effects of the drug, and age and sex of the patient must be considered. Adverse effects are observed in up to one-third of patients on anticonvulsant therapy and are divided into two groups - common dose-related toxicity and idiosyncratic toxicity. Both types of adverse events associated with anticonvulsants are discussed according to the organ system affected. Postmarketing surveillance of the newer anticonvulsants is vital to monitor potentially rare idiosyncratic reactions or chronic toxicities.

Gender differences in adverse drug reactions.

The objective of this study is to identify gender-related differences in the types of symptoms and drugs reported to cause an adverse drug reaction. Patient data from the Sunnybrook Health Science Centre ADR Clinic for the period from April 1986 to May 1996 were reviewed. Of the 2,367 patients assessed, 74.1% were female. The mean age of the patients was 43 +/- 17 years. Drug classes most frequently reported to elicit an adverse event were general antiinfectives (60.4%), nervous system agents (21.5%), and musculoskeletal agents (3.7%). Skin-related reactions accounted for 49.0% of all reported adverse drug reactions. More than one agent was reported to be responsible for the adverse drug reaction(s) in 50% of the female patients, versus 33.1% of all male patients. Of the female patients, 47.6% were referred for skin or oral challenge testing, versus 41.6% of the male patients. Of the female patients, 6.2% tested positive to the agent compared with 6.1% of all male patients. These results support previous findings that female gender is a risk factor for the development of adverse drug reactions. Further work is required to elucidate the mechanisms explaining the differences observed between male and female patients.

Quantifying the costs of serious adverse drug reactions to antiepileptic drugs.

PURPOSE: We assessed from an institutional perspective the direct costs of severe adverse cutaneous or hypersensitivity reactions due to antiepileptic drug (AED) therapy that led to hospitalization or prolonged hospital stay. METHODS: Patients admitted for or developing severe AED-induced cutaneous or hypersensitivity reactions while in hospital from January 1990 through June 1996 were identified by ICD-9 codes E936, E937, E693, E695.1, E995.1, and E995.2. Identified cases were analyzed retrospectively by chart review and were included in the analysis if a causal relationship was determined to be possible, probable, or definite. Clinical outcomes were abstracted and related direct costs of the adverse drug reactions (ADRs) calculated. RESULTS: A total of 384 cases were identified by ICD-9 codes, of which 13 cases (mean age +/- SD 52.9+/-21.0 years) were included for further analysis. Eight patients (62%) were admitted because of an ADR (median length of stay 9.5 days; range 4-43), five (38%) experienced an ADR during hospitalization (median duration of ADR episodes 8.5 days; range: 7-21 days). The median direct medical costs of the ADRs were Canadian (CDN) $3,128 (range 1,149-21,293) per patient. CONCLUSIONS: The management of serious cutaneous and hypersensitivity ADRs due to AEDs is associated with considerable direct medical costs. These figures should be considered along with drug acquisition costs and treatment of clinical successes and failures in the overall assessment of the economic impact of pharmacotherapy. Prospective collection of direct costs associated with ADRs in clinical trials would be of value.

Lamotrigine-associated anticonvulsant hypersensitivity syndrome.

We systematically reviewed and analyzed published and unpublished cases of lamotrigine-associated adverse drug reactions consistent with the features of the anticonvulsant hypersensitivity syndrome (AHS) to identify characteristics of the syndrome. We identified 26 cases (mean age, 28+/-18 years; range, 3.5 to 74 years; 54% female), of which nine were published. The characteristics of the syndrome associated with lamotrigine are comparable to AHS induced by older aromatic anticonvulsants.