The unspoken disease: symptom experience in women with vulval neoplasia and surgical treatment: a qualitative study.

Women with vulval neoplasia often experience severe post-surgical complications. This study focuses on symptom experience of women during the first 6 months following surgical treatment for vulval neoplasia considering their socio-cultural context. In this qualitative study using a critical hermeneutic approach, narrative interviews were conducted. A purposeful sample of 20 patients was recruited from one Swiss and two German university hospitals. Content analysis was employed to analyse the transcribed interviews considering women's experiences and social perceptions. Narratives showed eight interrelated themes: delayed diagnosis, disclosed disease, disturbed self-image, changed vulva care, experienced wound-related symptoms, evoked emotions, affected interpersonal interactions and feared illness progression. The women experienced a general lack of information pertaining to above themes and all described strategies used to handle their situation, which affected their distress. The communication, assessment and treatment of symptoms were hampered by the society's and the health system's tendency to overlook these symptoms and leave them in the realm of the unspeakable. Health professionals need new strategies to support these women to recognise, assess and evaluate the seriousness of symptoms, and to communicate their symptom experience so that timely medical treatment is sought. This support may minimise potentially preventable complications and symptom-related distress.

The use of medical emergency teams in medical and surgical patients: impact of patient, nurse and organisational characteristics.

Medical emergency teams (METs) were developed to respond more rapidly to changes in patient condition. While effective, METs do not address events prior to the response. This study examined differences in patient, nurse, and organisational characteristics for 108 MET calls on five medical and five surgical units in a university hospital. MET calls occurred more often on the day shift (p = 0.007) for medical (p = 0.036), but not surgical, patients. Of the 108 events, 44% were delayed, defined as events with documented evidence that pre-established criteria for a MET call were present for >30 min. More delays occurred on the night shift (p = 0.012). Delayed events were not related to the number of patients assigned (p = 0.608). However, there was a trend for more delays when more patients were assigned (4:1 = 21% vs 6:1 = 43%). In a logistic regression model, shift and patient-unit-match (medical, surgical) were significant predictors of delays. The model correctly predicted 68% of delayed events. Study findings indicate that a combination of patient, nurse and organisational characteristics influence timely rescue.

Methodological considerations for grounded theory research in critical care settings.

BACKGROUND: The context of critical care and human phenomena involved in critical illness offer rich opportunity for nursing research. Naturalistic investigation with grounded theory methods can uncover previously unexamined elements and interactions in the critical care setting. This article presents methodological considerations for conducting grounded theory research in fast-paced physiologically and technologically complex critical care settings. APPROACH: Critique and recommendations are based in review and analysis of grounded theory research in adult critical care settings and on the literature describing grounded theory methods. The authors' experiences in medical and surgical intensive care units provide added practical context for this article. RESULTS: Barriers to achieving grounded theory in critical care settings, such as communication impairments, participant attrition, and observational difficulties, are explored. Methodological strategies and data sources particular to critical care settings are also discussed. Critical care settings offer a variety of data sources that should be rigorously pursued in grounded theory research. DISCUSSION: Given current trends in healthcare treatments and demographics, future research must examine physiological and technological data as integral components of basic social psychological or social structural processes in critical care interactions and should include technology as a component of nurse-patient interaction.

Communicating with mechanically ventilated patients: state of the science.

The literature clearly establishes the problems and difficulties of loss of speech among mechanically ventilated patients in the intensive care unit. Critical care nurses typically receive little or no training in the interpretation of nonvocal communication or in the assessment and application of augmentative communication methods. This article presents an integrative review of the research and related literature on communication with adult patients in critical care settings. Clinical issues and technological advancements in assistive and augmentative communication applicable to critical care are discussed and a new research agenda is proposed.

Using a best practice approach to prevent treatment interference in critical care.

Treatment interference, also known as therapy disruption, device disruption, or self extubation, is a common and especially difficult clinical problem in critical care. This paper presents creative and practical clinical innovations and relevant research findings as a "best practice approach" to prevent treatment interference in critical care settings. Key principles are presented to guide patient assessment and selection of nursing strategies. Nursing assessment parameters are described and a wide range of nonrestraint strategies are discussed.

Intratracheal administration to the lung enhances therapeutic benefit of an MBP peptide in the treatment of murine experimental autoimmune encephalomyelitis.

The treatment of autoimmune diseases by targeted down-regulation of autoantigen-specific cells has been accomplished by the administration of high doses of autoantigen. We performed direct comparisons between injection of myelin basic protein peptide and administration by several nonparenteral routes to determine whether route impacted benefit in the treatment of murine allergic encephalomyelitis, a model for multiple sclerosis. The range of effective peptide doses spanned over 1000-fold, and route of delivery played a major role in determining optimal dose. The oral route of administration was the least effective, requiring at least 50- to 100-fold more antigen than subcutaneous injection, which in turn required at least 10-fold more antigen than delivery of peptide to the lung using an intratracheal instillation. Intratracheal delivery was also considerably more effective than inhalation of peptide, and, unlike inhalation, resulted in obvious penetration of delivered material deep into the lung. The increase in therapeutic efficacy did not appear to result from slower systemic delivery of antigen. Accumulation of peptide on antigen presenting cells in the spleen and in the brain was less efficient using the intratracheal route of administration compared to subcutaneous injection, implicating a special role for the lung microenvironment in the induction of immune nonresponsiveness.

Interpretation of nonvocal behavior and the meaning of voicelessness in critical care.

This paper presents two interrelated psychosocial constructs, voicelessness and interpretation, which were derived from a participant observation study of critically ill older adults in the USA. Voicelessness occurs when physiological, psychosocial and/or technological barriers limit the abilities of critically ill patients to represent their thoughts, feelings, desires and needs fully to others. Voicelessness influences not only the responses of critically ill patients to their condition, environment and caregivers, but also profoundly effects the responses of family members and clinicians. Thus, communicative interactions as well as certain clinical and treatment decisions in ICU hinge on clinician and family member interpretation of patients' nonvocal behaviors. Conditions and factors contributing to interpretation are described and a hypothesis proposed, that interpretation mitigates the detrimental effects of voicelessness.

Preventing treatment interference: the nurse's role in maintaining technologic devices.

BACKGROUND: Treatment interference, the disruption or self-removal of technologic devices, is a primary reason for application of physical restraints in acute and critical care settings. The processes of care surrounding treatment interference and the prevention of device disruption have not been comprehensively analyzed. OBJECTIVES: To describe the processes used by critical care nurses to prevent treatment interference in critically ill older adults. METHODS: Participant observation field research was conducted in medical and intermediate medical intensive care units. Data were analyzed by using the constant comparative method and event analysis. RESULTS: Maintaining technologic devices is almost exclusively a nursing responsibility and involves the skillful assessment of patient awareness and trustworthiness and interpretation of behaviors. Critical care nurses are most protective of those devices for which accidental removal is perceived as life threatening: endotracheal tubes, arterial catheters, and central venous catheters. Nurses assess patients' cognitive status, mobility, strength, and trustworthiness, as well as device considerations such as replacement difficulty and device necessity. In addition to verbal strategies, such as explaining, nurses use distraction, deception, comfort measures, watchful family members, physical restraints, and sedation to prevent treatment interference. CONCLUSION: This analysis considers the social context of the intensive care unit, including roles and the human-technology interaction. It illustrates the tremendous responsibility that nurses assume in maintaining technologic devices. Next steps in research and policy development are also considered.

Nurse practitioner services: content and relative work value.

The resource-based relative value scale is used to quantify work for reimbursement of services in the Medicare Fee Schedule. This pilot study explored use of the resource-based relative value scale for services provided by nurse practitioners. Estimation of relative work values for office visits by nurse practitioners was consistent with the Medicare Fee Schedule. Content analysis revealed that nurse practitioners provide additional services including comprehensive patient evaluation and education and attendance to social factors. Future research is needed to examine systems that identify and reimburse nurse practitioners for their services.

B cells are critical to induction of experimental allergic encephalomyelitis by protein but not by a short encephalitogenic peptide.

While the pathology of multiple sclerosis implicates a role for B cells and antibodies in the disease process, results from animal models have yielded conflicting results. To further characterize the role of B cells in experimental allergic encephalomyelitis (EAE), wild-type and B cell-deficient C57BL/6 mice were immunized with either a recombinant form of myelin oligodendrocyte glycoprotein (MOG) or with the encephalitogenic MOG(35-55) peptide. B cell-deficient mice did not develop EAE when immunized with MOG, although they were susceptible to MOG(35-55)-induced disease. In contrast, wild-type mice were fully susceptible to both MOG and MOG(35-55)-induced EAE. B cell-deficient mice immunized with MOG were primed to the encephalitogenic MOG(35- 55) epitope, as their spleen cells responded with Th1 cytokine production in a fashion similar to WT cells when challenged in vitro with MOG protein or MOG(35-55) peptide. These results demonstrate that the form of inducing antigen (protein vs. peptide) plays a role in the pathogenesis of EAE and may be relevant when applying results from the EAE model to multiple sclerosis.

Treatment of murine experimental autoimmune encephalomyelitis with a myelin basic protein peptide analog alters the cellular composition of leukocytes infiltrating the cerebrospinal fluid.

Experimental autoimmune encephalomyelitis (EAE) can be effectively treated during disease exacerbation by administration of a peptide corresponding to the major T cell epitope of myelin basic protein (MBP), but the mechanism by which T cell tolerance leads to clinical improvement is not well-defined. Acute exacerbations of EAE are accompanied by an infiltration of blood-borne leukocytes into the brain and spinal cord, where they mediate inflammation and demyelination. To investigate peptide effects on infiltrating cells, we collected cerebrospinal fluid (CSF) from (PL/JxSJL)F1 mice with MBP-induced EAE. Pleiocytosis by lymphocytes, neutrophils, and macrophages was seen throughout the course of relapsing-remitting disease. A single administration of the MBP peptide analog, Ac1-11[4Y], reduced disease severity, accompanied by a dramatic and selective loss of neutrophil pleiocytosis. A longer course of peptide therapy resulted in complete recovery from clinical signs of disease, and decreased pleiocytosis by all cell types. Clinical severity throughout the course of disease and therapy was directly related to the degree of infiltration by neutrophils and macrophages, and the clinical improvement following peptide therapy was accompanied by decreased central nervous system (CNS) expression of chemoattractants for these cell types. These observations support a model of disease exacerbation mediated by phagocytic cellular infiltration under the ultimate control of T cell-derived factors, amenable to treatment by down-regulation of the T cell activation state.

Experimental autoimmune encephalomyelitis induced with a combination of myelin basic protein and myelin oligodendrocyte glycoprotein is ameliorated by administration of a single myelin basic protein peptide.

Multiple sclerosis is an autoimmune disease of the central nervous system in which T cell reactivity to several myelin proteins, including myelin basic protein (MBP), proteolipid protein, and myelin oligodendrocyte glycoprotein (MOG), has been implicated in the perpetuation of the disease state. Experimental autoimmune encephalomyelitis (EAE) is used commonly as a model in which potential therapies for multiple sclerosis are evaluated. The ability of T cell epitope-containing peptides to down-regulate the disease course is well documented for both MBP- and proteolipid protein-induced EAE, and recently has been shown for MOG-induced EAE. In this study, we describe a novel EAE model, in which development of severe disease symptoms in (PL/J x SJL)F1 mice is dependent on reactivity to two different immunizing Ags, MBP and MOG. The disease is often fatal, with a relapsing/progressive course in survivors, and is more severe than would be predicted by immunization with either Ag alone. The MOG plus MBP disease can be treated postinduction with a combination of the MOG 41-60 peptide (identified as the major therapeutic MOG epitope for this strain) and the MBP Ac1-11[4Y] peptide. A significant treatment effect can also be obtained by administration of the MBP peptide alone, but this effect is strictly dose dependent. This MBP peptide does not treat the disease induced only with MOG. These results suggest that peptide immunotherapy can provide an effective means of mitigating disease in this model, even when the treatment is targeted to only one component epitope or one component protein Ag of a diverse autoimmune response.

Treatment interference in acutely and critically ill adults.

OBJECTIVES: To examine the state of knowledge of treatment interference, the self-removal of technological devices, in acutely or critically ill adults and to propose a multidisciplinary research agenda to further understanding of this clinical problem. METHOD: A combined computerized and hand search of the nursing and medical literature (MEDLINE, 1966 to June 1996; Cumulative Index to Nursing and Allied Health Literature, 1985 to June 1996; and holdings at the Center for the Study of Nursing History at the University of Pennsylvania) was conducted. Literature on specific technological devices and articles that contained the terms self-removal, withdrawal, devices, self-extubation, unplanned extubation, and involuntary treatment were searched. RESULTS: Literature on treatment interference was found in four main topic areas: (1) maintaining treatment, (2) unplanned extubation, (3) disruption or manipulation of a medical device, and (4) involuntary treatment. CONCLUSIONS: The results clearly establish the clinical importance of treatment interference and underscore the multidisciplinary and multifactorial nature of this perplexing, life-threatening clinical problem. Future research on treatment interference should emphasize systematically building an understanding of the processes involved, including patients' attributes, behavioral cues, and consequences, to develop appropriate multidisciplinary strategies to prevent patients' self-removal of technological devices.

Factors contributing to rehospitalization of elderly patients with heart failure.

This article describes factors contributing to rehospitalizations of elderly patients with heart failure. Advanced practice nurses' logs, study questionnaires, and medical record summaries from a recent clinical trial provided rich, descriptive information about a variety of social and behavioral factors surrounding rehospitalization in these medically fragile older people. Medication and dietary nonadherence were factors affecting symptom appearance and rehospitalization. Social and behavioral factors, such as the absence of strong social support or motivation, contributed to nonadherence. These results suggest that social and behavioral factors must be identified and addressed in an individualized manner to prevent recurrent hospitalizations for elderly patients with heart failure.

IL-4 production by allergen-stimulated primary cultures: identification of basophils as the major IL-4-producing cell type.

As a potent inducing agent for IgE production and differentiation factor for allergen-specific Th2 cells, IL-4 is a key regulatory cytokine both in the pathogenesis of allergic disease and in the ongoing allergic response. The assay of in vitro IL-4 production has often been used to compare the allergen responses of T cells isolated from atopic and non-atopic subjects. Because peripheral blood basophils also have the capacity to respond to specific allergen by producing IL-4, we investigated the relative contribution of these two cell types to IL-4 production in allergen-stimulated primary cultures. Among unfractionated peripheral blood mononuclear cells (PBMC), the major producers of detectable IL-4 in primary in vitro cultures were found to be basophils based on: (i) an allergen dose-response corresponding closely to that required for basophil histamine release and lower than that required for T cell activation; (ii) a rapid time course for IL-4 production (detectable at 3 h), inconsistent with the typical activation requirements of fresh T cells; (iii) the production of comparable levels of IL-4 in cultures stimulated with allergen or anti-IgE; and (iv) the complete loss of detectable IL-4 production following specific depletion of basophils from PBMC. The T cells in these cultures were functionally able to produce IL-4, as demonstrated by mitogen activation of basophil-depleted PBMC. These findings demonstrate that although IL-4 production in primary in vitro cultures can be used as a sensitive indicator of allergen responsiveness, the accurate interpretation of this result requires identification of the responding cell type. Furthermore, these findings raise the possibility that basophil production of IL-4 early in the course of allergen stimulation may shape subsequent T cell responses both in vivo and in vitro.

Individualized care for frail elders: theory and practice.

Individualized care for frail elders is defined as an interdisciplinary approach which acknowledges elders as unique persons and is practiced through consistent caring relationships. The four critical attributes of individualized care for frail elders are: 1) knowing the person, 2) relationship, 3) choice, and 4) participation in and direction of care. Cognitively impaired elders can direct their care through the staff's knowledge of individual past patterns and careful observation of behavior for what is pleasing and comfortable to each resident.