Cultural Meanings of Childbirth

In no known culture in the world is childbearing treated with indifference. Cultural beliefs about and values associated with childbearing touch all aspects of social life in any given culture. Such beliefs and values lend perspective to the meaning of childbirth to the childbearing woman. Having the opportunity to share the woman's perceptions of the meaning of childbearing may foster the self-actualization, promote maternal role attainment, and improve her relationship with her significant other and enrich the family perspective. Nursing interventions across the childbearing year should be culturally sensitive to promote positive outcomes for the woman and her family.     

Predicting life span for applicants to inpatient hospice

The advent of hospice programs and their funding under Medicare has recently made eligibility for substantial insured services turn on whether a patient has less than three or six months to live. The implicit assumption is that physicians can provide this prediction accurately. To test this assumption and to improve predictions, the life spans of 108 consecutive applications for inpatient hospice care were estimated independently by two oncologists, an internist, an oncology nurse, and a hospice social worker, based on data in a ten-page multidisciplinary application packet. The applicants were followed up until death. Actual life span was correlated with predictions. The median (+/- SD) life span was 3.5 +/- 12.4 weeks. The predictions as a group were overly optimistic about survival by an average of 3.4 weeks. The best prognosticator's prediction was only moderately correlated with actual life span, and no two prognosticator's predictions correlated closely with one another. Predicting actual interval until death was more accurate than predicting a 90% confidence interval around the time of death, though the latter procedure was better at avoiding the error of unpredicted long-term survivors. This imprecision in "expert" estimation of life span poses substantial problems for hospice programs and policymakers.     

Using simulation to instruct emergency medicine residents in cognitive forcing strategies.

PURPOSE: Recent literature defines certain cognitive errors that emergency physicians will likely encounter. The authors have utilized simulation and debriefing to teach the concepts of metacognition and error avoidance. METHOD: The authors conducted a qualitative study of an educational intervention at Lehigh Valley Hospital during academic year 2002-03. Fifteen emergency medicine residents--eight from postgraduate year three (PGY3) and seven from postgraduate year two (PGY2)--experienced a difficult simulator lab scenario designed to lead them into a cognitive error trap. The debriefing was a PowerPoint with audio format CD-ROM with a didactic on succinylcholine (15 minutes) and cognitive forcing strategies (30 minutes). After debriefing, residents were interviewed by an ethnographer with an 11-question (15-minute) interview and completed an eight-question written survey. RESULTS: The residents ranked this experience second only to direct patient care for educational effectiveness. Survey results (Likert scale, 1 = disagree completely to 5 = agree completely) included "Improved my ability to use succinylcholine" (mean = 4.73), "Improved my ability to diagnose and treat hyperkalemia" (mean = 4.6), and "Cognitive forcing strategies is a useful educational effort" (mean = 4.33). The major interview themes that evolved were that the simulation lab was a positive experience; succinylcholine knowledge was gained; mistakes caused reflection/motivation; the lab was stressful; attending feedback was desired; the lab was realistic; and cognitive forcing strategies were discussed. When asked what they learned, more of the PGY3s commented on cognitive strategies or heuristic techniques (six out of eight), whereas the PGY2s commented on knowledge gained about succinylcholine (five out of seven) and only one PGY2 mentioned cognitive strategies. CONCLUSION: Pilot data suggest that metacognitive strategies can be taught to residents, though they may be better understood by upper-level residents.     

Assessment of the COBAS Amplicor HBV Monitor Test for quantitation of serum hepatitis B virus DNA levels

Treatment of patients with chronic hepatitis B virus (HBV) infections with potent antiviral therapy often results in dramatic reductions in the levels of viremia to very low levels. Monitoring of serum HBV DNA levels is a consistent method for the assessment of antiviral potency; however, widely used hybridization assays for the monitoring of HBV DNA levels have limited sensitivities and are not effective for the monitoring of patients whose serum HBV DNA levels have decreased to below approximately 700,000 HBV genomes/ml. The objective of the present study was to assess a PCR-based assay (the COBAS-AM assay) for quantitation of serum HBV DNA levels and to compare the results of the COBAS-AM assay with those of a solution hybridization assay with a radiolabeled probe. The precision and accuracy of the assay were determined with low-positive and high-positive controls consisting of a plasmid DNA molecule containing HBV-specific primer binding regions, and the sensitivity of the assay was determined by using serial dilutions of sera from subjects with chronic HBV infection. HBV DNA levels were quantitated in 1,695 serum samples from subjects with chronic HBV infection who were enrolled in clinical trials of lamivudine in North America or Asia. The COBAS-AM assay demonstrated high levels of inter- and intra-assay precision and accuracy, and the linear range of the COBAS-AM assay was greater than that of the solution hybridization assay. The assay is linear over a 3-log(10) range and is able to quantitate serum HBV DNA at levels 3 log(10) lower than those that can be detected by the solution hybridization assay. We found that the COBAS-AM assay is an accurate PCR-based assay for quantitation of serum HBV DNA levels in subjects with chronic HBV infection.     

The importance of chronicity and controllability of stress in the context of stress-illness relationships

The primary purpose of the present study was to increase our understanding of the roles of chronicity and controllability in the measurement of stress within the context of stress-illness relationships. Controllability and chronicity were assessed directly using a modified version of the Everyday Problems Scale. In addition to this scale, measures of depression, psychosomatic symptoms, and social support were administered to 128 women and 100 men. The results indicated that, for both men and women, the number of stressors was the best single predictor of symptoms. However, for women, chronicity and controllability of the stressors accounted for a significant amount of the variance in health outcomes over and above that accounted for by the number of stressors endorsed; for men, the addition of neither chronicity nor controllability consistently increased the strength of the association. While available social support was not found to influence the stress-illness relationships, greater willingness to utilize social support was associated with lower levels of depression.     

Human immunodeficiency virus (HIV-1) cytotoxicity: perturbation of the cell membrane and depression of phospholipid synthesis

The molecular mechanism(s) by which human immunodeficiency virus (HIV-1) injures a T-cell line was studied. A pathological role for viral env proteins, which are inserted into the plasma membrane, has been previously demonstrated for HIV as well as other retroviruses which are cytopathic. We therefore initiated studies examining whether perturbations of the cell membrane or membrane-associated biochemical events may be occurring in cells acutely infected with HIV and whether such perturbations, if present, may be responsible for cytopathology. A human T-cell line (ERIC), which is sensitive to the cytopathic effects of HIVs, was infected with HTLV-IIIB and its membrane permeability to cations and its lipid metabolism were studied coincident with the peak expression of viral p24 and with the first sign of cytopathology (slowing of cell division) 72 to 96 hr after infection. It was found that the rate of influx of Ca2+ into the cell increased over that of uninfected cells and that phospholipid synthesis, primarily phosphatidylcholine, became depressed. Diacylglycerol, which serves both as an intermediate for synthesis of phospholipids and as a second-messenger for lymphocyte activation, was also greatly reduced. However, triglyceride synthesis was enhanced, indicating that not all lipid metabolic pathways were being shut down. This decreased membrane-synthetic ability and reduced second-messenger for cell division are likely to be important causes of HIV-1 cytopathology in ERIC cells. This hypothesis was supported by our finding that HIV cytopathology of ERIC cells could be partially prevented by treatment with compounds (diacylglyceride or PMA and transiently by oleic acid) which either replenish diacylglycerol in the infected cell and/or activate protein kinase C or phosphocholine cytidyltransferase, the latter being the rate-limiting step in synthesis of the major structural phospholipid in most cells.     

Utilization of the 2017 diagnostic criteria for hEDS by the Toronto GoodHope Ehlers–Danlos syndrome clinic: A retrospective review

The new 2017 diagnostic criteria for hypermobile Ehlers–Danlos Syndrome (hEDS) provide a framework for diagnosing hEDS but are more stringent than the previous Villefranche criteria. Our clinical experience at the GoodHope EDS clinic was that the 2017 criteria left many highly symptomatic patients without a diagnosis of hEDS. We conducted a retrospective cohort study to confirm our clinic experience and assess the accuracy of the 2017 diagnostic criteria for hEDS in patients who had a previous hEDS diagnosis based on the Villefranche criteria. Our study found that 15% (n = 20 of 131) of patients with a prior diagnosis of hEDS met the 2017 diagnostic criteria, and many of the traits used to distinguish hEDS were not significantly more frequent in patients who met 2017 criteria versus those who did not. In both groups objective systemic manifestations were found less frequently than subjective systemic manifestations. Beighton score (BS) as assessed by primary care practitioner was found to be higher than assessment by EDS practitioner in 81% (n = 74 of 91) of cases. Generalized joint hypermobility was confirmed in only 46% (n = 51 of 111) of patients who had a previous diagnosis of hEDS. Higher BS did not correlate with increased number of systemic manifestations in our cohort. Common comorbidities of hEDS were found with similar frequency in those who met 2017 criteria and those who did not. Based on our cohort, the 2017 hEDS diagnostic criteria require refinement to improve its diagnostic accuracy.