Reflecting Before, During, and After the Heat of the Moment: A Review of Four Approaches for Supporting Health Staff to Manage Stressful Events.

Being a healthcare professional in both paediatric and adult hospitals will mean being exposed to human tragedies and stressful events involving conflict, misunderstanding, and moral distress. There are a number of different structured approaches to reflection and discussion designed to support healthcare professionals process and make sense of their feelings and experiences and to mitigate against direct and vicarious trauma. In this paper, we draw from our experience in a large children's hospital and more broadly from the literature to identify and analyse four established approaches to facilitated reflective discussions. Each of the four approaches seeks to acknowledge the stressful nature of health professional work and to support clinicians from all healthcare professions to develop sustainable skills so they continue to grow and thrive as health professionals. Each approach also has the potential to open up feelings of uncertainty, frustration, sorrow, anguish, and moral distress for participants. We argue, therefore, that in order to avoid unintentionally causing harm, a facilitator should have specific skills required to safely lead the discussion and be able to explain the nature, scope, safe application, and limits of each approach. With reference to a hypothetical but realistic clinical case scenario, we discuss the application and key features of each approach, including the goals, underpinning theory, and methods of facilitation.

"I was really sceptical...But it worked really well": a qualitative study of patient perceptions of telephone-delivered exercise therapy by physiotherapists for people with knee osteoarthritis.

OBJECTIVE: Physiotherapists typically prescribe exercise therapy for people with osteoarthritis (OA) via face-to-face consultations. This study aimed to explore peoples' perceptions of exercise therapy delivered by physiotherapists via telephone for their knee OA. DESIGN: A qualitative study (based on interpretivist methodology) embedded within a randomised controlled trial. Semi-structured individual interviews were conducted with 20 people with knee OA who had received exercise advice and support from one of eight physiotherapists via telephone over 6 months. Interviews were audio recorded, transcribed verbatim and thematically analysed. RESULTS: Although people with OA were initially sceptical about receiving exercise therapy via telephone, they described mostly positive experiences, valuing the convenience and accessibility. However, some desired visual contact with the physiotherapist and suggested including video-conferencing calls or an initial in-person clinic visit. Participants valued the sense of undivided focus and attention they received from the physiotherapist and believed that they were able to communicate effectively via telephone. Participants felt confident performing their exercise program without supervision and described benefits including increased muscular strength, improved pain, and ability to perform tasks that they had not been previously able to. CONCLUSIONS: People with knee OA held mostly positive perceptions about receiving exercise therapy from a physiotherapist via telephone, suggesting that such a service is broadly acceptable to consumers. Such services were generally not viewed as a substitute for face-to-face physiotherapy care, but rather as a new option that could increase accessibility of physiotherapy services, particularly for follow-up consultations.

"Sounds a Bit Crazy, But It Was Almost More Personal:" A Qualitative Study of Patient and Clinician Experiences of Physical Therapist-Prescribed Exercise For Knee Osteoarthritis Via Skype.

OBJECTIVE: To explore the experience of patients and physical therapists with Skype for exercise management of knee osteoarthritis (OA). METHODS: This was a qualitative study. The Donabedian model for quality assessment in health care (structure, process, and outcomes) informed semistructured individual interview questions. The study involved 12 purposively sampled patients with knee OA who received physical therapist-prescribed exercise over Skype, and all therapists (n = 8) who delivered the intervention in a clinical trial were interviewed about their experiences. Interviews were audio recorded and transcribed. Two investigators undertook coding and analysis using a thematic approach. RESULTS: Six themes arose from both patients and therapists. The themes were Structure: technology (easy to use, variable quality, set-up assistance helpful) and patient convenience (time efficient, flexible, increased access); Process: empowerment to self-manage (facilitated by home environment and therapists focusing on effective treatment) and positive therapeutic relationships (personal undivided attention from therapists, supportive friendly interactions); and Outcomes: satisfaction with care (satisfying, enjoyable, patients would recommend, therapists felt Skype more useful as adjunct to usual practice) and patient benefits (reduced pain, improved function, improved confidence and self-efficacy). A seventh theme arose from therapists regarding process: adjusting routine treatment (need to modify habits, discomfort without hands-on, supported by research environment). CONCLUSION: Patients and physical therapists described mostly positive experiences using Skype as a service delivery model for physical therapist-supervised exercise management of moderate knee OA. Such a model is feasible and acceptable and has the potential to increase access to supervised exercise management for people with knee OA, either individually or in combination with traditional in-clinic visits.

Replacing stressful challenges with positive coping strategies: a resilience program for clinical placement learning.

Clinical education is foundational to health professional training. However, it is also a time of increased stress for students. A student's perception of stressors and their capacity to effectively manage them is a legitimate concern for educators, because anxiety and decreased coping strategies can interfere with effective learning, clinical performance and capacity to care for patients. Resilience is emerging as a valuable construct to underpin positive coping strategies for learning and professional practice. We report the development and evaluation of a psycho-education resilience program designed to build practical skills-based resilience capacities in health science (physiotherapy) students. Six final year undergraduate physiotherapy students attended four action research sessions led by a clinical health psychologist. Resilience strategies drawn from cognitive behavioural therapy, and positive and performance psychology were introduced. Students identified personal learning stressors and their beliefs and responses. They chose specific resilience-based strategies to address them, and then reported their impact on learning performance and experiences. Thematic analysis of the audio-recorded and transcribed action research sessions, and students' de identified notes was conducted. Students' initial descriptions of stressors as 'problems' outside their control resulting in poor thinking and communication, low confidence and frustration, changed to a focus on how they managed and recognized learning challenges as normal or at least expected elements of the clinical learning environment. The research suggests that replacing stressful challenges with positive coping strategies offers a potentially powerful tool to build self-efficacy and cognitive control as well as greater self-awareness as a learner and future health practitioner.

Folic acid supplement use in the prevention of neural tube defects.

In 2008, planned folic acid fortification for the prevention of Neural Tube Defects (NTD) was postponed. Concurrently, the economic recession may have affected dietary folic acid intake, placing increased emphasis on supplement use. This study examined folic acid supplement use in 2009. A cross-sectional survey of 300 ante-natal women was undertaken to assess folic acid knowledge and use. Associations between demographic, obstetric variables and folic acid knowledge and use were examined. A majority, 284/297 (96%), had heard of folic acid, and 178/297 (60%) knew that it could prevent NTD. Most, 270/297 (91%) had taken it during their pregnancy, but only 107/297 (36%) had used it periconceptionally. Being older, married, planned pregnancy and better socioeconomic status were associated with periconceptional use. Periconceptional folic acid use in 2009 was very low, little changed from economic status were associated with periconceptional use. Periconceptional folic acid use in 2009 was very low, little changed from earlier years. Continuous promotion efforts are necessary. Close monitoring of folic acid intake and NTD rates is essential, particularly in the absence of fortification.

Warfarin use in hemodialysis patients: what is the risk?

BACKGROUND: There is a paucity of data concerning the risks associated with warfarin in hemodialysis (HD) patients. We compared major bleeding episodes in this group with HD patients not receiving warfarin and with a cohort of non-HD patients receiving warfarin. METHODS: A retrospective review of 141 HD patients on warfarin (HDW), 704 HD patients not on warfarin (HDNW) and 3,266 non-dialysis warfarin patients (NDW) was performed. Hospital admissions for hemorrhagic events and ischemic strokes were examined as was hospital length of stay and blood product use. INR variability was also assessed. RESULTS: The incidence rates for major hemorrhage per 100 patient years was 10.8 in the HDW group as compared to 8.0 in the HDNW (p = 0.593) and 2.1 in the NDW (p < 0.001) groups. Mean units of red blood cell transfusions required was higher in patients on dialysis with no significant difference between HDW and HDNW groups. The risk of ischemic stroke per 100 patient years was 1.7 in the HDW group as compared to 0.7 in the HDNW groups (p = 0.636) and 0.4 in the NDW (p = 0.003). The HDW group had higher inter-measurement INR variability compared to the NDW group (p = 0.034). In patients with atrial fibrillation, HDW group had a higher incidence of ischemic stroke than the NDW group (2.2 versus 0.4 events per 100 patient years; p = 0.024). CONCLUSIONS: This study confirms the higher bleeding risk associated with HD/ESRD but suggests that warfarin use in these patients may not add significantly to this risk. We also demonstrated high rates of ischemic stroke in HD patients despite warfarin use. SUMMARY: Our study compares the frequency of major hemorrhage and secondarily, ischemic stroke in HD patients receiving or not receiving warfarin, with non-HD patients receiving warfarin. The major finding was that frequency of hemorrhage was higher in HD patients receiving warfarin than in non-HD patients receiving warfarin, but not different in HD patients with or without warfarin. A secondary finding was that INR variability was significantly higher in HD patients than non-HD patients on warfarin.

Making a difference: incorporating theories of autonomy into models of informed consent.

BACKGROUND: Obtaining patients' informed consent is an ethical and legal obligation in healthcare practice. Whilst the law provides prescriptive rules and guidelines, ethical theories of autonomy provide moral foundations. Models of practice of consent, have been developed in the bioethical literature to assist in understanding and integrating the ethical theory of autonomy and legal obligations into the clinical process of obtaining a patient's informed consent to treatment. AIMS: To review four models of consent and analyse the way each model incorporates the ethical meaning of autonomy and how, as a consequence, they might change the actual communicative process of obtaining informed consent within clinical contexts. METHODS: An iceberg framework of consent is used to conceptualise how ethical theories of autonomy are positioned and underpin the above surface, and visible clinical communication, including associated legal guidelines and ethical rules. Each model of consent is critically reviewed from the perspective of how it might shape the process of informed consent. RESULTS AND DISCUSSION: All four models would alter the process of obtaining consent. Two models provide structure and guidelines for the content and timing of obtaining patients' consent. The two other models rely on an attitudinal shift in clinicians. They provide ideas for consent by focusing on underlying values, attitudes and meaning associated with the ethical meaning of autonomy. CONCLUSIONS: The paper concludes that models of practice that explicitly incorporate the underlying ethical meaning of autonomy as their basis, provide less prescriptive, but more theoretically rich guidance for healthcare communicative practices.

Relationships between 24h observations in intraocular pressure vs blood pressure, heart rate, nitric oxide and age in the medical chronobiology aging project.

OBJECTIVE: To evaluate associations between intraocular pressure (IOP) and blood pressure (BP), heart rate (HR), serum nitric oxide (NO), diurnal variations, diabetes and aging in data collected during 24h studies of men conducted over 34y. MATERIALS AND METHODS: As part of the Medical Chronobiology Aging Project, male Army veterans, ages 22 to 81y, without a history of eye disease, were studied around-the-clock in May 1969 (n = 13), 1979 (n = 11), 1988 (n = 11), 1993 (n = 11), 1998 (n =12) and 2003 (n = 10). Measurements of IOP (R & L eyes, supine position), BP and HR (sitting position), and collection of blood were obtained every 3h (8 readings/24h) from 19:00h to 16:00h the next day. Individual time series were analyzed for circadian characteristics by the least-squares fit of a 24& 12h cosine. After normalizing all data to percent of mean to reduce inter-subject variability in levels, grouped data were analyzed for time-effect by ANOVA and for circadian rhythm by multiple component (24h&12h) cosine fitting. Individual 24h averages were analyzed by simple and multiple regression for relationships between IOP and systemic variables, diabetic status and age. RESULTS: Over the 34y study span, 22 men provided sixty-three 24h profiles for IOP & HR, 61 for BP, and 21 for NO. Using all normalized data, a significant circadian rhythm was found for each variable at p <0.001. Circadian peaks (orthophases) are located in the late morning for IOP-R (10:20h) and IOP-L (10:52h), and in the evening for HR (18:52h), NO (20:00h), SBP (20:40h) and DBP (21:44h). An out-of-phase relationship of about 10h is noted on a group basis between IOP vs BP, HR and NO. The locations of individual circadian peaks for IOP-R were found around the clock, but with a significant predominance between 10:00 and 16:00h (day type), and 04:00-10:00h (morning type). In contrast, BP, HR and NO showed a significant clustering of evening type or night type peaks. The overall mean IOP for the right eye was slightly, but not significantly, higher than the left eye (17.60+/-0.21 vs 17.34+/-0.18 mmHg; p = 0.385), with a strong positive correlation between both eyes (R = 0.952, p <0.0001). IOP showed a significant positive correlation with SBP (R = 0.49, p <0.001), diabetic status (R = 0.47, p <0.001), age (R = 0.32, p = 0.011), and HR (R = 0.28, p = 0.031). A multiple regression using SBP, DBP, HR, age and diabetic status (5 men became diabetic over the 34y study span) as independent variables resulted in SBP being the strongest predictor of IOP (p = 0.0001), followed by DBP (p = 0.0103). After adjustment for BP, independent effects of age (p = 0.187), HR (p = 0.789) and diabetic status (p = 0.153) were eliminated from the prediction equation. CONCLUSIONS: The results of these studies reveal significant circadian variations in IOP, BP, HR and NO, with peak levels, on average, near noon for IOP and in the evening for BP, HR and NO. An increase in SBP was associated with an increase in IOP. While SBP and DBP are significant predictors of IOP levels, single measurements during regular clinic hours may not reveal the full functional relationship between the variables measured in our studies. Therefore, circadian information on total 24h patterns may contribute to the reliability of diagnosis and guide proper individualized timing of optimal patient management (e.g., for glaucoma, hypertension, diabetes, among other conditions).

Synaptic activation of a presynaptic kainate receptor facilitates AMPA receptor-mediated synaptic transmission at hippocampal mossy fibre synapses.

The development of GluR5-selective kainate receptor ligands is helping to elucidate the functions of kainate receptors in the CNS. Here we have further characterised the actions of a GluR5 selective agonist, ATPA, and a GluR5 selective antagonist, LY382884, in the CA3 region of rat hippocampal slices. In addition, we have used LY382884 to study a novel synaptic mechanism. This antagonist substantially reduces frequency facilitation of mossy fibre synaptic transmission, monitored as either AMPA or NMDA receptor-mediated EPSCs. This suggests that GluR5-containing kainate receptors on mossy fibres function as autoreceptors to facilitate the synaptic release of L-glutamate, in a frequency-dependent manner.

Laser photocoagulation for choroidal neovascularization associated with sympathetic ophthalmia.

PURPOSE: To present a case of choroidal neovascularization associated with sympathetic ophthalmia successfully treated with photocoagulation. DESIGN: Interventional case report. METHODS: A 41-year-old man with a history of penetrating injury right eye, as well as sympathetic ophthalmia left eye, developed a classic choroidal neovascular membrane that threatened the center of the fovea. RESULTS: The patient was treated with argon laser photocoagulation. He has maintained stable visual acuity without evidence of recurrence of the membrane with 4 years' follow-up. CONCLUSION: Thermal laser should be considered as a treatment option in cases of choroidal neovascularization associated with sympathetic ophthalmia.

Kainate receptors are involved in synaptic plasticity.

The ability of synapses to modify their synaptic strength in response to activity is a fundamental property of the nervous system and may be an essential component of learning and memory. There are three classes of ionotropic glutamate receptor, namely NMDA (N-methyl-D-aspartate), AMPA (alpha-amino-3-hydroxy-5-methyl-4-isoxazole-4-propionic acid) and kainate receptors; critical roles in synaptic plasticity have been identified for two of these. Thus, at many synapses in the brain, transient activation of NMDA receptors leads to a persistent modification in the strength of synaptic transmission mediated by AMPA receptors. Here, to determine whether kainate receptors are involved in synaptic plasticity, we have used a new antagonist, LY382884 ((3S, 4aR, 6S, 8aR)-6-((4-carboxyphenyl)methyl-1,2,3,4,4a,5,6,7,8,8a-decahydro isoquinoline-3-carboxylic acid), which antagonizes kainate receptors at concentrations that do not affect AMPA or NMDA receptors. We find that LY382884 is a selective antagonist at neuronal kainate receptors containing the GluR5 subunit. It has no effect on long-term potentiation (LTP) that is dependent on NMDA receptors but prevents the induction of mossy fibre LTP, which is independent of NMDA receptors. Thus, kainate receptors can act as the induction trigger for long-term changes in synaptic transmission.