Certified Nurse-Midwives in Rural Kansas Hospitals: A Survey of Senior Hospital Administrators.

INTRODUCTION: Little is known about the nurse-midwifery workforce in rural Kansas hospitals, despite Kansas facing a shortage of primary care physicians providing maternity care rurally. This study investigated the current number of hospitals with certified nurse-midwives (CNMs) with privileges to attend births in Kansas hospitals located in frontier, rural, and densely settled rural counties and anticipated trends in the size of the CNM workforce at hospitals over the next 5 years. METHODS: Electronic surveys were distributed to senior hospital administrators at 94 hospitals in rural Kansas from June to July 2019. The survey included both open and closed-ended questions related to scope of CNM privileges, collaborative agreements, and forecasted trends in the CNM workforce in rural Kansas. RESULTS: Fifty-six hospitals completed the survey. Only one hospital reported having CNM-attended births. Twenty-eight of 37 hospital administrators agreed CNMs should have collaborative agreements with physicians. Most respondents did not anticipate the number of CNMs with privileges to increase at their hospitals over the next 5 years. DISCUSSION: Future research should focus on understanding the factors limiting CNM expansion in rural Kansas, because CNMs represent an untapped, additional maternity care workforce for rural Kansas.

Randomized clinical trial of expressive writing on wound healing following bariatric surgery.

OBJECTIVE: Writing emotionally about upsetting life events (expressive writing) has been shown to speed healing of punch-biopsy wounds compared to writing objectively about daily activities. We aimed to investigate whether a presurgical expressive writing intervention could improve surgical wound healing. METHOD: Seventy-six patients undergoing elective laparoscopic bariatric surgery were randomized either to write emotionally about traumatic life events (expressive writing) or to write objectively about how they spent their time (daily activities writing) for 20 min a day for 3 consecutive days beginning 2 weeks prior to surgery. A wound drain was inserted into a laparoscopic port site and wound fluid analyzed for proinflammatory cytokines collected over 24 hr postoperatively. Expanded polytetrafluoroethylene tubes were inserted into separate laparoscopic port sites during surgery and removed after 14 days. Tubes were analyzed for hydroxyproline deposition (the primary outcome), a major component of collagen and marker of healing. Fifty-four patients completed the study. RESULTS: Patients who wrote about daily activities had significantly more hydroxyproline than did expressive writing patients, t(34) = -2.43, p = .020, 95% confidence interval [-4.61, -0.41], and higher tumor necrosis factor-alpha, t(29) = -2.42, p = .022, 95% confidence interval [-0.42, -0.04]. Perceived stress significantly reduced in both groups after surgery. CONCLUSIONS: Expressive writing prior to bariatric surgery was not effective at increasing hydroxyproline at the wound site 14 days after surgery. However, writing about daily activities did predict such an increase. Future research needs to replicate these findings and investigate generalizability to other surgical groups. (PsycINFO Database Record

End-of-life medical decision making in general practice in New Zealand--13 years on.

AIMS: The aim of this study was to explore medical decision-making practices at the end-of-life made by GPs (MDEL) in New Zealand and to identify changes in practice with a previous study published in 2004. METHODS: A postal questionnaire was sent to 3,420 GPs in New Zealand in May 2013. Anonymous phone interviews were also undertaken. Analysis of the questionnaire was done on IBM SPSS Statistics 21. RESULTS: There was a 21% response rate from two mail outs. Of the 650 GPs who responded, 547 had contact with a patient prior to death and had the potential to make a MDEL. Of these, 359 (65.6%) reported making a MDEL. Of the 359 GPs who reported making a MDEL, 16 (4.5%) attributed death to a drug that had been prescribed, supplied or administered explicitly for the purpose of hastening the patient's death. The alleged involvement of nurses in practices that intentionally hasten death is high. CONCLUSION: Our study shows that some GPs have explicitly assisted their patients to die, that nurses are allegedly involved, and there is a tendency towards more discussion with patients about MDEL.

A systematic review and meta-analysis of the Brief Illness Perception Questionnaire.

OBJECTIVE: This paper aims to systematically review the use and performance of the Brief Illness Perception Questionnaire (Brief IPQ). DESIGN: Electronic databases were searched for papers administering the Brief IPQ published in peer-reviewed journals. Data were extracted from the results for meta-analysis. MAIN OUTCOME MEASURES: Use by illness population, country, language and study design. The questionnaire's concurrent validity, predictive validity, sensitivity to change, discriminant validity and mean scores for different populations were summarised. RESULTS: The review included 188 papers. The Brief IPQ has been administered to patients from age 8 to over 80, with a wide range of illnesses, in 26 languages from 36 countries. Pooled correlations between illness perceptions and depression, anxiety, blood glucose levels and quality of life were consistent with previous research and theory (range .25-.49 for consequences, identity and emotional representations; -.12 to -.27 for personal control). All items were able to predict some outcomes up to one-year follow-up. Each subscale demonstrated sensitivity to change after intervention in randomised controlled trials with the personal control and causal items showing most frequent change. CONCLUSIONS: The Brief IPQ is widely used and has good psychometric properties. More studies should include and analyse the causal item.

Stress-related changes to immune cells in the skin prior to wounding may impair subsequent healing.

Higher psychological stress is associated with slower dermal wound healing, but the immunological mechanisms behind this effect are only partially understood. This paper aims to investigate whether immune cells present in the skin prior to wounding can affect subsequent healing in high-stress and low-stress participants. Two studies are presented in which skin biopsies were analysed using immunohistochemistry for numbers of macrophages and Langerhans cells, and immune cell activation (Study 2 only). Immune cells were related to perceived stress levels and subsequent healing. Study 1 included 19 healthy older adults and showed that higher stress was associated with significantly fewer macrophages in the skin. Study 2 included 22 younger adults and showed that higher stress was associated with significantly lower activation of immune cells in the skin. Furthermore, lower activation of immune cells (as measured by human leukocyte antigen (HLA expression)) and fewer Langerhans cells were associated with slower healing. Together these studies show the first preliminary evidence that the number and activation of immune cells in the skin prior to wounding are affected by stress and can impact healing. Larger studies are needed to confirm these effects.

Expressive writing and wound healing in older adults: a randomized controlled trial.

OBJECTIVE: To investigate whether expressive writing could speed wound reepithelialization in healthy, older adults. METHODS: In this randomized controlled trial, 49 healthy older adults aged 64 to 97 years were assigned to write for 20 minutes a day either about upsetting life events (Expressive Writing) or about daily activities (Time Management) for 3 consecutive days. Two weeks postwriting, 4-mm punch biopsy wounds were created on the inner, upper arm. Wounds were photographed routinely for 21 days to monitor wound reepithelialization. Perceived stress, depressive symptoms, health-related behaviors, number of doctor visits, and lipopolysaccharide-stimulated proinflammatory cytokine production were also measured throughout the study. RESULTS: Participants in the Expressive Writing group had a greater proportion of fully reepithelialized wounds at Day 11 postbiopsy compared with the Time Management group, with 76.2% versus 42.1% healed, χ(2)(1, n = 40) = 4.83, p = .028. Ordinal logistic regression showed more sleep in the week before wounding also predicted faster healing wounds. There were no significant group differences in changes to perceived stress, depressive symptoms, health-related behaviors, lipopolysaccharide-induced proinflammatory cytokine production, or number of doctor visits over the study period. CONCLUSIONS: This study extends previous research by showing that expressive writing can improve wound healing in older adults and women. Future research is needed to better understand the underlying cognitive, psychosocial, and biological mechanisms contributing to improved wound healing from these simple, yet effective, writing exercises. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (trial number 343095).

Expectation and the placebo effect in inflammatory skin reactions: a randomised-controlled trial.

OBJECTIVE: This study investigated the placebo effect on experimentally induced skin reactions via the manipulation of expectation. METHODS: Fifty-eight healthy volunteers were randomised into either expectancy or control groups. All participants received a baseline administration of histamine on one arm (Time 1), then a second administration on the other arm, approximately 30 minutes later (Time 2). Prior to the second administration, the expectancy group was told that an antihistamine cream (the placebo) had been applied that would reduce their skin reaction to the histamine. Expected wheal area, actual wheal area, heart rate, and heart rate variability were measured at each time point. RESULTS: There was a positive relationship between expected and actual wheal area at Time 1. While the expectancy group expected a smaller skin reaction on the second arm they did not experience a greater reduction in wheal area, compared to control. The expectancy group had a greater reduction in heart rate during the second skin reaction, after the manipulation of expectation (p<.05). CONCLUSION: While wheal area was not modulated, it may be worth further investigating this possibility, with modifications to the protocol. The reduction of heart rate appears to be an expectation effect and future research could elucidate mechanisms involved. There is an indication that expectations and inflammatory skin reactions are associated. Further study might aim to clarify the direction and nature of this relationship.

Immunosuppressant nonadherence in heart, liver, and lung transplant patients: associations with medication beliefs and illness perceptions.

BACKGROUND: Nonadherence to immunosuppressant medication is a significant problem among solid organ transplant recipients. Previous research suggests that patients' perceptions about their medications may be a better predictor of nonadherence than demographic factors. This study aimed to further investigate the role of patients' perceptions about their transplant and medication beliefs in nonadherence. METHODS: This was a cross-sectional observational study. Participants were 87 heart, 46 lung, and 193 liver transplant patients. All surviving heart, lung, and liver transplant patients from Auckland City Hospital and Greenlane Hospital older than 16 years who had received their transplant at least 3 months before study commencement were mailed questionnaires. Standardized self-report measures were used to assess illness perceptions, medication beliefs, and adherence. RESULTS: Nonadherent patients had lower perceptions about the necessity of medication, weaker beliefs that medication could prevent rejection, and higher concerns about its harms, than adherers. Nonadherers perceived that their transplant and immunosuppressant medication caused more symptoms and were more distressed about symptoms than adherers; they understood their transplant less, perceived their transplant had a larger impact on their lives, affected them more emotionally, and caused greater concern, than patients who were more adherent. A regression model that included these perceptions and demographic variables correctly classified 71% of patients as adherent or nonadherent. CONCLUSIONS: The perceptions that patients hold about their transplant and medications are associated with adherence to immunosuppressant medications. Future research could investigate whether a psychologic intervention could change patients' perceptions to improve adherence.

The psychology of wound healing.

PURPOSE OF REVIEW: Research into the effects of psychological factors on wound healing represents an ideal research model for psychoneuroimmunology, as both the impact on clinically relevant health outcomes and the underlying biological mechanisms can be examined. Mounting interest in this topic from biological scientists, psychologists, and medical specialists has resulted in new findings that are discussed in this review. RECENT FINDINGS: Known psychological influences on wound healing include stress as well as coping styles, positive affect, environmental enrichment, and social support. Research has highlighted the roles of oxytocin, vasopressin, epinephrine, cortisol, and leukocyte redistribution in wound healing. Clinical significance has been demonstrated by a growing number of studies in patient populations. Furthermore, pragmatic interventions with clinical samples have demonstrated clear benefits of psychological interventions on wound healing. SUMMARY: Recent studies add to growing evidence that psychology impacts wound repair, and highlight in particular the positive role of social support on modulating the negative effects of stress. The first few studies to demonstrate that psychological interventions can improve healing in clinical populations are exciting developments. New knowledge of psychobiological mechanisms provides opportunities to develop further interventions to improve health outcomes.

The use of wound healing assessment methods in psychological studies: a review and recommendations.

PURPOSE: To provide a critical review of methods used to assess human wound healing in psychological research and related disciplines, in order to guide future research into psychological influences on wound healing. METHODS: Acute wound models (skin blister, tape stripping, skin biopsy, oral palate biopsy, expanded polytetrafluoroethylene tubing), surgical wound healing assessment methods (wound drains, wound scoring), and chronic wound assessment techniques (surface area, volumetric measurements, wound composition, and assessment tools/scoring systems) are summarized, including merits, limitations, and recommendations. RESULTS: Several dermal and mucosal tissue acute wound models have been established to assess the effects of psychological stress on the inflammatory, proliferative, and repair phases of wound healing in humans, including material-based models developed to evaluate factors influencing post-surgical recovery. There is a paucity of research published on psychological factors influencing chronic wound healing. There are many assessment techniques available to study the progression of chronic wound healing but many difficulties inherent to long-term clinical studies. CONCLUSIONS: Researchers need to consider several design-related issues when conducting studies into the effects of psychological stress on wound healing, including the study aims, type of wound, tissue type, setting, sample characteristics and accessibility, costs, timeframe, and facilities available. Researchers should consider combining multiple wound assessment methods to increase the reliability and validity of results and to further understand mechanisms that link stress and wound healing.

Percutaneous window chamber method for chronic intravital microscopy of sensor-tissue interactions.

BACKGROUND: A dorsal, two-sided skin-fold window chamber model was employed previously by Gough in glucose sensor research to characterize poorly understood physiological factors affecting sensor performance. We have extended this work by developing a percutaneous one-sided window chamber model for the rodent dorsum that offers both a larger subcutaneous area and a less restrictive tissue space than previous animal models. METHOD: A surgical procedure for implanting a sensor into the subcutis beneath an acrylic window (15 mm diameter) is presented. Methods to quantify changes in the microvascular network and red blood cell perfusion around the sensors using noninvasive intravital microscopy and laser Doppler flowmetry are described. The feasibility of combining interstitial glucose monitoring from an implanted sensor with intravital fluorescence microscopy was explored using a bolus injection of fluorescein and dextrose to observe real-time mass transport of a small molecule at the sensor-tissue interface. RESULTS: The percutaneous window chamber provides an excellent model for assessing the influence of different sensor modifications, such as surface morphologies, on neovascularization using real-time monitoring of the microvascular network and tissue perfusion. However, the tissue response to an implanted sensor was variable, and some sensors migrated entirely out of the field of view and could not be observed adequately. CONCLUSIONS: A percutaneous optical window provides direct, real-time images of the development and dynamics of microvascular networks, microvessel patency, and fibrotic encapsulation at the tissue-sensor interface. Additionally, observing microvessels following combined bolus injections of a fluorescent dye and glucose in the local sensor environment demonstrated a valuable technique to visualize mass transport at the sensor surface.

In vitro, in vivo and post explantation testing of glucose-detecting biosensors: current methods and recommendations.

To date, there have been a number of cases where glucose sensors have performed well over long periods of implantation; however, it remains difficult to predict whether a given sensor will perform reliably, will exhibit gradual degradation of performance, or will fail outright soon after implantation. Typically, the literature emphasizes the sensor that performed well, while only briefly (if at all) mentioning the failed devices. This leaves open the question of whether current sensor designs are adequate for the hostile in vivo environment, and whether these sensors have been assessed by the proper regimen of testing protocols. This paper reviews the current in vitro and in vivo testing procedures used to evaluate the functionality and biocompatibility of implantable glucose sensors. An overview of the standards and regulatory bodies that govern biomaterials and end product device testing precedes a discussion of up-to-date invasive and non-invasive technologies for diabetes management. Analysis of current in vitro, in vivo, and then post explantation testing is presented. Given the underlying assumption that the success of the sensor in vitro foreshadows the long-term reliability of the sensor in the human body, the relative merits of these testing methods are evaluated with respect to how representative they are of human models.