'We're just sick people, nothing else': ... factors contributing to elderly stroke patients' satisfaction with rehabilitation

Objective: To identify factors contributing to elderly stroke patients' satisfaction with rehabilitation following stroke.Design: Qualitative study using semi-structured interviews.Setting: Interviews conducted in two phases, once in a stroke rehabilitation unit and once after hospital discharge.Subjects: Twelve elderly stroke patients (seven women and five men, aged 60-87 years).Results: One main category: 'To be treated with respect and dignity' was identified as a core factor contributing to patients' satisfaction with the rehabilitation services. This main factor was divided into five subcategories: (1) Being treated with humanity, (2) Being acknowledged as individuals, (3) Having their autonomy respected, (4) Having confidence and trust in professionals, (5) Dialogue and exchange of information. The statements covered a continuum from satisfaction via indifference to dissatisfaction. Expressions of satisfaction emerged mainly as general statements while expressions of dissatisfaction described situations in greater detail. Satisfaction was merely connected to daily care experiences and fulfilment of basic needs. Trust in providers and being dignified seemed more closely associated with satisfaction than being involved in treatment decisions. The findings demonstrate how the quality of patient-professional interaction influences patients' satisfaction with stroke rehabilitation.Conclusion: To be treated with respect and dignity seems to be a core element influencing vulnerable elderly stroke patients' satisfaction with rehabilitation. A merely functional definition of the success of rehabilitation should be expanded into an approach encompassing patients' perceptions and personal preferences. The meaning of dignity for elderly stroke patients in the rehabilitation setting should be further clarified and given practical substance.     

A screening and intervention program aimed to reduce mortality and serious morbidity associated with severe neonatal alloimmune thrombocytopenia

The study's objective was to identify HPA 1a-negative women and to offer them an intervention program aimed to reduce morbidity and mortality of neonatal alloimmune thrombocytopenia (NAIT). HPA 1 typing was performed in 100 448 pregnant women. The HPA 1a-negative women were screened for anti-HPA 1a. In immunized women, delivery was performed by Cesarean section 2 to 4 weeks prior to term, with platelets from HPA 1a-negative donors reserved for immediate transfusion if petechiae were present and/or if platelet count was less than 35 x 10(9)/L. Of the women screened, 2.1% were HPA 1a negative, and anti-HPA 1a was detected in 10.6% of these. One hundred seventy pregnancies were managed according to the intervention program, resulting in 161 HPA 1a-positive children. Of these, 55 had severe thrombocytopenia (< 50 x 10(9)/L), including 2 with intracranial hemorrhage (ICH). One woman with a twin pregnancy missed the follow-up and had one stillborn and one severely thrombocytopenic live child. In 15 previous prospective studies (136 814 women) there were 51 cases of severe NAIT (3 intrauterine deaths and 7 with ICH). Acknowledging the limitation of comparing with historic controls, implementation of our screening and intervention program seemed to reduce the number of cases of severe NAIT-related complications from 10 of 51 to 3 of 57.     

The time dimension in stress responses: relevance for survival and health

Within the Cognitive Activation Theory of Stress (CATS), the stress response occurs whenever there is a discrepancy between what the organism is expecting, and what really exists. It affects the biochemistry of the brain, mobilizes resources, affects performance, and endocrine, vegetative, and immune systems. Initial positive feedback and feed-forward mechanisms are gradually changed by homeostatic mechanisms. Slower reactive hormones such as cortisol seem to dampen the initial response. The time course may depend on psychological mechanisms. Subjects with efficient coping show the fast- and short-lasting catecholamine response, while subjects with high defense mechanisms (related to stimulus expectancies) may show more signs of prolonged activation. Non-coping individuals show a sustained general activation which may develop into somatic disease or illness.     

The cognitive activation theory of stress

This paper presents a cognitive activation theory of stress (CATS), with a formal system of systematic definitions. The term "stress" is used for four aspects of "stress", stress stimuli, stress experience, the non-specific, general stress response, and experience of the stress response. These four meanings may be measured separately. The stress response is a general alarm in a homeostatic system, producing general and unspecific neurophysiological activation from one level of arousal to more arousal. The stress response occurs whenever there is something missing, for instance a homeostatic imbalance, or a threat to homeostasis and life of the organism. Formally, the alarm occurs when there is a discrepancy between what should be and what is-between the value a variable should have (set value (SV)), and the real value (actual value (AV)) of the same variable. The stress response, therefore, is an essential and necessary physiological response. The unpleasantness of the alarm is no health threat. However, if sustained, the response may lead to illness and disease through established pathophysiological processes ("allostatic load"). The alarm elicits specific behaviors to cope with the situation. The level of alarm depends on expectancy of the outcome of stimuli and the specific responses available for coping. Psychological defense is defined as a distortion of stimulus expectancies. Response outcome expectancies are defined as positive, negative, or none, to the available responses. This offers formal definitions of coping, hopelessness, and helplessness that are easy to operationalize in man and in animals. It is an essential element of CATS that only when coping is defined as positive outcome expectancy does the concept predict relations to health and disease.     

Effects of zimeldine, a selective 5-HT reuptake inhibitor, combined with ritanserin, a selective 5-HT2 antagonist, on waking and sleep stages in rats

Sleep and waking in rats were studied 8 h following administration of a selective 5-hydroxytryptamine (5-HT) reuptake inhibitor (zimeldine), a selective 5-HT₂ antagonist (ritanserin) and a combination of ritanserin and zimeldine. Consistent with earlier findings, zimeldine gave a biphasic effect on sleep and waking. Waking was increased the first 3 h, followed by an increase in deep slow wave sleep (SWS-2), maximal in hours 4 and 5. Ritanserin gave an increase in SWS-2 that was spread out over the recording period. Ritanserin + zimeldine also gave a biphasic effect as zimeldine did, and the initial increase in waking and the following increase in SWS-2 tended to be stronger. Thus, ritanserin did not block the initial waking effect seen after zimeldine administration, indicating that this waking effect was not due to 5-HT₂ stimulation. The increase in SWS-2 seemed to reflect an addition of the increases following the zimeldine and ritanserin alone conditions. This suggests that the increase in SWS-2 seen after 5-HT reuptake inhibition and 5-HT₂ blockade are independent phenomena. Zimeldine alone, ritanserin alone and the combination all gave a clear reduction of rapid eye movement sleep.     

Being an intensive care nurse related to questions of withholding or withdrawing curative treatment

Aims and objectives. The aim of the study was to acquire a deeper understanding of what it is to be an intensive care nurse in situations related to questions of withholding or withdrawing curative treatment. Background. Nurses in intensive care units regularly face critically ill patients. Some patients do not benefit from the treatment and die after days or months of apparent pain and suffering. A general trend is that withdrawal of treatment in intensive care units is increasing. Physicians are responsible for decisions concerning medical treatment, but as nurses must carry out physicians’ decisions, they are involved in the consequences. Design and methods. The research design was qualitative, based on interpretative phenomenology. The study was carried out at an adult intensive care unit in Norway. Data were collected by group interviews inspired by focus group methodology. Fourteen female intensive care nurses participated, divided into two groups. Colaizzi's model was used in the process of analysis. Results. The analysis revealed four main themes which captured the nurses’ experiences: loneliness in responsibility, alternation between optimism and pessimism, uncertainty – a constant shadow and professional pride despite little formal influence. The essence of being an intensive care nurse in the care of patients when questions were raised concerning curative treatment or not, was understood as ‘being a critical interpreter and a dedicated helper.’ Conclusions. The findings underpin the important role of intensive care nurses in providing care and treatment to patients related to questions of withholding or withdrawing curative treatment. Relevance to clinical practice. The findings also show the need for physicians, managers and intensive care nurses themselves to recognize the burdens intensive care nurses carry and to appreciate their knowledge as an important contribution in decision making.     

Traceability and distribution of <Emphasis Type="Italic">Neisseria meningitidis</Emphasis> DNA in archived post mortem tissue samples from patients with systemic meningococcal disease

Background

The pathophysiology and outcome of meningococcal septic shock is closely associated with the plasma level of N. meningitidis lipopolysaccharides (LPS, endotoxin) and the circulating level of meningococcal DNA. The aim of the present study was to quantify the number of N. meningitidis in different formalin-fixed, paraffin-embedded (FFPE) tissue samples and fresh frozen (FF) tissue samples from patients with systemic meningococcal disease (SMD), to explore the distribution of N. meningitidis in the body.

Methods

DNA in FFPE and FF tissue samples from heart, lungs, liver, kidneys, spleen and brain from patients with meningococcal shock and controls (lethal pneumococcal infection) stored at variable times, were isolated. The bacterial load of N. meningitidis DNA was analyzed using quantitative real-time PCR (qPCR) and primers for the capsule transport A (ctrA) gene (1 copy per N. meningitidis DNA). The human beta-hemoglobin (HBB) gene was quantified to evaluate effect of the storage times (2-28 years) and storage method in archived tissue.

Results

N. meningitidis DNA was detected in FFPE and FF tissue samples from heart, lung, liver, kidney, and spleen in all patients with severe shock. In FFPE brain, N. meningitidis DNA was only detected in the patient with the highest concentration of LPS in the blood at admission to hospital. The highest levels of N. meningitidis DNA were found in heart tissue (median value 3.6 × 10⁷ copies N. meningitidis DNA/μg human DNA) and lung tissue (median value 3.1 × 10⁷ copies N. meningitidis DNA/μg human DNA) in all five patients. N. meningitidis DNA was not detectable in any of the tissue samples from two patients with clinical meningitis and the controls (pneumococcal infection). The quantity of HBB declined over time in FFPE tissue stored at room temperature, suggesting degradation of DNA.

Conclusions

High levels of N. meningitidis DNA were detected in the different tissue samples from meningococcal shock patients, particularly in the heart and lungs suggesting seeding and major proliferation of meningococci in these organs during the development of shock, probably contributing to the multiple organ failure. The age of archived tissue samples appear to have an impact on the amount of quantifiable N. meningitidis DNA.

     

Angiopoietin-2 and angiopoietin-like 4 protein provide prognostic information in patients with suspected acute coronary syndrome

Background

Plasma levels of angiopoietin-2 (ANGPT2) and angiopoietin-like 4 protein (ANGPTL4) reflect different pathophysiological aspects of cardiovascular disease. We evaluated their association with outcome in a hospitalized Norwegian patient cohort (n = 871) with suspected acute coronary syndrome (ACS) and validated our results in a similar Argentinean cohort (n = 982).

Methods

A cox regression model, adjusting for traditional cardiovascular risk factors, was fitted for ANGPT2 and ANGPTL4, respectively, with all-cause mortality and cardiac death within 24 months and all-cause mortality within 60 months as the dependent variables.

Results

At 24 months follow-up, 138 (15.8%) of the Norwegian and 119 (12.1%) of the Argentinian cohort had died, of which 86 and 66 deaths, respectively, were classified as cardiac. At 60 months, a total of 259 (29.7%) and 173 (17.6%) patients, respectively, had died. ANGPT2 was independently associated with all-cause mortality in both cohorts at 24 months [hazard ratio (HR) 1.27 (95% confidence interval (CI), 1.08–1.50) for Norway, and HR 1.57 (95% CI, 1.27–1.95) for Argentina], with similar results at 60 months [HR 1.19 (95% CI, 1.05–1.35) (Norway), and HR 1.56 (95% CI, 1.30–1.88) (Argentina)], and was also significantly associated with cardiac death [HR 1.51 (95% CI, 1.14–2.00)], in the Argentinean population. ANGPTL4 was significantly associated with all-cause mortality in the Argentinean cohort at 24 months [HR 1.39 (95% CI, 1.15–1.68)] and at 60 months [HR 1.43 (95% CI, 1.23–1.67)], enforcing trends in the Norwegian population.

Conclusions

ANGPT2 and ANGPTL4 were significantly associated with outcome in similar ACS patient cohorts recruited on two continents.

Clinical Trial Registration

ClinicalTrials.gov Identifier: NCT00521976. ClinicalTrials.gov Identifier: NCT01377402.

     

A Framework for Hospice Nursing

The paper presents a conceptual framework for hospice nursing. Nursing is viewed as assistance to the person whose self-care activities are insufficient to meet self-care needs. A literature review on needs of the hospice client is included toward developing a hospice nursing philosophy. The paper shows how guidelines for nursing practice in hospice can be structured around the client’s self-care needs. Such guidelines include common nursing diagnoses, standards, policies and procedures. A suggested nursing documentation system is built upon the nursing process and structured around the patient’s self-care needs.