Assessment of regional lung recruitment and derecruitment during a PEEP trial based on electrical impedance tomography

Objective To investigate whether electrical impedance tomography (EIT) is capable of monitoring regional lung recruitment and lung collapse during a positive end-expiratory pressure (PEEP) trial. Design Experimental animal study of acute lung injury. Subject Six pigs with saline-lavage-induced acute lung injury. Interventions An incremental and decremental PEEP trial at ten pressure levels was performed. Ventilatory, gas exchange, and hemodynamic parameters were automatically recorded. EIT and computed tomography (CT) scans of the same slice were simultaneously taken at each PEEP level. Measurements and results A significant correlation between EIT and CT analyses of end-expiratory gas volumes (r = 0.98 up to 0.99) and tidal volumes (r = 0.55 up to r = 0.88) could be demonstrated. Changes in global and regional tidal volumes and arterial oxygenation (PaO₂/FiO₂) demonstrated recruitment/derecruitment during the trial, but at different onsets. During the decremental trial, derecruitment first occurred in dependent lung areas. This was indicated by lowered regional tidal volumes measured in this area and by a decrease of PaO₂/FiO₂. At the same time, the global tidal volume still continued to increase, because the increase of ventilation of the non-dependent areas was higher than the loss in the dependent areas. This indicates that opposing regional changes might cancel each other out when combined in a global parameter. Conclusions EIT is suitable for monitoring the dynamic effects of PEEP variations on the regional change of tidal volume. It is superior to global ventilation parameters in assessing the beginning of alveolar recruitment and lung collapse.     

The burden of the ‘RA RA’ positive: survivors’ and hospice patients’ reflections on maintaining a positive attitude to serious illness

Goals This article seeks to make a contribution to fostering work on the neglected area of research about how individuals maintain a positive outlook during their confrontation with serious illness. Insights are presented from both haematology survivors and hospice patients about the factors that hinder and facilitate their capacity to be positive.Patients and methods Open-ended interviews with 14 hospice patients and 12 haematology survivors on their construction of meaning in the face of serious illness were audio-recorded, transcribed verbatim and thematically analysed. The findings on the topic of maintaining a positive outlook are presented in this article.Main results Although the participants affirmed the value of a positive perspective on their illness experience, they were critical of unwanted pressure from others to be positive: a phenomenon they called the RA RA positive. Such pressure interfered with the natural process of continually having to re-negotiate a positive outlook through exploring the fullness of feeling, both positive and negative. The participants indicated that at times of relapse or worsening physical condition they had to cycle through a process of despair/negativity and re-adjustment before they were able to find the positive. The process could not be rushed and required freedom from an imposed pressure to be positive.Conclusions The essential message is that a positive outlook cannot be imposed but requires a nurturing orientation that allows the expression of a full range of feelings in a supportive environment.     

Automated monitoring of symptoms during ambulatory chemotherapy and oncology providers’ use of the information: a randomized controlled clinical trial

Purpose

Monitoring patient-reported symptoms is necessary to adjust and improve supportive care during chemotherapy. Continuing advances in computerized approaches to symptom monitoring can enhance communication about unrelieved symptoms between patients and oncology providers and may facilitate intensified symptom treatment.

Methods

An automated IT-based telephone monitoring system was developed to enable oncology providers to receive and act on alert reports from patients about unrelieved symptoms during chemotherapy treatment. Daily, 250 participants (randomized to treatment or attentional control) were asked to call the automated system to report presence, severity, and distress for common chemotherapy-related symptoms (1–10 scale if present). For the treatment group, symptoms exceeding preset thresholds for moderate-to-severe intensity levels generated emailed alert reports to both the patient’s oncologist and oncology nurse.

Results

Patients reported high satisfaction and ease of use of the automated system. Over 80 % of providers reported usefulness of the symptom alert reports. Ten monitored symptoms resulted in, on average, nine moderate-to-severe intensity alerts per patient over 45 study days. However, providers rarely contacted patients after receiving alerts. There were no significant differences in change of symptom severity between the two groups (mean difference?=?0.06, p?=?0.58).

Conclusion

Despite patients’ use of a daily symptom monitoring system and providers’ receipt of information about unrelieved symptoms of moderate-to-severe intensity, oncology physicians and nurses did not contact patients to intensify symptom treatment nor did symptoms improve. Further research is indicated to determine if oncology providers initiated follow-up to intensify symptom treatment, whether symptom outcomes would improve.     

Innovative treatment of clinically diagnosed meniscal tears: a randomized sham-controlled trial of the Mulligan concept ‘squeeze’ technique

Objective: The purpose of this study was to examine the validity and test–retest reliability of the ScreenAssist Lumbar Questionnaire (SALQ). If a high degree of reliability and validity could be determined, the questionnaire could provide physical therapists with a formal instrument to assist with the identification of patients with nonmusculoskeletal back pain or emergent musculoskeletal causes of back pain requiring referral to an alternate medical provider.

Methods: Participants were patients presenting to an internal medicine physician's office with the main complaint of low back pain over a 6 months period. ScreenAssist Lumbar Questionnaire was performed twice on each patient within 48 hours of the appointment. A 4-month post-visit chart review was performed to compare scores and recommendations made by the questionnaire with the assessment and diagnosis made by the physician.

Results: The SALQ demonstrated a sensitivity of 0·100 (95% CI: 0·689–0·100) and specificity of 0·786 (95%CI: 0·492–0·951) compared to the assessment and diagnosis performed by the primary care physician. Overall, regarding the recommendation for referral, there was agreement on 20 of the 21 patients with a Kappa of 0·798.

Discussion: The overall test–retest reliability and validity for referral recommendation were high, which indicates that the SALQ may serve as an alternative to the use of red flags in isolation to assist the physical therapist in determining the need for medical referral as the practice continues to progress toward direct access. The positive outcome of this study supports the possible future benefit of the SALQ.     

‘Beyond the cushion’: a study of occupational therapists' perceptions of their role and clinical decisions in pressure care

Purpose.?Occupational therapists are frequently involved in pressure care management in rehabilitation and community settings. The purpose of this study was to investigate the perceptions of occupational therapists about their role within pressure care and the influences on clinical decisions in this area.

Methods.?A grounded theory approach was used and semi-structured interviews were conducted with nine occupational therapists who had provided pressure care to clients within the Hunter Region of Australia. Data were analysed using the constant comparative method.

Results.?The occupational therapy (OT) role in pressure care is diverse and shaped by contextual factors in the workplace. Informants perceived uncertainty surrounding some aspects of their role in pressure care, and with perceptions of other health professionals about their role. OT clinical decisions in pressure care are influenced by intrinsic and extrinsic factors including OT knowledge and experience, client centred approaches and the availability of resources. Relationships between study themes were summarised in a diagram to articulate the factors contributing to the perceptions of OT's about their role in pressure care.

Conclusions.?There is a need for further investigation into the role and clinical decision making of therapists involved in pressure care. Occupational therapists need to promote their role in pressure care to other health professionals.     

Changes of skin electrical potential in acupoints from Ren Mai and Du Mai conduits during Qigong practice: Documentation of a clinical phenomenon

Qigong is a therapeutic method of traditional Chinese medicine (TCM) that combines slow, soft movements and postures with breath control and a special mental state of ‘awareness’. TCM holds that the practice of Qigong promotes the ‘circulation of qi’ in the human body, the ‘flow’ of upward yang qi and downward yin qi to establish ‘balance’. In Western terms, this may be generally equivalent to vegetative homeostasis and the emotionally balanced state induced thereby. Researchers have often attempted to evaluate the functional movements of qi using measurements of the skin's electrical resistance. However, these methodologies have proven difficult to gauge, validate, repeat, and interpret. We aimed to overcome these limitations by measuring the skin's electrical potential between two points of the same system. The main goal of this study was to assess the skin's electrical potential changes in acupoints from the Ren Mai and Du Mai conduits, or meridians, as well as in other points of interest, during Qigong practice. While participants performed a specific Qigong exercise called ‘White Ball’, we observed significant changes in the skin electrical potential on Mìngmén (GV 4), Shèndáo (GV 11) and Baihuì (GV 20), from the Du Mai conduit, as well as on Huiyin (CV 1), Qìhai (CV 6), Zhongwan (CV 12) and Dànzhong (CV 17), from Ren Mai. These observations are in accordance with TCM theory and may contribute to the explanation of the vegetative physiological changes that are associated with ‘qi flow’ in TCM.     

How can the pressure in anti-embolism stockings be maintained during use? Laboratory evaluation of simulated ‘wear’ and different reconditioning protocols

BackgroundDeep vein thrombosis is a major global health issue, responsible for thousands of deaths each year. While thrombi can form under a variety of circumstances, lack of mobility significantly increases risk and therefore non-ambulant patients are frequently fitted with anti-embolism stockings on admission to hospital, to aid blood flow, prevent pooling and thus clotting. Anti-embolism stockings are the most widely used non-invasive medical device on the market and are believed to reduce the risk of deep vein thrombosis by 40%. Despite their widespread use in hospitals world-wide, there is remarkably little research addressing their use or reconditioning and a wide variety of different reconditioning protocols are used in hospitals.ObjectiveThe objective of this study was to establish the impact of different wear and reconditioning protocols on the pressure delivering ability of anti-embolism stockings.Design/methodsA laboratory investigation was undertaken to evaluate the pressure delivering ability of 2 major global brands of anti-embolism stockings over 5–8 days of simulated wear (extension on static cylinders) and 4 different reconditioning protocols. 1 set of samples was continuously ‘worn’ for 8 days without reconditioning, 1 set of samples was ‘worn’ for 5 days with a day of relaxation between each day of ‘wear’, 1 set was ‘hand washed’ and 1 set was machine washed and then allowed to relax between each day of ‘wear’. The pressure was measured at the beginning and end of each period of ‘wear’.SettingThis study was undertaken in a conditioned textile testing laboratory that complies with BS EN ISO 139:2005+A1:2011.ResultsThe pressure exerted by anti-embolism stockings reduced by between 15 and 24% after 24 h of wear, it reduced by between 21 and 32% when worn continuously for 8 days. Allowing stockings to rest for a day between days of wear allowed them to recover slightly but this recovery was only temporary. Washing stockings regenerated their pressure delivering potential significantly and machine washing allowed some to recover to exert more pressure than they had when new.ConclusionsDifferent brands of anti-embolism stockings exert different pressures on the same size of leg, when correctly fitted. The pressure exerted by anti-embolism stockings decreases with use but the correct pressure gradient is maintained if correctly fitted. Washing stockings after 24 h of wear is effective in restoring their pressure delivering abilities and in some cases can surpass their ‘as new’ pressure delivering ability.     

‘Violence is Not Part of Our Job’: A Thematic Analysis of Psychiatric Mental Health Nurses’ Experiences of Patient Assaults from a New Zealand Perspective

This paper describes psychiatric mental health nurses’ (PMHN) experiences of patient assaults within mental healthcare settings using a thematic analytical approach. The aim of the study was to explore and describe psychiatric mental health nurses’ experiences of patient assaults. The major findings of the study related to the nature and impact of assaults and supportive strategies associated with violence perpetrated by patients against psychiatric mental health nurses. Perpetrator risk factors for patients include mental health disorders, alcohol and drug use and the inability to deal with situational crises. The injuries sustained by nurses in the context of the study include lacerations, head injuries, dislocations and bruises. Psychological harm has also occurred, including quite severe mental health problems, such as post-traumatic stress disorder. Protective strategies for combating negative consequences of workplace violence include practice of self-defence, social support and a supportive and consultative workplace culture with access to counselling services and assistance in all aspects, including finances. The paper concludes that while healthcare employers need to provide better support services to the healthcare professionals who are assaulted, the legal system also needs to acknowledge that assaults against nurses are a violation of human rights and violence should not to be tolerated as part of working in mental healthcare settings.     

Caregivers’ information needs and their ‘experiences of care’ during treatment are associated with elevated anxiety and depression: a cross-sectional study of the caregivers of renal cancer survivors

Purpose

This study aims to examine the unmet needs and psychological distress (anxiety and depression) in family caregivers of renal cell carcinoma survivors.

Methods

A cross-sectional study design was used. Unmet needs were assessed with the Supportive Care Needs Survey-Partners and Caregivers (SCNS-P&C) questionnaire, and psychological distress was measured with the Hospital Anxiety and Depression Scale (HADS) in a telephone survey of 196 caregivers of renal cell carcinoma (RCC) survivors. Chi-square tests examined bivariate relationships, and multivariate logistic regression examined the associations between anxiety and depression and of unmet needs with caregivers’ experience of patients’ care, time spent caregiving, caregivers’ demographic characteristics and patients’ disease stage.

Results

Sixty-four percent of caregivers had at least one low, moderate or high unmet need, with 53 % reporting at least three needs and 29 % reporting 10 or more unmet needs (median 2, range 0–38). Elevated anxiety (HADS-A?>?8) and depression (HADS-D?>?8) were found in 29 and 11 % of the sample, respectively. Psychological and emotional needs were associated with advanced cancer stage (stages 3 and 4) (OR 3.07, 95 % CI 1.35–6.76) and with experience of care during surgery (OR 0.87, 95 % CI 0.78–0.99). Healthcare service needs were associated with time spent caregiving, with caregivers spending >1 h/day in the past week having three times higher odds (OR 3.44, 95 % CI 1.52–7.72) than those not spending any time. Odds of experiencing information needs were lower in caregivers who were in a relationship (OR 0.20, 95 % CI 0.04–0.83). Elevated anxiety (OR 1.59, 95 % CI 1.09–2.33) and depression (OR 2.02, 95 % CI 1.08–3.79) were associated with unmet information needs. Depression was also associated with experiences of care during treatment (OR 0.69, 95 % CI 0.49–0.96).

Conclusion

RCC caregivers’ unmet information needs are associated with elevated anxiety and depression. Improved experiences of cancer care are associated with lower odds of unmet needs and elevated depression in RCC caregivers.

     

‘Juggling amidst complexity’ – Hospice staff's experience of providing palliative care for infants referred from a neonatal unit

Hospice has been pivotal to children's palliative care provision in the United Kingdom (UK) for more than 3 decades. Some hospices have recently expanded to include care of infants transferred from neonatal units as well as antenatal referrals. Despite developments evidence suggests hospice care is often not offered to parents in neonatal units (NNU). This study examines perspectives of 17 staff from 3 children's hospices regarding the challenges and opportunities caring for infants in hospice. Data was collected from 3 focus groups and analysed using a thematic approach. Findings suggest that hospice staff juggle many complex issues when caring for infants at the end-of-life. Such issues centre round the referral process from hospital services borne from an apparent reluctance of hospital staff to let go, through involving hospice. Education, partnership working, planning for all possible outcomes seems crucial in further developing quality palliative care for infants and their families.     

Impact of aerobic exercise training during chemotherapy on cancer related cognitive impairments in patients suffering from acute myeloid leukemia or myelodysplastic syndrome — Study protocol of a randomized placebo-controlled trial

Cancer related cognitive impairments (CRCI) are frequently reported by patients prior to, during and after medical treatment. Although this cognitive decline severely affects patients' quality of life, little is known about effective treatments. Exercise programs represent a promising supportive strategy in this field. However, evidence is sparse and existing studies display methodological limitations.In the planned study, 83 men and women newly diagnosed with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) will be randomized into one of three treatment groups. During 4 weeks of induction chemotherapy with Anthracycline and Cytarabin patients allocated to exercise group will cycle 3 ×/week for 30 min at moderate to vigorous intensity on an ergometer. Patients allocated to placebo group will receive a supervised myofascial release training (3 ×/week, approx. 30 min) and patients at control group will get usual care. As primary endpoints a cognitive test battery will be conducted measuring performances depending on verbal/spatial memory and executive functioning. Secondary endpoints will be self-perceived cognitive functioning, as well as neurotrophic and inflammatory serum markers. All assessments will be conducted immediately after hospitalization and before chemotherapy is commenced, immediately before discharge of hospital after 4–5 weeks as well as before continuing medical treatment 3–4 weeks after discharge.This will be the first study investigating the impact of an aerobic exercise training on CRCI in AML/MDS patients. We hope that the study design and the state-of-the-art assessments will help to increase knowledge about CRCI in general and exercise as potential treatment option in this under investigated population.     

The anomalous origin of the left coronary artery from the right aortic sinus: is the coronary angiography still a ‘gold standard’?

Coronary artery anomalies remain a poorly understood topic in modern cardiology. The most important issue is the origin of the left coronary artery or the left anterior descending artery from the opposite aortic sinus, frequently associated with sudden cardiac death. We report our experience concerning the evaluation of these anomalies. From 15 April 1997 to 1 December 2004, we performed 13.407 coronary angiographies and found eight patients with these anomalies. In seven patients the coronary angiography was sufficient for the ultimate decision. However, in one case was the angiographic signs contradictory and the optimal imaging of the coronary tree was received by the multi-slice spiral computer tomography. We consider the coronary angiography a sufficient method of evaluation in most of the patients with the coronary artery anomalies, but the ‘gold standard’ is 3-dimensional examination by the multi-slice computer tomography or the magnetic resonance. The computer tomography is the method of the choice to distinguish interarterial, intraseptal and prepulmonary course of the left coronary artery originating from the right aortic sinus.     

What is the best support surface in prevention and treatment,as of 2012, for a patient at risk and/or suffering from pressure ulcer sore? Developing French guidelines for clinical practice

IntroductionThe use of support surfaces in the prevention and treatment of pressure ulcers prevention is an important part of care for a patient at risk and/or suffering from sore(s).ObjectivesDefine which support surfaces to use in prevention and treatment of at-risk and/or pressure sore patients.MethodologyA systematic review of the literature querying the several Pascal Biomed, PubMed and Cochrane Library databases from 2000 through 2010.Results (Grade A)In prevention, a structured foam mattress is more efficient than a standard hospital mattress. An alternating pressure mattress is more effective than a visco-elastic mattress limiting the occurrence heel pressure ulcers, but those that do occur are more serious. A low-air-loss bed is more efficient than a mixed pulsating air mattress in prevention of heel pressure ulcers. Some types of sheepskin can reduce sacral pressure ulcer incidence in orthopedic patients. Use of an overlay on an operating table limits the occurrence of peroperative and postoperative pressure ulcers. An air-fluidized bed improves pressure ulcer healing.DiscussionThe data in the literature are not always relevant and do not suffice to dictate a clinician's choices. We are compelled to recognize the methodological limitations of many studies, the lack of corporate interest in conducting such studies and the relatively small number of available trials. However, the effectiveness of some support surfaces reaches a sufficient level of evidence, especially when they are associated with postural, hydration and nutritional measures.ConclusionSupport surfaces are recommended in prevention and treatment of patients at risk and/or already suffering from pressure ulcer, and their use should constitute part of an overall preventive or curative strategy.     

Claims of a ‘new’ stuttering treatment using time-out from speaking are exaggerated: A brief review of the literature and commentary on Hewat et al. (2006)

In a recent article, Hewat et al. claimed to have developed novel procedures for treating stuttering. The present article reviews relevant literature, and shows that the Hewat et al. claims of originality are exaggerated. It is concluded that the Hewat et al. study includes conceptual and methodological weaknesses that render their findings predominantly uninterpretable.