Transformative change of self: The unique focus of (adolescent) mental health nursing?

In mental health nursing, inadequate nursing practice research has resulted in a deficit of knowledge concerning the nurse–client relationship; an area seen as the heart of practice. In turn, the specialty has experienced difficulty in identifying its unique domain of practice. Findings from a hermeneutic study into adolescent mental health nursing explicated its practice knowledge. These findings include (i) 'engaging in therapeutic relationships'; (ii) 'guiding the potential for change'; and (iii) 'facilitating positive outcomes'. A higher order finding was named 'fostering a functional self'. These findings are discussed. Findings point to the nature, purpose and processes of the nurse–client relationship, and to outcomes from that relationship. It is suggested they also represent a beginning understanding of the specialty's unique contribution to nursing; that mental health nursing fosters transformative change of self .     

The role of acyl‐CoA:diacylglycerol acyltransferase (DGAT) in energy metabolism

Acyl‐CoA:diacylglycerol acyltransferase (DGAT, EC2.3.1.20), a key enzyme in triglyceride (TG) biosynthesis, not only participates in lipid metabolism but also influences metabolic pathways of other fuel molecules. Changes in the expression and/or activity levels of DGAT may lead to changes in systemic insulin sensitivity and energy homeostasis. The synthetic role of DGAT in adipose tissue, the liver, and the intestine, sites where endogenous levels of DGAT activity and TG synthesis are high, is relatively clear. Less clear is whether DGAT plays a mediating or preventive role in the development of ectopic lipotoxicity in tissues such as muscle and the pancreas, when their supply of free fatty acids (FFAs) exceeds their needs. Future studies with tissue‐specific overexpression and/or knockout in these animal models would be expected to shed additional light on these issues.     

The Changing Incidence of Ventricular Fibrillation in Milwaukee,Wisconsin (1992–2002)

Objectives. To investigate the changes in annual incidence andsurvival of out-of-hospital cardiac-etiology arrests of different initial rhythms, particularly ventricular fibrillation (VF) andventricular tachycardia (VT), among adults (> 21 years old) in Milwaukee County between 1992 and2002 andestablish correlations with patient andemergency medical services (EMS) system-dependent factors. Methods. The study was a retrospective, observational study of all adult (> 21-year-old) patients with out-of-hospital cardiac-etiology arrests with identifiable rhythm andresuscitation attempted by the Milwaukee County EMS system from 1992 to 2002. Nine thousand one hundred seventy cases were enrolled. Primary outcome measures were changes in annual incidence of initial cardiac arrest rhythm, with a focus on VF/VT. Secondary outcome measures were changes in survival to hospital admission andhospital discharge for VF andVT. Patient andEMS system factors potentially affecting the outcome measures were identified andmodeled using multivariate logistic regression. Results. The incidence of out-of-hospital VF/VT arrests decreased steadily from 37.1 per 100,000 in 1992 to 19.4 per 100,000 in 2002. While the incidences of pulseless electrical activity andoverall cardiac arrest remained unchanged, the incidence of asystole during the study period increased from 27.3/100,000 to 44.9/100,000. Multivariate regression analyses revealed that age < 80 years, male gender, white race, previous cardiac surgery, andcardiac history were patient-dependent factors predictive of VF/VT. Witnessed arrest, public location, andshorter response time were EMS system-dependent factors predictive of VF/VT. Based on observed trends, none of these correlated factors could explain the decrease in the incidence of VF/VT arrests. Rates of patient survival to hospital admission anddischarge were not significantly changed over time. EMS system factors predictive of survival to admission anddischarge were witnessed arrest, public location, anddecreased number of defibrillations. Prior cardiac surgery andabsence of chronic problems were the only patient factors predictive of survival to hospital admission but were not significantly related to survival to hospital discharge. Conclusions. The incidence of out-of-hospital cardiac arrests in adult patients with presenting rhythm of VF/VT declined, while an increase in asystole occurred. This was not explained by any patient or EMS system-dependent factor. Rate of survival for VF/VT arrest did not significantly change over time. Survival was primarily influenced by EMS system factors andunrelated to patient-dependent factors.     

The anticoagulant effect of therapeutic levels of dabigatran in atrial fibrillation evaluated by thrombelastography (TEG®), Hemoclot Thrombin Inhibitor (HTI) assay and Ecarin Clotting Time (ECT)

Monitoring the effect of dabigatran (Pradaxa^®) is challenging. The aim of this study was to evaluate if thrombelastography reaction time (TEG^® R) could detect the anticoagulant effect of dabigatran showing a correlation between TEG^® R, Hemoclot Thrombin Inhibitor (HTI) assay and Ecarin Clotting Time (ECT) in patients with non-valvular atrial fibrillation (NVAF). Blood samples from 35?AF patients receiving either 110?mg (n 19) or 150?mg (n 16) dabigatran twice daily were analyzed with TEG^®, HTI and ECT 2–3?h after dabigatran intake. All patients had prolonged TEG^® R. The patients receiving dabigatran 110?mg ×2 had a TEG^® R mean 14.2?min (range 9.1–25), a mean dabigatran concentration measured by HTI of 268.5?ng/mL (range 54–837?ng/mL) and by ECT of 355.7?ng/mL (range 40–1020?ng/mL). The corresponding numbers for patients receiving dabigatran 150?mg ×2 were TEG^® R mean of 12.5?min (range 9.2–23.2?min), mean dabigatran concentration of 179.2?ng/mL by HTI (range 26–687?ng/mL) and by ECT 225.1?ng/mL (range 42–1020?ng/mL). The two dosage groups had comparable anticoagulation demonstrated by equally prolonged TEG^® R (p?=?.909), HTI (p?=?.707) and ECT (p?=?.567). No difference in creatinine levels in the two dosage groups was observed (p?=?.204) though patients with dabigatran concentration >400?ng/mL had significantly higher creatinine levels (p?=?.001). Large individual variation of the anticoagulant response was observed. Some patients had TEG^® R values up to three times upper normal limit with immediate risk of bleeding. Our data indicate that TEG^® R reflected dabigatran levels in NVAF patients and that TEG^® R correlated to HTI and ECT.     

γ-Hydroxybutyrate: experience of 9 years of γ-hydroxybutyrate (GHB)-related incidents during rave parties in The Netherlands

OBJECTIVE.?The objective of this study was to determine the health disturbances and to assess the severity of the incidents as reported during a 9-year experience of gamma-hydroxybutyrate (GHB)-related First Aid Attendees attending First Aid Stations at rave parties. DESIGN.?This study was a prospective observational study of self-referred patients from the year 2000 to 2008. During rave parties, First Aid Stations were staffed with specifically trained medical and paramedical personnel. Patients were diagnosed and treated, and data were recorded using standardized methods. RESULTS.?During a 9-year period with 202 rave parties, involving approximately three million visitors, 22 604 First Aid Attendees visited the First Aid Stations, of which 771 reported GHB-related health problems. The mean age of the GHB-using First Aid Attendees was 25.7 ± 6.1 years, most of them (66.4%) were male. Approximately one-third (32.7%) of them used one substance, while 48.1% combined GHB with ecstasy, alcohol, or cannabis. One of five (19.2%) combined GHB with other substances or more than one substance. One case was categorized as severe/life-threatening and 202 (26.2%) cases as moderate, requiring further medical care. In total, 43 (5.6%) First Aid Attendees needed hospital care. The most encountered health disturbance was altered consciousness. Combinations of altered consciousness, vomiting, and/or low body temperature were found in 186 cases (24.1%) and considered to be potentially dangerous. GHB-related First Aid Attendees required a longer stay at the First Aid Stations than the total group First Aid Attendees did (median 45 min vs 10 min). CONCLUSION.?We found very little, severe short-term GHB-related health disturbances during rave parties in The Netherlands. Hospital referrals were rare. The most found symptom was altered consciousness, sometimes accompanied by vomiting and low body temperature. At events where the visitors use GHB, a well-trained and qualified medical team, including nurses and physicians, is recommendable. They must be able to recognize GHB intake and prevent secondary problems such as aspiration and hypothermia.     

Lipoprotein apheresis in the management of severe hypercholesterolemia and hyperlipoproteinemia(a)—The Portuguese experience

Background

Low-density lipoprotein cholesterol (LDL-C) and lipoprotein(a) (Lp(a)) are established causal risk factors for cardiovascular disease (CVD). Lipoprotein apheresis is often required for treatment of patients with a high risk for CVD due to hypercholesterolemia and/or hyperlipoproteinemia(a).

The factor structure of the twelve item General Health Questionnaire (GHQ-12): the result of negative phrasing?

Background

The 12-item General Health Questionnaire (GHQ-12) is used routinely as a unidimensional measure of psychological morbidity. Many factor-analytic studies have reported that the GHQ-12 has two or three dimensions, threatening its validity. It is possible that these 'dimensions' are the result of the wording of the GHQ-12, namely its division into positively phrased (PP) and negatively phrased (NP) statements about mood states. Such 'method effects' introduce response bias which should be taken into account when deriving and interpreting factors.

Methods

GHQ-12 data were obtained from the 2004 cohort of the Health Survey for England (N = 3705). Following exploratory factor analysis (EFA), the goodness of fit indices of one, two and three factor models were compared with those of a unidimensional model specifying response bias on the NP items, using structural equation modelling (SEM). The hypotheses were (1) the variance of the responses would be significantly higher for NP items than for PP items because of response bias, and (2) that the modelling of response bias would provide the best fit for the data.

Results

Consistent with previous reports, EFA suggested a two-factor solution dividing the items into NP and PP items. The variance of responses to the NP items was substantially and significantly higher than for the PP items. The model incorporating response bias was the best fit for the data on all indices (RMSEA = 0.068, 90%CL = 0.064, 0.073). Analysis of the frequency of responses suggests that the response bias derives from the ambiguity of the response options for the absence of negative mood states.

Conclusion

The data are consistent with the GHQ-12 being a unidimensional scale with a substantial degree of response bias for the negatively phrased items. Studies that report the GHQ-12 as multidimensional without taking this response bias into account risk interpreting the artefactual factor structure as denoting 'real' constructs, committing the methodological error of reification. Although the GHQ-12 seems unidimensional as intended, the presence of such a large response bias should be taken into account in the analysis of GHQ-12 data.

     

The normalization of deviance: do we (un)knowingly accept doing the wrong thing?

There are many elements that contribute to errors within an industry or profession. Several human factors associated with safety breakdowns are outlined in Table 2. Experience and root-cause analyses usually document that 2 or more of these factors coalesce to form a "perfect storm" leading to a mishap. For example, expecting a fatigued provider to care for an emergency patient with concurrent production pressure to maintain the elective schedule, while using new and unfamiliar equipment, is a potent mix of risk factors. As Gaba et al. pointed out, production pressure "is a reality for many anesthesiologists and is perceived in some cases to have resulted in unsafe actions." One solution is to integrate standard protocols and expectations for safe practice and expected behavior throughout the practice. Other potential solutions may involve the design of better and "smarter" monitors that will reduce the noise pollution and attendant distractions in the OR, and variable priority training that helps clinicians focus on "optimal distribution of attention when performing multiple tasks simultaneously with the goal of flexible allocation of attention." We have also observed the phenomenon of intersecting curves of knowledge versus experience. When we exit our organized training period, our knowledge base is strong. We have studied for specialty examinations, experienced the idealized purity of an academic environment, and have been taught the "right way" to practice by our mentors and role models. As the years pass, our minute, detailed knowledge may decrease, but our practical experience increases greatly, and patient care and safety are assured. However, as we are increasingly challenged to "do more with less," the temptation will arise to "cut a few comers" where we can to achieve productivity and efficiency benchmarks. To that end, we caution our colleagues to avoid the slippery slope of accepting a decrease in vigilance and safety while striving for "faster, better, cheaper." We encourage every individual to maintain vigilance, advocate for patient safety, aim for excellence and efficiency, and avoid the temptation of normalizing deviance from accepted safety standards.