The constraints of the ordinary: 'being with' in the context of end-of-life nursing care

The concept of 'being with' was an essential part of the hospice philosophy developed by Cicely Saunders, and one that she believed was a key element in the care of the dying. In Saunders' philosophy, 'being with' is a specific moment of engagement between a health professional and a patient whereby the patient has the opportunity to examine and express their thoughts and feelings relating to their imminent death. This study examined how 'being with' was implemented as a part of ordinary day-to-day practice in a hospice in Scotland. The study was based on the principles of ethnomethodology, which aims to reveal embedded and taken-for-granted rules and behaviours that determine practice. The data collection and analysis revealed that the nursing practice was constructed in such a way that 'being with', as Saunders understood it, could not be initiated either by a member of the nursing staff or by the patients. By adopting the philosophical framework of Heidegger, the study offers an understanding of how the nursing staff had developed 'being with' as provision of comfort in order to protect both themselves and the patients from engaging with painful emotions associated with facing death.     

Diagnostic accuracy of 64-slice multidetector CT for detection of in-stent restenosis in an unselected, consecutive patient population

Objectives

To investigate the diagnostic accuracy of 64-slice multidetector computed tomography (64-CT) for detection of in-stent restenosis (ISR) in an unselected, consecutive patient population.

Background

Detection of in-stent restenosis by cardiac CT would be a major advance for the evaluation of patients suspected of having ISR. However, the diagnostic accuracy of current generation 64-CT in this context is not fully established.

Methods

We conducted a prospective study on patients with stable angina or acute coronary syndrome with no prior history of coronary artery disease. Six months after percutaneous coronary intervention (PCI) with stent placement they underwent a 64-CT scan (Toshiba Multi-Slice Aquilion 64) and consequently a repeat coronary angiography for comparison. Cardiac CT data sets were analyzed for the presence of in-stent restenosis by two independent expert readers blinded to the coronary angiographic data.

Results

Ninety-three patients with a total of 140 stents were evaluated. Males comprised 82% of the study group and the mean age was 63 ± 10 years. The mean time from PCI to the repeat coronary angiography was 208 ± 37 days and the mean time from 64-CT to repeat coronary angiography was 3.7 ± 4.9 days. The restenosis rate according to coronary angiography was 26%. Stent diameter, strut thickness, heart rate and body mass index (BMI) significantly affected image quality. The sensitivity, specificity, positive and negative predictive values of 64-CT for detection of in-stent restenosis were 27%, 95%, 67% and 78%, respectively.

Conclusions

Current generation, 64-slice CT, remains limited in its ability to accurately detect in-stent restenosis.     

Clinical manifestation, prevalence and prognosis of sarcoid arthropathy. A nationwide study: the Icelandic Sarcoidosis Study

STUDY OBJECTIVE: The Icelandic Sarcoidosis Study (ISS) contains all tissue-verified cases of sarcoidosis in Iceland since 1981. The present study has extended registration and verification to the start of 2004, thus covering over 23 years and a total of 234 cases. The aim of this study was to elucidate the prevalence, clinical manifestation and long-term prognosis of sarcoid arthritis in this unselected nationwide cohort. The presence of joint or muscle symptoms was registered in 20% of these cases. METHODS: We used a questionnaire to register the lung and joint symptoms and all participants were offered a clinical evaluation with standardized interview and physical examination, including a count of the number of painful and/or inflamed joints. RESULTS: Forty-seven (20%) of the 234 individuals in the ISS reported skeletal symptoms. In thirty-nine cases (17%) it was possible to confirm a history of inflammatory joint disorder. The mean age was 45 years: women 46 years (30-66), men 43 years (28-66). In 82% of the cases one or both ankles were involved. In 22 or 56% of the cases (13 female and 9 male) reliable data on the disease course were obtained; 87% of the patients had full recovery in less than 6 months, while 13% of the patients (all female) experienced chronic arthritic disease. CONCLUSIONS: Our nationwide-based data confirmed that around a fifth of all those diagnosed with sarcoidosis will develop joint symptoms associated with their sarcoidosis, most usually in the ankle. The prognosis is favourable, but a subgroup of female patients may develop chronic polyarthritis. It is urgent to study further in detail the risk factors for a chronic arthritic condition in sarcoidosis; thus, it would be possible to offer those at risk of arthritis modifying anti-rheumatic treatment in the early phase of their disease course.     

Dynamic connectivity regression: determining state-related changes in brain connectivity

Most statistical analyses of fMRI data assume that the nature, timing and duration of the psychological processes being studied are known. However, often it is hard to specify this information a priori. In this work we introduce a data-driven technique for partitioning the experimental time course into distinct temporal intervals with different multivariate functional connectivity patterns between a set of regions of interest (ROIs). The technique, called Dynamic Connectivity Regression (DCR), detects temporal change points in functional connectivity and estimates a graph, or set of relationships between ROIs, for data in the temporal partition that falls between pairs of change points. Hence, DCR allows for estimation of both the time of change in connectivity and the connectivity graph for each partition, without requiring prior knowledge of the nature of the experimental design. Permutation and bootstrapping methods are used to perform inference on the change points. The method is applied to various simulated data sets as well as to an fMRI data set from a study (N=26) of a state anxiety induction using a socially evaluative threat challenge. The results illustrate the method's ability to observe how the networks between different brain regions changed with subjects' emotional state.     

Monoclonal gammopathy: natural history studied with a retrospective approach

The aim of this study was to examine the natural history of monoclonal gammopathy using a retrospective approach and a long observation period. Protein electrophoresis (PE) and immunofixation (IF) was performed on frozen prediagnosis serum samples from 65 multiple myeloma (MM) and 10 Waldenstr?m's macroglobulinemia (WM) cases. Paraprotein was found in 28% and 46% of the samples from cases using PE and IF respectively. The type of paraprotein was IgA in 33.4% of cases, IgG in 57%, and IgM in 8.5%. Excluding light chain or non-secretory disease, 72 % of MM cases had a prodromal MGUS phase within 10 years of diagnosis MM and WM were preceded by MGUS in at least half of the cases, confirming the premalignant nature of this condition.     

COVID-19 in US Youth Soccer Athletes During Summer 2020

ContextAs sports are reinitiated around the United States, the incidence of COVID-19 among youth soccer athletes remains unknown.ObjectiveTo determine the incidence of COVID-19 among youth soccer athletes and the risk-mitigation practices used by youth soccer organizations.DesignCohort study.SettingSurvey distributed to Elite Clubs National League member clubs.Patients or Other ParticipantsYouth soccer club directors throughout the United States.Main Outcome Measure(s)Surveys were completed in late August 2020 regarding the club''s current phase of return to soccer (individual only, group noncontact, group contact), date of reinitiation, number of players, cases of COVID-19, and risk-reduction procedures being implemented. Case and incidence rates were compared with national pediatric data and county data from the prior 10 weeks. A negative binomial regression model was developed to predict club COVID-19 cases using the local incidence rate and phase of return as covariates and the log of club player-days as an offset.ResultsA total of 124 respondents had reinitiated soccer, representing 91 007 players with a median duration of 73 days (interquartile range = 53–83 days) since restarting. Of the 119 clubs that had progressed to group activities, 218 cases of COVID-19 were reported among 85 861 players. Youth soccer players had a lower case rate and incidence rate than children in the United States (254 versus 477 cases per 100 000; incidence rate ratio = 0.511, 95% CI = 0.40, 0.57; P < .001) and the general population in the counties where data were available (268 versus 864 cases per 100 000; incidence rate ratio = 0.202, 95% CI = 0.19, 0.21; P < .001). After adjusting for the local COVID-19 incidence, we found no relationship between the club COVID-19 incidence and the phase of return (noncontact: b = 0.35 ± 0.67, P = .61; contact: b = 0.18 ± 0.67, P = .79). Soccer clubs reported using a median of 8 (interquartile range = 6–10) risk-reduction procedures.ConclusionsThe incidence of COVID-19 among youth soccer athletes was relatively low when compared with the background incidence among children in the United States during the summer of 2020. No relationship was identified between the club COVID-19 incidence and the phase of return to soccer.     

Clinical evaluation and stress test have limited value in the diagnosis of in-stent restenosis

Objectives. In-stent restenosis (ISR) is the main limitation of percutaneous coronary interventions (PCI), occurring in approximately 25% of cases. Although frequently asymptomatic, many PCI patients present with recurrent symptoms of chest pain at follow-up raising a clinical suspicion of ISR. The diagnosis of ISR can be challenging in these patients and difficult to rule out without repeat coronary angiography. Design. We prospectively investigated the diagnostic accuracy of clinical evaluation and exercise stress testing to detect ISR as compared to coronary angiography, in a consecutive, unselected cohort of PCI patients. Results. We studied 91 patients with a total of 143 stents. Clinical evaluation predicted ISR to be likely in 19% of cases and the exercise test was positive in 29%. The binary restenosis rate was 21%. Clinical evaluation had a positive predictive value of 29% and accuracy of 71%, while exercise stress testing had a positive predictive value of 19% and accuracy of 65%. Conclusion. In conclusion, we found the diagnostic accuracy of clinical evaluation to be low and not significantly improved by exercise stress testing when evaluating PCI patients for ISR.