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PubMed2001

Vertebral artery injuries.

Vertebral artery injuries are identified more frequently now than in the past for both penetrating and blunt trauma. This is as a result of increased suspicion and awareness, liberal use of color flow Doppler, CT angiography, and traditional four-vessel angiography. The vast majority of patients who are not exsanguinating at the time of presentation can be managed nonoperatively or by angiographic embolization. Operative management should be reserved only for patients with severe active bleeding or when interventional radiology fails. The surgical exposure is complex and demands excellent knowledge of the local anatomy.

Humans↗

PubMed2000

The role of complement anaphylatoxin C5a in neurodegeneration: implications in Alzheimer's disease.

There is evidence that the complement system, a major component of inflammatory responses, may play an important role in neurodegenerative conditions such as Alzheimer's disease (AD). Work from our lab demonstrated that mice genetically deficient in the complement component C5 are more susceptible to hippocampal excitotoxic lesions (Pasinetti et al., 1996) and that the C5-derived ana;hylatoxin C5a may protect against excitotoxicity in vitro and in vivo (Osaka et al., 1999). Potential mechanisms identified in C5a-mediated neuroprotection include activation of mitogen activated protein (MAP)-kinase (Osaka et al., 1998; Osaka et al., 1999). This novel neuroprotective role of C5a complicates current theories that complement proteins augment beta-amyloid (Abeta) toxicity in AD. In view of the fact that the complement system represents a target for therapeutic interventions in AD, further characterization of the complex role of complement proteins is essential. Towards this aim, we have characterized a transgenic C5a receptor (C5aR) knockout (KO) mouse. Recent studies in the lab using C5aR-KO mice show that disruption of C5aR alters calcium calmodulin kinase (CaM-KII) signal transduction in brain cells. We are presently using C5aR-KO mice to study the role of C5a in caspase mediated apoptotic neuronal death. In this review we will attempt to delineate possible neuroprotective roles for C5a in mechanisms of neurotoxicity pertaining to AD.

Alzheimer Disease↗

PubMed2003

Collaboration of nursing and child life: a palette of professional practice.

This evidence-based practice (EBP) article begins with a case study background. Case studies can be used to illustrate the unfolding of the nursing process, from assessment to reassessment, for particular patient care situations. The evidence-based process, and its importance for successful clinical outcomes, is explicated after the case study presentation. This is an example of how EBP is an integral part of what we do as healthcare professionals: When we are faced with clinical dilemmas, evidence-based tools are there to guide us to solutions. In this example, Child Life and Nursing worked collaboratively to identify key clinical issues. They consulted with clinical experts within the hospital, and they used scientific rationale to select therapeutic interventions to support a patient and her family through several crisis situations. The EBP tools, seeking clinical expertise and applying research-based interventions, resulted in successful outcomes for a complex patient care situation.

Child↗

PubMed1998

Surrogates' agreement with patients' resuscitation preferences: effect of age, relationship, and SUPPORT intervention. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment.

PURPOSE: The purpose of this study was to evaluate an intervention to improve patient-surrogate agreement on end-of-life resuscitation preferences. MATERIALS AND METHODS: Seven hundred seventeen patients with a 50% 6-month survival rate and their surrogate decision-makers were recruited for a randomized clinical trial from five teaching hospitals participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). Intervention patients (n=386) were assigned specially trained nurses who spent extra time with patients and families explaining prognoses and treatments. Control patients (n=331) received usual care. Patient preferences and surrogate's perception of those preferences at pre- and post-intervention interviews were compared. RESULTS: Agreement between patients and surrogates was 75.0% at the day 3 interview and 79.6% at the month 2 interview, increasing 4.6% (95% CI: 0.1%, 9.1%). Improvements in agreement from day 3 to month 2 were seen equally in both study groups. A multivariable analysis verified that the intervention did not have an effect on agreement and indicated a decrease in agreement among older patients and among surrogates not in the immediate family. CONCLUSIONS: The SUPPORT intervention was not successful in increasing agreement between patients and surrogates. Because of the complex issues involved in end-of-life decision-making, a more aggressive intervention may be needed. Other findings suggest that improvements in communication are particularly needed when patients are older and when the surrogate is not a patient's immediate relative.

Advance Directives↗

PubMed2003

Fibromuscular dysplasia: when is intervention warranted?

Fibromuscular dysplasia is a multifactorial arteriopathy that primarily affects small and medium-sized arteries. It is most common in the renal and internal carotid arteries. Pathological classification is based on the arterial wall layer most significantly involved. The natural history and incidence of asymptomatic disease is unknown. The most common lesions become symptomatic as a high-grade stenosis producing renovascular hypertension or as an embolic source for the cerebral circulation. Treatment is reserved for symptomatic lesions. Most simple lesions are effectively treated by catheter-based intervention. Surgical therapy is warranted for more complex lesions. Both produce durable, long-term results.

Fibromuscular Dysplasia↗

PubMed2000

The impact of HIV on family size preference in Zambia.

This paper examines the way in which concerns about HIV infection are affecting thinking in Zambia about preferred number of children. It draws on research on the impact of HIV/AIDS in peri-urban and rural households in 1995, based mainly on in-depth interviews with 65 of 300 people who were initially surveyed. In spite of high levels of anxiety about AIDS in these communities, risk from HIV was not always associated with the act of conceiving children, nor did this association necessarily influence actual behaviour or family size preferences. In some cases, however, the threat of contracting HIV had led to a decision to have fewer children. Many also worried about leaving orphans for others to look after and the costs which might be incurred in taking over the care of orphans left by others. A related reason for limiting fertility was the hope that orphaned children would be better cared for if there were fewer of them. Greater access to contraceptives, and specifically to condoms, is an important element in supporting women's efforts to protect themselves, and men also need to be involved in strategies for mutual protection. In both communities, however, there was a shared sense of limited control, not just over fertility, but also over the wider economic and health environment. An understanding of the complexity of these factors is essential for intervention programmes intended to enhance women's reproductive rights and support their fertility choices so as to ensure greater protection against HIV/AIDS.

Adult↗

PubMedDate not supplied

Bearing witness to suffering in AIDS: constructing meaning from loss.

The phenomenon of AIDS volunteerism has been described as an act of bearing witness. It has been suggested that bearing witness assists individuals affected by the suffering in HIV/AIDS to heal. The purpose of this research was to explore AIDS volunteerism as a potentially healing phenomenon. Using grounded theory methodology, open-ended interviews were conducted with 17 participants over a 7-month period of time. The constant comparative method was used for data analysis. A substantive theory was generated that identified the basic sociological process as constructing meaning from loss and described the transformative psychosocial and spiritual healing process individuals undergo as they volunteer. Constructing meaning from loss is described within the following three major stages: (a) experiencing suffering, (b) containing suffering, and (c) transforming suffering. Characteristics within each stage are described. Suffering and complex loss are major issues in HIV/AIDS. Interventions are recommended for nurses who care for those affected by HIV disease.

Acquired Immunodeficiency Syndrome↗

PubMed1997

Influence of the addition of restorations on the diagnosis of caries from digitized bitewing radiographs.

OBJECTIVES: The purpose of this study was to assess the influence of additional caries and restorations on the detection of caries on the same radiograph. STUDY DESIGN: Six participants examined five series of four radiographs in which natural carious lesions were present. Each series consisted of the same image with progressively more restorative treatment digitally painted on. The films were randomly presented to the observers who examined the films for the presence and depth of carious lesions. The observers were not informed that the 20 films were disguised versions of the same original five radiographs. RESULTS: The number of carious lesions reported by the six observers did not increase despite the apparent increased restorative intervention viewed on the radiographs. CONCLUSIONS: The complexity of restorative care does not affect observers' ability to correctly detect approximal carious lesions.

Adult↗

PubMed2006

What makes for a compassionate patient-caregiver relationship?

BACKGROUND: During Summer 2005, the Kenneth B. Schwartz Center asked hospitals to hold rounds to discuss the topic, "What Makes for a Compassionate Patient-Caregiver Relationship?" Review of questionnaires and transcripts of the rounds held at 54 hospitals in 21 states yielded three major categories: communication, common ground, and respect for individuality. COMMUNICATION: Suggestions to improve compassionate care often focused on style and content. Rounds attendees felt that compassionate care also depends on imparting medical facts in a clear and useful manner to patients--often difficult for complex medical issues. COMMON GROUND: Compassionate care depends on showing empathy for a patient's illness experience no matter what his or her background. Rounds participants felt that caregivers could make a conscious choice to care deeply for patients. Sharing personal information with patients and admitting mistakes were key methods for identifying common ground. TREATING THE PATIENT AS AN INDIVIDUAL: Compassionate care requires striking an individualized balance between providing guidance and allowing autonomy to achieve shared consensus, especially with complex information. A PRESCRIPTION FOR CHANGE: Most interventions target students yet do not continually reinforce compassion. Advocates for compassionate care should instead treat lack of compassion not as an acute trauma but as a chronic condition requiring a lifetime of continuous support, regular guidance, repeated reinforcement, specific targeted outcomes, and more innovative care programs.

Communication↗

PubMed1998

A conceptual framework for mental health services: the matrix model.

BACKGROUND: The reform of mental health services needs to be guided by an overall conceptual framework. Such a framework is important to avoid many risks, including extrapolating from a specific service site to other services, without taking into account local and regional variables. METHODS: A conceptual framework, the 'matrix model', is proposed. This model has been developed using the most relevant information that is necessary for describing and interpreting mental health services data as well as patient-based information. RESULTS: The 'matrix model' has two dimensions: the geographical, which refers to three levels (country, local and patient) and the temporal, which refers to three phases (inputs, processes and outcomes). Using these two dimensions a nine-cell matrix is constructed to bring into focus critical issues for mental health services. The relevance of each level and each phase is briefly presented. CONCLUSIONS: The matrix is intended to assist clinicians, planners and researchers to deal with clinical phenomena, organizational issues, and research questions that share a degree of complexity that render inadequate analyses and the interventions made only at one level. The matrix model applies particularly to mental health systems of care that are provided with a public health framework, and is less useful for contexts that consist of clinicians offering only one-to-one treatments, within fragmented programmes of care.

Case Management↗

PubMedDate not supplied

Post-war Kosovo: Part 3. Development and rehabilitation of emergency services.

The recent crisis in Kosovo led to nearly complete destruction of a healthcare system serving the needs of approximately 2 million people. Even prior to the crisis, the pre-existing healthcare system had inadequate provisions for the delivery of Emergency Medical Services. More than 440 diverse governmental and non-governmental organizations (NGOs) arrived to assist (and often compete) in the rehabilitation of Kosovo's healthcare needs. Each brought with them individual biases and strategies for how this rehabilitation should occur, and each faced numerous unforeseen barriers to the implementation of its programs. The authors used a four-step, multi-modal, needs assessment to gather information on the needs and potential barriers to the implementation of a program to rehabilitate emergency services as discussed in Part II. This paper chronicles the phases of the Emergency Medicine program development and the process of responding to barriers and changing needs. The program's successes and failures are noted, and the actual barriers encountered are reviewed. Overall, the needs assessment tool employed in this program was useful in the implementation of a program to restore and rehabilitate Emergency Services in Kosovo. The authors recommend the use of combined quantitative and qualitative methods for developing priorities for interventions in post-conflict settings following complex emergencies.

Emergency Medical Services↗

PubMed1998

Understanding neurotransmitter receptors: molecular biology-based strategies.

Neurotransmitter receptor proteins can be divided into GPCRs and ligand-gated ion channels. Members within each family utilize a similar signalling mechanism and are structurally related. Multiple receptor subtypes are expressed for individual neurotransmitters, generating orders of complexity that have been exploited for therapeutic intervention. GPCRs have been cloned and extensively studied by using a range of molecular biological strategies, particularly recombinant expression systems. These have located functional domains for ligand binding and G-protein coupling. A combination of molecular biology and computer modelling has increased our understanding of receptor activation and will aid drug design.

Animals↗

PubMed2001

Palliative radiotherapy of bone metastases: an evaluation of outcome measures.

The objective of this study was to identify and evaluate important patient-based outcomes that are specific to the palliative radiotherapy of bone metastases. We first conducted a literature review to identify and evaluate outcomes that are currently in use. To identify outcomes that are important to patients, in-depth patient interviews were conducted. Finally, issues identified through the interviews were quantified through a prospective survey, in which patients completed a questionnaire prior to commencing radiotherapy and again after 6 weeks. In our literature review, we found that there was no standardized definition of either response to radiotherapy or assessment of pain relief. Pain measurement in many studies was undertaken using very simple measures, which could possibly yield inaccurate results. The vast majority of studies did not include quality of life as an endpoint. The patient interviews and survey showed that chronic pain and associated limitation of movement were the disease symptoms causing the most concern. Having a clear, alert mind and being able in self-care were the aspects of daily living given the highest priority. Sustained pain relief and minimizing the risk of future complications were the main priorities relating to radiotherapy treatment. The practical aspects of treatment (travelling distance, remaining at home and brevity of treatment) were of least importance. This study indicates the complexity of evaluating the outcomes of palliative interventions, and confirms the deficiencies of pain relief as the primary end-point. The patient's quality of life is affected by many factors other than pain (such as limited mobility, reduced performance, side effects and impaired role functioning); hence a wider range of end-points is required. Greater sensitivity is required than in currently used end-points. Concurrent diseases as well as concurrent therapies can make it difficult to attribute effects with precision. Unless such factors are considered in research design, the results may prove unreliable.

Analgesics↗

PubMed2001

[Malnutrition in COPD].

During the last years our knowledge about the malnutrition of patients with COPD has grown. Weight loss is a problem of some patients with COPD, but, as we know today by techniques of body composition measurement much more patients have reduced muscle mass. The reason for this is complex and involves many body systems. Nutritional intervention alone is not successful in many patients. We have to accept that COPD is a kind of systemic disease which does not only involve the lung. Thus, future therapies have to include not only treatment of the bronchial system.

Body Composition↗

PubMedDate not supplied

[Spinal cord stimulation (SCS) using an 8-pole electrode and double-electrode system as minimally invasive therapy of the post-discotomy and post-fusion syndrome--prospective study results in 34 patients].

AIM: Therapy of a pronounced post-discotomy (PDS) and post-fusion syndrome (PFS) is often unsatisfactory because of the complexity and multifactorial pain genesis. If surgical interventions cannot promise relief and if the entire interdisciplinary spectrum of conservative treatment measures is inadequate, the area of neuromodulative procedures offers spinal cord stimulation (SCS). The objective of this study was to examine the therapeutic possibilities of SCS using an 8-pole electrode and double electrode system in PDS and PFS with extensive back-leg pain areas. METHOD: An appropriate SCS system was implanted in 34 patients with PDS and PFS. Follow-up examinations were made prospectively over a period of 24 months using general criteria and psychometric test measuring instruments validated for German-language use. RESULTS: An 8-pole double electrode system was implanted 23 times, a single electrode sufficed in 11 cases. The area of pain was covered in all patients. This required special technical capabilities of the SCS system. The results remained constant over 24 months. The morphine dose could be reduced by at least 50 %. All measuring instruments confirmed a clear reduction in pain and improvement in quality of life as a result of SCS implantation. CONCLUSION: The SCS is an minimally invasive surgical procedure which can enlarge the therapeutical possibilities of pronounced PDS and PFS resistant to other modes of treatment. Special technical possibilities of parameter setting are required to cover the pain areas.

Adult↗

PubMed1997

Parents as partners in the treatment of childhood stuttering.

Speech-language pathologists involved in treating childhood stuttering have increasingly emphasized the need for parental involvement in intervention. In this article, we review prevailing theoretical models of stuttering and illustrate various ways in which these models can be used to guide practitioners in determining how best to include parents in intervention. We argue that successful parental involvement depends upon the ability of parents and clinicians to reach consensus on issues such as the parents' role in the onset and development of stuttering, the rationale for including parents in fluency intervention, and the importance early intervention. The article concludes with a discussion of specific ways that parents can assist in intervention through modeling, managing conversational pace and complexity, and, in some cases, directly instructing their children.

Child↗

PubMed1996

Group treatment for adult women who experienced childhood sexual trauma: is telling the story enough?

Long-term process-oriented psychotherapy groups for adult survivors of childhood sexual abuse allow an in-depth exploration of both the individual meaning of traumatic experiences and the subsequent effects on current adult life functioning. It may not be curative just to tell the traumatic story. Therapists must also pay careful attention to unconscious reenactments by examining the process of interpersonal relating between and among group members and their therapists. Rather than avoidances, these reenactments are better viewed as a necessary form of remembering and can contribute to the understanding of the past trauma and recognition of current, previously unconscious manifestations in maladaptive behaviour. Such therapeutic benefit began to be evident in some members within 6 months in the group; for others, more time was necessary, often a year or more. Additional study and understanding of the role of reenactments in trauma treatment may lead to more effective intervention strategies that can further elucidate the complexity of this form of memory.

Adult↗

PubMed2006

The brain and fatigue: new opportunities for nutritional interventions?

It is clear that the cause of fatigue is complex, influenced by events occurring in both the periphery and the central nervous system. Work conducted over the last 20 years has focused on the role of brain serotonin and catecholamines in the development of fatigue, and the possibility that manipulation of neurotransmitter precursors may delay the onset of fatigue. While there is some evidence that branched-chain amino acid and tyrosine ingestion can influence perceived exertion and some measures of mental performance, the results of several apparently well-controlled laboratory studies have not demonstrated a positive effect on exercise capacity or performance under temperate conditions. As football is highly reliant upon the successful execution of motor skills and tactics, the possibility that amino acid ingestion may help to attenuate a loss in cognitive function during the later stages of a game would be desirable, even in the absence of no apparent benefit to physical performance. There are several reports of enhanced performance of high-intensity intermittent exercise with carbohydrate ingestion, but at present it is difficult to separate the peripheral effects from any potential impact on the central nervous system. The possibility that changes in central neurotransmission play a role in the aetiology of fatigue when exercise is performed in high ambient temperatures has recently been examined, although the significance of this in relation to the pattern of activity associated with football has yet to be determined.

Amino Acids, Branched-Chain↗