Psychological flexibility as a potential change factor in cognitive behavioural therapy of OCD.

BACKGROUND: To gain a better understanding about which aspects of the treatment work for obsessive-compulsive disorders (OCD), the investigation of possible change factors is essential. Psychological flexibility (PsyF) has been of interest in research on successful OCD therapy for some time. Exposure interventions and cognitive strategies in cognitive behavioural therapy (CBT) for OCD may enhance PsyF. To date, however, no process studies have been published that clarify the role of PsyF as a possible change factor for the reduction of OCD symptoms. AIMS: This study investigates whether PsyF works as a mediator in successful CBT treatment of OCD. METHOD: The study recruited 112 adults diagnosed with OCD in a multi-modal in-patient treatment with specific CBT including exposure and response prevention (ERP). The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was used to measure OCD symptoms and three self-constructed items to assess PsyF. PsyF was conceptualised as the capability of patients to accept stressful feelings and thoughts. Data were collected weekly. For statistical analysis at the process level, longitudinal multi-level models (MLMs) with random intercepts and linear growth curves were estimated to test for mediation of PsyF on Y-BOCS. RESULTS: OCD symptoms decreased significantly and PsyF increased in patients throughout the course of therapy. MLM revealed that higher average values in PsyF were associated with lower Y-BOCS sum values, but only values between subjects significantly predicted the degree of obsessions and compulsions. CONCLUSIONS: Although research shows that PsyF is enhanced by CBT and also shows a connection with Y-BOCS values, its role as a mediator could not be confirmed.

Macroergonomic factors in the patient work system: examining the context of patients with chronic illness.

Human factors/ergonomics recognises work as embedded in and shaped by levels of social, physical and organisational context. This study investigates the contextual or macroergonomic factors present in the health-related work performed by patients. We performed a secondary content analysis of findings from three studies of the work of chronically ill patients and their informal caregivers. Our resulting consolidated macroergonomic patient work system model identified 17 factors across physical, social and organisational domains and household and community levels. These factors are illustrated with examples from the three studies and discussed as having positive, negative or varying effects on health and health behaviour. We present three brief case studies to illustrate how macroergonomic factors combine across domains and levels to shape performance in expected and unexpected ways. Findings demonstrate not only the importance of context for patients' health-related activities but also specific factors to consider in future research, design and policy efforts. Practitioner Summary: Health-related activities of patients are embedded in and shaped by levels of social, physical and organisational context. This paper combined findings from three studies to specify 17 contextual or macroergonomic factors in home- and community-based work systems of chronically ill patients. These factors have research, design and policy implications.

ACCULTURATION AS A PREDICTOR OF HEALTH PROMOTING AND LIFESTYLE PRACTICES OF ARAB AMERICANS: A DESCRIPTIVE STUDY.

A cross-sectional descriptive study was done using the Acculturation Rating scale of Arab Americans-II, and the Health Promotion and Lifestyle Profile II to assess the relationship between acculturation and health promotion practices among Arab Americans. Findings showed that attraction to American culture was the most important predictor of physical activity; whereas attraction to Arabic culture was the most important predictor of stress management and nutritional practices. Results suggest that, when demographics are controlled, acculturation predicts various health promotion practices in different patterns among members of this group. These findings contribute to a better understanding of acculturation's influence on immigrants' health promotion practices.

Self-care Barriers Reported by Emergency Department Patients With Acute Heart Failure: A Sociotechnical Systems-Based Approach.

STUDY OBJECTIVE: We pilot tested a sociotechnical systems-based instrument that assesses the prevalence and nature of self-care barriers among patients presenting to the emergency department (ED) with acute heart failure. METHODS: A semistructured instrument for measuring self-reported self-care barriers was developed and administered by ED clinicians and nonclinician researchers to 31 ED patients receiving a diagnosis of acute heart failure. Responses were analyzed with descriptive statistics and qualitative content analysis. Feasibility was assessed by examining participant cooperation rates, instrument completion times, item nonresponse, and data yield. RESULTS: Of 47 distinct self-care barriers assessed, a median of 15 per patient were indicated as "sometimes" or "often" present. Thirty-four specific barriers were reported by more than 25% of patients and 9 were reported by more than 50%. The sources of barriers included the person, self-care tasks, tools and technologies, and organizational, social, and physical contexts. Seven of the top 10 most prevalent barriers were related to patient characteristics; the next 3, to the organizational context (eg, life disruptions). A preliminary feasibility assessment found few item nonresponses or comprehension difficulties, good cooperation, and high data yield from both closed- and open-ended items, but also found opportunities to reduce median administration time and variability. CONCLUSION: An instrument assessing self-care barriers from multiple system sources can be feasibly implemented in the ED. Further research is required to modify the instrument for widespread use and evaluate its implementation across institutions and cultural contexts. Self-care barriers measurement can be one component of broader inquiry into the distributed health-related "work" activity of patients, caregivers, and clinicians.

The patient work system: an analysis of self-care performance barriers among elderly heart failure patients and their informal caregivers.

Human factors and ergonomics approaches have been successfully applied to study and improve the work performance of healthcare professionals. However, there has been relatively little work in "patient-engaged human factors," or the application of human factors to the health-related work of patients and other nonprofessionals. This study applied a foundational human factors tool, the systems model, to investigate the barriers to self-care performance among chronically ill elderly patients and their informal (family) caregivers. A Patient Work System model was developed to guide the collection and analysis of interviews, surveys, and observations of patients with heart failure (n = 30) and their informal caregivers (n = 14). Iterative analyses revealed the nature and prevalence of self-care barriers across components of the Patient Work System. Person-related barriers were common and stemmed from patients' biomedical conditions, limitations, knowledge deficits, preferences, and perceptions as well as the characteristics of informal caregivers and healthcare professionals. Task barriers were also highly prevalent and included task difficulty, timing, complexity, ambiguity, conflict, and undesirable consequences. Tool barriers were related to both availability and access of tools and technologies and their design, usability, and impact. Context barriers were found across three domains-physical-spatial, social-cultural, and organizational-and multiple "spaces" such as "at home," "on the go," and "in the community." Barriers often stemmed not from single factors but from the interaction of several work system components. Study findings suggest the need to further explore multiple actors, contexts, and interactions in the patient work system during research and intervention design, as well as the need to develop new models and measures for studying patient and family work.

Inpatient insulin pump therapy: assessing the effectiveness of an educational program.

Technological advances in diabetes management include continuous subcutaneous insulin infusion. This article describes a pilot project using an educational intervention by a diabetes nurse educator aimed at familiarizing nurses with insulin pump therapy at a large teaching hospital. Teaching points included appropriate patient selection, principles of insulin therapy, and safe insulin pump operation. An embedded mixed-method design was employed to assess educational effectiveness. Results of the pretest and posttest analysis indicated that the program significantly increased knowledge and confidence among nurses for managing pump therapy.

Characterizing novice-expert differences in macrocognition: an exploratory study of cognitive work in the emergency department.

STUDY OBJECTIVE: The objectives of this study are to elicit and document descriptions of emergency physician expertise, to characterize cognitive differences between novice and expert physicians, and to identify areas in which novices' skill and knowledge gaps are most pronounced. The nature of the differences between novices and experts needs to be explored to develop effective instructional modalities that accelerate the learning curve of inexperienced physicians who work in high-complexity environments. METHODS: We interviewed novice emergency physicians (first-year residents) and attending physicians with significant expertise, working in an academic Level I trauma center in Southern California. With cognitive task analysis, we used task diagrams to capture nonroutine critical incidents that required the use of complex cognitive skills. Timelines were constructed to develop a detailed understanding of challenging incidents and the decisions involved as the incident unfolded, followed by progressive deepening to tease out situation-specific cues, knowledge, and information that experts and novices used. A thematic analysis of the interview transcripts was conducted to identify key categories. Using classification techniques for data reduction, we identified a smaller set of key themes, which composed the core findings of the study. RESULTS: Five interns and 6 attending physicians participated in the interviews. Novice physicians reported having difficulties representing the patient's story to attending physicians and other health care providers. Overrelying on objective data, novice physicians use linear thinking to move to diagnosis quickly and are likely to discount and explain away data that do not "fit" the frame. Experienced physicians draw on expertise to recognize cues and patterns while leaving room for altering or even changing their initial diagnosis. Whereas experts maintain high levels of spatial, temporal, and organizational systems awareness when overseeing treatment modalities of multiple patients, novices have difficulty seeing and maintaining the "big picture." CONCLUSION: Novice physicians use sense-making styles that differ from those of experts. Training novices to respond to the high cognitive demand of complex environments early in their careers requires instructional modalities that not only increase their knowledge base but also accelerate the integration of knowledge and practice. Simulation and custom-designed avatar-mediated virtual worlds are a promising new technology that may facilitate such training. Future research should expand on the results of this study through the use of larger sample sizes and interviews conducted at multiple sites to increase generalizability.

Validity and reliability of an adapted german version of scoliosis research society-22 questionnaire.

STUDY DESIGN: Study to determine the internal consistency and validity of adapted German version of Scoliosis Research Society-22 (SRS-22) questionnaire. OBJECTIVE: To evaluate the validity and reliability of adapted German version of SRS-22 questionnaire. SUMMARY OF BACKGROUND DATA: The SRS-22 questionnaire was developed to assess the health-related quality of life for English-speaking patients with idiopathic scoliosis. For scientific purpose and standardized comparison of outcome studies for the treatment of idiopathic scoliosis its adaptation into German is necessary to respect cultural and lingual differences. METHODS: Translation/retranslation of the English version of the SRS-22 was conducted, and all steps for cross-cultural adaptation process were performed. Thus, SRS-22 questionnaire and previously validated Roland-Morris score were mailed to 222 patients who had been treated surgically or conservatively for idiopathic scoliosis. Seventy-eight patients (35%) responded to the first set of questionnaires and 54 of the first time responder returned their second survey. The median age of all patients who joined the study was 19 years. Measures of reliability namely, selectivity, internal consistency, and reproducibility were determined by Cronbach's alpha statistics and intraclass correlation coefficient, respectively. Concurrent validity was measured by comparing with an already validated questionnaire (Roland-Morris score). Measurement was made using the Spearman correlation coefficient. RESULTS: The study demonstrated satisfactory internal consistency with high Cronbach's alpha values for 4 of the corresponding domains (pain, 0.75; self-image, 0.84; mental health, 0.88; and satisfaction, 0.61). However, the Cronbach's alpha value for function/activity domain (0.67) was considerably lower than the original English questionnaire. For the same domains intraclass correlation coefficient demonstrating satisfactory test/retest reproducibility. CONCLUSION: The adapted German version of the SRS-22 questionnaire can be used to assess the outcome of treatment for German-speaking patients with idiopathic scoliosis.

Varicella-zoster virus infection induces the secretion of interleukin-8.

Interleukin-8 (IL-8) is an important mediator in neutrophil-mediated acute inflammation but has also a wide range of actions on various cells types. We demonstrated that infection of melanoma cells and fibroblasts with cell-associated varicella-zoster virus (VZV) and infection of a T cell line with cell-free VZV resulted in an induction of IL-8 secretion in vitro. The inhibition of the VZV replication with a drug interfering with its DNA replication had no effect on the IL-8 release. Since the IL-8 promoter contains binding sites for NF-kappaB and AP-1, melanoma cells and the T cell line were treated with inhibitors of NF-kappaB, JNK/SAPK or p38/MAPK prior to infection. In melanoma cells, the JNK/SAPK pathway was shown to be important for the IL-8 secretion during the VZV replication, whereas in the T cell line, not only the JNK/SAPK but also the p38/MAPK pathways were required for IL-8 secretion. The neutralisation of the IL-8 bioactivity had no significant consequence on the VZV replication, suggesting that IL-8 acts neither as a proviral nor as an antiviral cytokine during the VZV replication in vitro.