Emotional responses of family members during a critical care hospitalization

BACKGROUND: The needs and satisfaction levels of family members of critically ill patients have received much attention in the literature. The feelings of family members, however, have not been thoroughly investigated. To develop appropriate nursing interventions to assist family members in coping with a critical care hospitalization, accurate information about their emotional response to the situation is needed. OBJECTIVE: To examine emotional responses of family members and their descriptions of supportive behaviors of others during a critical care hospitalization. METHODS: An exploratory design was used to study 52 subjects with critically ill family members in the pediatric, neonatal, medical, surgical and cardiovascular intensive care units in a large tertiary care hospital. The subjects kept daily logs of their feelings and the supportive behaviors of others. Thematic analysis was used to identify major themes. RESULTS: Analysis revealed a broad range of powerful emotions throughout the intensive care unit stay. Negative and positive emotions such as despair and joy were sometimes identified by subjects within a 24-hour period. Although fear, worry, anger and exhaustion were dominant themes during the first 24 hours and when the family received bad news about the patient, there was no pattern of emotional response evident as the stay progressed. Some differences between subjects drawn from the medical and neonatal intensive care units were evident. CONCLUSIONS: The findings suggest that family members of critically ill patients experience deep emotional turmoil throughout the intensive care unit stay. Specific nursing interventions to promote adaptive coping are needed throughout the experience.

Emotional responses of family members during a critical care hospitalization

BACKGROUND

The needs and satisfaction levels of family members of critically ill patients have received much attention in the literature. The feelings of family members, however, have not been thoroughly investigated. To develop appropriate nursing interventions to assist family members in coping with a critical care hospitalization, accurate information about their emotional response to the situation is needed.

OBJECTIVE

To examine emotional responses of family members and their descriptions of supportive behaviors of others during a critical care hospitalization.

METHODS

An exploratory design was used to study 52 subjects with critically ill family members in the pediatric, neonatal, medical, surgical and cardiovascular intensive care units in a large tertiary care hospital. The subjects kept daily logs of their feelings and the supportive behaviors of others. Thematic analysis was used to identify major themes.

RESULTS

Analysis revealed a broad range of powerful emotions throughout the intensive care unit stay. Negative and positive emotions such as despair and joy were sometimes identified by subjects within a 24-hour period. Although fear, worry, anger and exhaustion were dominant themes during the first 24 hours and when the family received bad news about the patient, there was no pattern of emotional response evident as the stay progressed. Some differences between subjects drawn from the medical and neonatal intensive care units were evident.

CONCLUSIONS

The findings suggest that family members of critically ill patients experience deep emotional turmoil throughout the intensive care unit stay. Specific nursing interventions to promote adaptive coping are needed throughout the experience.

Behavioral responses of family members during critical illness

This articles describes the behavioral responses of adult family members to critical illness and how these responses change over the course of the hospitalization. A convenience sample of 52 family members of patients in intensive units completed the Iowa ICU Family Scale, a self-report tool measuring sleep, eating, activity, family role, and support behaviors. Scales were completed by family members each day during the first week and then weekly throughout the patient's ICU stay. Family members reported sleeping less with a poorer quality of sleep, less nutritional intake, an increased use of cigarettes, alcohol, and over-the-counter and prescription medications, and spending more time talking, visiting the patient, and waiting. Stress was highest at the time of the ICU admission, began to plateau at Day 6, and then dropped considerably by Day 28. These findings suggest that crisis intervention is important during the early phase of caring for critically ill patients and their family members.

Group functioning of a collaborative family research team

Collaborative research teams are an attractive means of conducting nursing research in the clinical setting because of the many opportunities that collaboration can supply. These opportunities include a chance to: (1) network with other nurses who have similar interests, (2) share knowledge and expertise for designing clinical studies that directly affect daily practice, (3) develop instruments, (4) write grant proposals, (5) collect and analyze data, and (6) prepare manuscripts for publication. The effectiveness of research teams, however, is strongly influenced by group functioning. This article describes the functioning of a collaborative family interventions research team of nursing faculty members and CNSs at a large Midwestern university setting. The formation of the group and membership characteristics are described, along with strategies used to identify the research focus and individual and group goals. Aspects related to the influence of the group on members and the internal operations of the group are also addressed. Future strategies to be explored will focus on the size of the group and joint authorship issues. The authors also set forth a number of recommendations for development of collaborative research groups.

Are accidents poisson distributed? A statistical test

The common and convenient assumption in accident count analysis, that accidents are Poisson-distributed, is reexamined. Two statistical tests, for evaluating the assumption are described and compared. It is shown that a test based upon a combinatorial analysis is much more accurate than the alternative chi-square test when accident counts are expected to be small. The more accurate test is used to reinterpret data on accident count variability, the results indicating that the Poisson distribution is appropriate for the analysis of accidents at individual sites.

Neuromuscular and cardiovascular effects of atracurium in isoflurane-anesthetized chickens

Atracurium besylate, a nondepolarizing neuromuscular blocking agent, was administered to 24 isoflurane-anesthetized domestic chickens. Birds were randomly assigned to 4 groups, and atracurium was administered at dosage of 0.15, 0.25, 0.35 or 0.45 mg/kg of body weight. The time of onset of twitch depression, the amount of maximal twitch depression, and the duration of muscular relaxation were recorded. After return to control twitch height, atracurium was further administered to achieve > 75% twitch depression. When twitch depression reached 75% during noninduced recovery, 0.5 mg of edrophonium/kg was administered to reverse the muscle relaxation. Throughout the experimental period, cardiovascular, arterial blood gas, and acid-base variables were monitored. The effective dosage of atracurium to result in 95% twitch depression in 50% of birds, (ED95/50) was calculated, using probit analysis, to be 0.25 mg/kg, whereas the ED95/95, the dosage of atracurium to result in 95% twitch depression in 95% of birds, was calculated by probit analysis to be 0.46 mg/kg. The total duration of action at dosage of 0.25 mg/kg was 34.5 +/- 5.8 minutes; at the highest dosage (0.45 mg/kg), total duration increased to 47.8 +/- 10.3 minutes. The return to control twitch height was greatly hastened by administration of edrophonium. Small, but statistically significant changes in heart rate and systolic blood pressure, were associated with administration of atracurium and edrophonium. These changes would not be clinically relevant. In this study, atracurium was found to be safe and reliable for induction of muscle relaxation in isoflurane-anesthetized chickens.

Cerebral palsy--an increasing contributor to severe mental retardation?

It is estimated that the prevalence of nongenetic SMR associated with cerebral palsy has risen from 0.7 to about 0.9 per 1000 live births in the last decade. This is due to the predicted rise in total cerebral palsy prevalence to 2.5/1000 live births. This predicted prevalence of cerebral palsy is similar to that given for Western Australia in 1979-82, allowing for postnatal causes, but is higher than prevalence data from England and Sweden for that period. The estimated rise is due largely to improved survival and increased proportion of low birthweight babies since 1983 and also reflects the use of prevalence rates based on Mersey data. Improvements in prenatal diagnosis, and a parental choice of selective termination may lead to reductions in other causes of SMR, such as Down's syndrome and neural tube defects, so it seems that children both physically and mentally handicapped due to brain damage will contribute a greater proportion of the SMR population. The careload of these children is greater than that associated with many other causes of SMR and most survive into adult life. The implications for planning future services will need to be recognised.

Oat cell carcinoma of urinary bladder

Oat cell carcinoma of the urinary bladder is extremely uncommon. There have been 52 reported cases in world literature to date. On light microscopic, histochemical, and ultrastructural grounds, these tumors are similar to oat cell carcinoma of the bronchus and other extrapulmonary oat cell carcinomas. Furthermore, they may be grouped together as a clinical entity characterized by an aggressive clinical course with early and extensive metastases, and partial remission with certain chemotherapeutic agents. We report a case of primary small cell carcinoma of the urinary bladder in a forty-two-year-old man and review previous reports with similar histology. The importance of establishing this diagnosis and the optimum forms of therapy are discussed.

Developmental delay in congenital myotonic dystrophy after neonatal intensive care

Six infants with congenital myotonic dystrophy survived after neonatal intensive care. In later childhood they were assessed by the Griffiths Mental Development Scales: five children were functioning in the mildly handicapped to borderline range of development (DQ 64.0 to 79.0) and the remaining child was severely delayed in development (DQ 33.0). The five children with higher DQ values had a history of ventilatory support of 30 days or less after birth. By contrast, the remaining child with the lowest DQ value had been ventilated for 43 days. This study provides further evidence that prolonged ventilation after birth has prognostic significance in identifying severely affected cases with congenital myotonic dystrophy.

Fat malassimilation in three cats

Three cats were thin despite eating well. Steatorrhoea was confirmed in each by 72-hour fat assimilation tests. Fat digestibility in all 3 increased twofold when the diet was supplemented with pancreatic enzymes, suggesting the possibility of exocrine pancreatic insufficiency. However, examination of stained faecal smears gave evidence of both maldigestion and malabsorption of fat, without maldigestion of starch, and only one case had indications of protein maldigestion. In the latter cat, fat digestibility normalised with pancreatic enzyme supplementation and exocrine pancreatic insufficiency was considered likely. However, at post-mortem examination enteropathy and pancreatitis, but not exocrine pancreatic insufficiency, were found. The cause of fat malassimilation in these cats was unknown. The evaluation of malassimilation in cats is difficult because investigative tests used in other species are either unsuitable or have not been evaluated in cats.

The effect of L-glutamic acid on airway function and reactivity in the rabbit

The ingestion of monosodium glutamate in sensitive individuals has been reported to cause severe asthma. We therefore studied the effects of L-glu on airway function and histamine (H) responsiveness in the rabbit. Histamine dose response curves (HDR's) were performed by measuring total lung resistance (RL) after inhalation of saline and increasing concentrations of H (1-30 mg/ml). The concentration of H producing a 20% increase in RL (PC20H) was obtained by interpolation. To assess the effects of L-glu, 8 rabbits were infused with L-glu (0.2 g/kg/hr) or saline in random order (14 days apart) for 4 hours followed by an HDRC. To look at possible late effects, a repeat HDRC was also performed in 6 rabbits 12 hours after completion of the L-glu infusion. In order to see whether rabbits rendered hyperresponsive responded to L-glu, the above protocol was performed in 7 rabbits following the inhalation of 3 micrograms of the activated complement fragment C5a des Arg. The L-glu infusions increased the plasma levels approx. ten-fold (mean +/- SEM 0.119 +/- 0.012 base-line, 1.272 +/- 0.061 mmol/l post infusion). L-glu did not increase the PC20H or baseline RL in either the normal rabbits at 4 or 12 hours or in the C5a des Arg treated rabbits at 4 hours. It is concluded that L-glu does not cause bronchoconstriction or an increase in airway responsiveness to H in the rabbit.

Deferoxamine infusion does not inhibit bleomycin-induced lung damage in the rat

It has been proposed that the pneumonitis and subsequent lung fibrosis induced by bleomycin occurs when bleomycin is complexed with ferrous iron and oxygen. In order to see whether chelation of free iron reduced tissue damage induced by intratracheal bleomycin, deferoxamine (DFO) was administered by continuous subcutaneous infusion to overcome its rapid renal excretion. Thirty-three rats received DFO and 30 rats received an equivalent volume of saline by 7-day infusion pumps. Three days after commencement of infusion, half of each group received intratracheal bleomycin, the remainder received intratracheal saline. Three weeks after intratracheal injection, the rats were killed and their lungs were removed for histologic and morphometric assessment and collagen estimation. When compared with animals given intratracheal saline, both bleomycin-treated groups had significant evidence of lung toxicity, but DFO was not protective. Similarly, DFO infusion did not reduce the elevation in collagen concentration (bleomycin/saline, 49 +/- 3.6; bleomycin/DFO, 49.8 +/- 4.1; saline/saline, 39.6 +/- 3.9; saline/DFO, 43.4 +/- 3.8 mg.g-1 wet lung weight) or total lung collagen (bleomycin/saline, 29.9 +/- 6.3; bleomycin/DFO, 33.7 +/- 1.8; saline/saline, 15.5 +/- 2.2; saline/DFO, 17.8 +/- 1.9 mg.left lung-1) induced by bleomycin. This lack of effect was not due to iron contamination of the DFO in the pump or to loss of chelation capacity of DFO, at least for as long as 6 days after pump implantation. No DFO was detected in homogenized lung tissue (limits of detection of assay was 8 x 10(-5) M).(ABSTRACT TRUNCATED AT 250 WORDS)

Failure of systemic N-acetyl cysteine to protect the rat lung against bleomycin toxicity

In order to see whether systemically administered N-acetyl cysteine (NAC) could protect the lung from bleomycin lung injury, 24 rats were given a constant subcutaneous infusion of NAC (mean 195 mg.kg-1.day-1) for 7 days while 23 rats were given a similar volume of saline. Two days after the start of infusion, half of each group received an endotracheal injection of bleomycin and the other half received a similar volume of saline. All animals were killed 7 days after intratracheal injection and their lungs were prepared for wet-weight to dry-weight ratio (W:D) and morphometric assessment of histological changes. In animals given intratracheal saline, NAC infusion had no effect on weight gain, W:D or morphometry compared to those animals given saline infusions. However, all bleomycin-treated animals had obvious evidence of lung damage. Compared to either group of animals treated with intratracheal saline, the bleomycin-treated groups gained less weight (p less than 0.001), had a higher W:D (p less than 0.001) and an increase in the volume densities of alveolar and duct walls (p less than 0.001), intra-alveolar cells (p less than 0.05) and consolidation (p less than 0.001). There were no significant differences between the two bleomycin-treated groups in any parameter measured. It is concluded that administration of NAC by a constant subcutaneous infusion was not protective against bleomycin lung injury.

Dr. Copeland on cardiac transplantation. Interview by Monica Kalker

The following interview is an exchange between Jack Copeland, M.D., Robert Emery, M.D., and Anne Nicholson, R.N., members of the heart transplant team at the University of Arizona Medical Center in Tucson, Arizona. Dr. Copeland currently is the chief cardiac surgeon as well as professor and chief of Cardiovascular and Thoracic Surgery. Dr. Emery is an associate professor in the division of cardiothoracic surgery. Ms. Nicholson is a cardiac transplant coordinator for the Center. The University of Arizona's Heart Transplant program has proven itself in terms of actuarial survival, innovative approaches to recipients, surgical techniques, and with the maintenance of relatively short hospital stays and low costs to the patient.

Sarcocystis encephalitis in a cockatiel

A sporozoan organism was considered to be the causative agent of central nervous system disease in a cockatiel. The ultrastructural characteristics were typical of the coccidian group Apicomplexa, and the fact that organisms were free within the cytoplasm of infected cells and not within a vacuole, indicated they were Sarcocystis. Light and electron microscopic evaluation of brain tissue demonstrated protozoal organisms associated with areas of necrosis. Differential diagnosis of central nervous system disease in pet birds should include protozoal encephalitis.

Randomized comparative trial of a ward discussion group

A randomized controlled study of 38 catchment unit psychiatric in-patients in a discussion group showed no significant additional benefit compared with 36 in-patients in an activity group. Symptom change scored by three rating groups agreed closely, average r = +0.64. Patients treated with ECT showed 2.6 times as much reduction in morbidity as those not so treated, but there was still no appreciable difference between discussion and activity groups when this was allowed for. Other treatment factors and the Hawthorne effect appeared to obscure any effect due to group therapy.

Salivary tumours--experience over thirty years

A clinicopathological survey of tumours of salivary glands seen in a special surgical clinic at the Christie Hospital and Holt Radium Institute is reported. Nine hundred and seventy-seven benign and malignant tumours have been seen within the past 30 years. The results of treatment are included with particular attention to those of the parotid glands which present the greatest therapeutic problem. The approach to surgical treatment of pleomorphic adenomas is described in detail and guidelines offered as to the procedure that should be used based on full exploration and assessment of each tumour. The need for adjuvant irradiation depends on the standard of surgery that is done. The relationship between carcinomas and benign adenomas is discussed and the need for surgery in all cases is stressed in order to make a definite histological diagnosis in view of the wide range of pathological abnormality encountered.

Host defense against Neisseria meningitidis requires a complement-dependent bactericidal activity

Some individuals, with severe or recurrent infection with Neisseria species, have been identified as lacking a component in the terminal attack sequence of complement (complement components 5 to 9). The relevance of the terminal attack sequence to various phases of host defense was tested with the use of the C-11 strain of meningococci and human serum genetically deficient in complement component 8 (C8-D). The C8-D serum was comparable to normal serum in supporting ingestion and intracellular killing by leukocytes but was not bactericidal in the fluid phase unless reconstituted with C8. Thus, serum complement-dependent bactericidal activity may be especially critical for the host's defense against invasive Neisseria species.

Lymphocytes forming stable E-rosettes in acute and chronic hepatitis

Lymphocytes forming E-rosettes with sheep erythrocytes which do not disintegrate at 37 degrees C have been demonstrated in increased numbers in peripheral blood of patients with acute type B hepatitis (6--20% of lymphocytes) and with HBsAg negative active chronic hepatitis (9--28% of lymphocytes). They were not increased in patients with HBsAg positive active chronic hepatitis. Such lymphocytes were adherent to nylon wool and a large proportion of them had FcIgG receptors (21--69%). These are properties of a subpopulation of T lymphocytes having suppressor function.

The spectrum of Bacillus bacteremias in heroin addicts

Bacillus bacteremias occurred in two heroin addicts. The first patient had one day of fever and chills after intravenous heroin use. Persistent cereus bacteremia consistent with endocarditis was documented and responded to four weeks of antibiotic therapy. The second patient had non-cereus Bacillus species isolated from blood cultures three times over eight days, each time after renewed heroin use. The patient remained well, and the bacteremias cleared spontaneously. Because Bacillus species frequently contaminate heroin injection materials and because the Bacillus bacteremias were temporally associated with intravenous heroin use, Bacillus bacteremias in both patients probably eventuated from heroin abuse. These cases, in conjunction with two previously reported cases of Bacillus endocarditis in heroin addicts, suggest that heroin addicts are at risk for developing Bacillus bacteremias, which may vary in severity from endocarditis to benign transient bacteremias.

Isolation and characterization of Guinea pig properidin

Guinea pig properdin was purified to homogeneity by employing as an assay during isolation its capacity to augment the hemolytic activity of a heterologous human C3b-dependent C3 convertase, C3B. The purified protein elicited a monospecific antibody response in a rabbit. The antiserum, by immunodiffusion, gave a reaction of identity between a protein in whole guinea pig serum and the immunogen. A solid phase immunoadsorbent prepared with the antiserum removed properdin function from the purified protein. The purified guinea pig protein exhibited the classical properdin function of reconstituting a human RP for zymosan-induced C3 inactivation. The guinea pig properdin also agglutinated red cell intermediates bearing either guinea pig or human C3b and retarded the decay of homologous C3 convertase, C3B. These activities are the same as those observed for purified human properdin and validate the amplification function of properdin on terminal component activation in a second species.

Hydrolysis of peptides within lumen of small intestine

The quantitative significance of intraluminal peptide hydrolases in the terminal stages of peptide digestion has been investigated, and the precise origins of these enzymes have been determined. Intestinal contents and mucosae were obtained from rats anethetized with ether. Experiments carried out on pancreaticobiliary secretions and germfree rats show that pancreatic and bacterial enzymes do not contribute significantly toward the luminal digestion of dipeptides. Chemical assay data, thermostability studies, and examination of electrophoretic mobilities of luminal peptide hydrolases indicate that jejunal enzymes originate predominantly from the cytoplasm of intestinal mucosal cells, whereas the brush border of muosal cells is a major source of the enzymes in the ileum. With glycl-L-phenylalanine and L-phenylalanyl-glycine as substrates, jejunal luminal activity was less than 2.6% of mucosal activity. Brush-border peptide hydrolase activity in ileal contents, however, was 11.9% and 40.7% of mucosal brush-border activity for the two substrates. Luminal enzymes thus play an insignifcant role in the terminal digestion of peptides in the jejunum, but have a much more important role in the ileal digestion of peptides.

Isolation and Characterization of Guinea Pig Properdin Using an EAC4h3g Intermediate

The properdin assay consisted of incubating 0.1 ml of an EAC4h3g (1 × 108) suspension in DGVB++ containing limited factor B and excess D̄, plus 0.1 ml of serum fractions for 5 min at 30C. Then 0.3 ml of guinea pig serum diluted 1:4 in 0.04 M EDTA buffer was added and the mixtures were incubated for 60 min at 37°C. One unit of properdin was defined as the reciprocal of the dilution of properdin which gave a Z of 1.0 above the background lysis caused by limited B and excess D̄ alone. The EAC4h3g intermediate was made by modifying the procedure described by Fearon et al. for making EAC4h3h (J. Exp. Med. 138:1305, 1975). Factors B and D̄ were purified from guinea pig serum by modifications of previously published methods (Brade et al., J. Immunol. 109:1174, 1972 and 112:1845, 1974). The factor B preparation contained 1495 units/O.D.280; the factor D̄ preparation contained 10,450 units/O.D.280.

On the mechanism of cytolysis by complement: evidence on insertion of C5b and C7 subunits of the C5b,6,7 complex into phospholipid bilayers of erythrocyte membranes

The doughnut hypothesis of cytolysis by complement [Mayer, M. M. (1972) Proc. Nat. Acad. Sci. USA 69, 2954-2958] describes an annular structure made up of C5b-9 (complement factors C5b, C6, C7, C8, and C9) which becomes inserted in the lipid bilayer of the cell membrane, thus creating a hole. We now present initial explorations of this hypothesis. EAC1-6 and EAC1-7 (sheep erythrocytes carrying rabbit antibody and complement factors C1 through C6 or C1 through C7, respectively), prepared with either 125I-C3 or 125I-C5 were incubated with trypsin and the release of bound 125I was measured. In the case of 125I-C3, all of the radioactivity was released by trypsin from both intermediates. With 125I-C5, trypsin released all of the 125I from EAC1-6, but only 40-55% from EAC1-7. Possible reasons for resistance of the C5b subunit in EAC1-7 to tryptic digestion are discussed; in terms of the doughnut hypothesis it would be due to shielding by lipid molecules as a consequence of insertion into the lipid bilayer. In accord with this interpretation we have also found that C5b in EAC1-7, but not in EAC1-6, resists elution by 0.3 M NaC1. Similarly, we have found that 125I-C7 in EAC1-7 resists stripping by trypsin. Hence, we now propose the hypothesis that hydrophobic polypeptide chains from the C5b and the C7 subunits of C5b,6,7 complex become inserted in the phospholipid bilayer and that subsequent reactions with C8 and C9 open a channel across the membrane.

Suicidal attempts in an outer region of metropolitan Melbourne and in a provincial region of Victoria

A two year study of attempted suicide was undertaken in two Victorian regions. Incidence rates of 16.7 and 22.1 per 10,000 population were found in the metropolitan and provincial regions respectively. A number of factors were considered and found relevant to the difference in incidence. In addition, other parameters including multiple attempts, seasonal distribution, method used, association with alcohol and referral to psychiatric care were considered. Our findings are compared with those of earlier studies reported in Australia.

Interaction of C3b, B, and D in the alternative pathway of complement activation

The interaction of ZXd2, an insoluble intermediate of the alternative pathway on zymosan (Z5), with factor B and the enzyme D proceeds in a two-step reaction: 1) B binds in the presence of Mg++ to ZXd2 to form the intermediate ZXd2B, 2) B bound to ZXd2 is subsequently activated enzymatically by D to yield the complex ZXd2B which cleaves C3. Evidence was obtained that C3b, which is present on ZXd2, is required for ZXd2B formation. Studies of the functional role of C3b for ZXd2B formation revealed that C3b is involved in the first reaction step i.e., binding of B to ZXd2 to yield ZXd2B. Formation of ZXd2B is inhibited by pretreatment of ZXd2 with either anti-C3 Fab or with C3b-INA. Low ionic strength of about 2 mS was found to favor the interaction of the C3b with B. Mg++ concentrations from 1 to 31 mM as well as variation of pH in the range from 6.2 to 8.5 did not greatly influence the reaction of B with ZXd2. For the enzymatic activation of B only C3b on ZXd2 and factor D are required. This is concluded from the finding that fluid phase C3b is sufficient for the activation of B in the presence of D. This does not exclude the fact that other proteins present on ZXd2 may help to stabilize the intermediate ZXd2B or the enzymatically active complex AXd2B, or both of them.