The experiences of support staff in a traumatic brain injury rehabilitation center

PURPOSE

Employee turnover is a major issue for health care organizations. Burnout is a leading contributor to such turnover. Extensive research on burnout has been conducted in health care settings; however, it has primarily been focused on health care professionals ignoring other critical staff. In particular, traumatic brain injury rehabilitation is an area of health care that includes unique challenges and stressors that may contribute to burnout. Brain injury professionals report experiencing high levels of burnout that further increase as they spend more time with patients; however, little is known about the experiences of brain injury paraprofessionals. This study explores the unique experiences of support staff in traumatic brain injury rehabilitation centers.

METHOD

The present study used a grounded theory method to explore the phenomena of burnout, turnover, and job satisfaction from the perspective of paraprofessional support staff in 1 posthospital brain injury rehabilitation center. Support staff participated in the research via small group interviews (N = 4) and survey (N = 11).

RESULTS

The analysis resulted in a grounded theory model, entitled "The Balance model of Rehabilitation Support Work." This model is a framework of risk and protective factors that appeared to influence whether these frontline rehabilitation staff experienced negative outcomes from this often challenging/stressful work environment. The model includes 4 axial-level themes: doing the work, protective factors, risk factors, and imbalance of factors. Within the 4 axial categories are twenty open-coding level categories.

IMPLICATIONS

Implications for traumatic brain injury rehabilitation organizations and areas for future research are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

A synthesis of terrestrial mercury in the western United States: Spatial distribution defined by land cover and plant productivity

A synthesis of published vegetation mercury (Hg) data across 11 contiguous states in the western United States showed that aboveground biomass concentrations followed the order: leaves (26μgkg(-1))~branches (26μgkg(-1))>bark (16μgkg(-1))>bole wood (1μgkg(-1)). No spatial trends of Hg in aboveground biomass distribution were detected, which likely is due to very sparse data coverage and different sampling protocols. Vegetation data are largely lacking for important functional vegetation types such as shrubs, herbaceous species, and grasses. Soil concentrations collected from the published literature were high in the western United States, with 12% of observations exceeding 100μgkg(-1), reflecting a bias toward investigations in Hg-enriched sites. In contrast, soil Hg concentrations from a randomly distributed data set (1911 sampling points; Smith et al., 2013a) averaged 24μgkg(-1) (A-horizon) and 22μgkg(-1) (C-horizon), and only 2.6% of data exceeded 100μgkg(-1). Soil Hg concentrations significantly differed among land covers, following the order: forested upland>planted/cultivated>herbaceous upland/shrubland>barren soils. Concentrations in forests were on average 2.5 times higher than in barren locations. Principal component analyses showed that soil Hg concentrations were not or weakly related to modeled dry and wet Hg deposition and proximity to mining, geothermal areas, and coal-fired power plants. Soil Hg distribution also was not closely related to other trace metals, but strongly associated with organic carbon, precipitation, canopy greenness, and foliar Hg pools of overlying vegetation. These patterns indicate that soil Hg concentrations are related to atmospheric deposition and reflect an overwhelming influence of plant productivity - driven by water availability - with productive landscapes showing high soil Hg accumulation and unproductive barren soils and shrublands showing low soil Hg values. Large expanses of low-productivity, arid ecosystems across the western U.S. result in some of the lowest soil Hg concentrations observed worldwide.

Multi-centre analysis of incidental findings on low-resolution CT attenuation correction images

OBJECTIVE

To review new incidental findings detected on low-resolution CT attenuation correction (CTAC) images acquired during single-photon emission CT (SPECT-CT) myocardial perfusion imaging (MPI) and to determine whether the CTAC images had diagnostic value and warrant reporting.

METHODS

A multicentre study was performed in four UK nuclear medicine departments. CTAC images acquired as part of MPI performed using SPECT were evaluated to identify incidental findings. New findings considered to be clinically significant were evaluated further. Positive predictive value (PPV) was determined at the time of definitive diagnosis.

RESULTS

Of 1819 patients studied, 497 (27.3%) had a positive CTAC finding. 51 (2.8%) patients had findings that were clinically significant at the time of the CTAC report and had not been previously diagnosed. Only four (0.2%) of these were potentially detrimental to patient outcome.

CONCLUSION

One centre had a PPV of 0%, and the study suggests that these CTAC images should not be reported. Two centres with more modern equipment had low PPVs of 0% and 6%, respectively, and further research is suggested prior to drawing a conclusion. The centre with best quality CT had a PPV of 67%, and the study suggests that CTAC images from this equipment should be reported.

ADVANCES IN KNOWLEDGE

This study is unique compared with previous studies that have reported only the potential to identify incidental findings on low-resolution CT images. This study both identifies and evaluates new clinically significant incidental findings, and it demonstrates that the benefit of reporting the CTAC images depends on the type of equipment used.

Somnolence in adult craniopharyngioma patients is a common, heterogeneous condition that is potentially treatable

CONTEXT AND OBJECTIVE

Somnolence and obesity are prevalent in craniopharyngioma patients. We hypothesized that somnolence was because of obstructive sleep apnoea in craniopharyngioma patients.

DESIGN, PATIENTS AND MEASUREMENTS

We assessed prevalence of somnolence and sleep apnoea in 28 craniopharyngioma and 23 obese controls attending a tertiary referral centre, by means of the Epworth Sleepiness Score (ESS) and polysomnography. All subjects with sleep apnoea were offered continuous positive airway pressure therapy (CPAP) or modafinil. All craniopharyngioma patients, with unexplained somnolence, were offered modafinil.

RESULTS

Somnolence was reported by 20/28 (71·5%) craniopharyngioma patients and 4/23 (17%) obese subjects (P < 0·001). Median ESS was 7·5 (IQR 6, 10·7) in craniopharyngioma patients and 4·0 (4,8) in controls, P < 0·01. Eleven somnolent craniopharyngioma patients had obstructive sleep apnoea, in whom treatment led to a reduction in ESS by 6·4 ± 1·4, P = 0·01. Among the remaining nine patients, five were offered modafinil therapy, of whom four had benefit, three were not compliant with hormone replacement, and one died before intervention. There was no difference in the prevalence of obstructive sleep apnoea between craniopharyngioma (n = 13, 46%) and obese subjects (n = 14, 61%, P = 0·4). Body mass index (BMI) does not correlate with apnoea hypopnoea index [apnoea - hypopnoea index (AHI), r = 0·25, P = 0·08], which suggests that obesity alone does not explain the prevalence of sleep apnoea in craniopharyngioma patients.

CONCLUSIONS

Somnolence is common in craniopharyngioma patients and in the majority is because of obstructive sleep apnoea. An additional group of somnolent craniopharyngioma patients benefits from modafinil.

Efficacy and safety of nurse-administered propofol sedation during emergency upper endoscopy for gastrointestinal bleeding: a prospective study

BACKGROUND AND STUDY AIMS

Recent studies have documented the safety of propofol sedation for endoscopic procedures, but many endoscopists are reluctant to use propofol for high-risk patients because of adverse effects. The aim of this study was to demonstrate the safety and efficacy of nurse-administered propofol sedation during emergency upper endoscopy for patients with gastrointestinal bleeding.

PATIENTS AND METHODS

Over a period of 18 months, 120 patients suffering from acute upper gastrointestinal bleeding received propofol sedation administered by a registered nurse. Among these, 15 patients were classified into American Society of Anesthesiologists (ASA) class IV, 84 were ASA class III, and 21 were ASA class II. Patients without gastrointestinal bleeding, who also received propofol during the same period and were matched for age, gender, and ASA class, served as controls.

RESULTS

Endoscopic hemostasis was achieved in 98.3 % of patients, and 97.5 % were satisfied with the procedure. In patients with gastrointestinal bleeding, the rates of hypotension (systolic blood pressure < 90 mmHg) and hypoxemia (peripheral oxygen saturation < 90 %) were 8.3 % and 6.7 % respectively, values higher than those in the control group. However, neither mask ventilation nor endotracheal intubation was necessary. Although two patients with gastrointestinal bleeding developed pneumonia, most likely due to aspiration during the procedure, they recovered within 5 days of treatment. There were no sedation-associated severe complications or mortalities.

CONCLUSION

Using a strict protocol designed to protect the patient's airway and cardiovascular function, nurse-administered propofol sedation during emergency upper gastrointestinal endoscopy is safe and appropriate in cases of acute gastrointestinal bleeding.

Propofol sedation during endoscopic procedures: safe and effective administration by registered nurses supervised by endoscopists

BACKGROUND AND STUDY AIMS

Propofol has several attractive properties, including a rapid onset of action and rapid recovery. However, the administration of propofol sedation in the absence of anesthesiologists remains controversial. This report describes the safety profile of propofol sedation for endoscopy when administered by registered nurses under the supervision of endoscopists.

PATIENTS AND METHODS

The study was conducted in the endoscopic center of a Japanese private hospital. With assistance from an anesthesiologist, a protocol for administration of propofol by registered nurses was developed. Over the past 6 years, 27,500 patients received nurse-administered propofol sedation. The safety and patient satisfaction with this sedation procedure were evaluated.

RESULTS

Among the participating patients, 6.7% developed hypoxemia (Sp(O2) < 90%); 6.2% required oxygen administration via a nasal cannula. Severe hypoxemia (Sp(O2) < 85%) occurred in 121 patients (0.62%) during upper gastrointestinal endoscopy and 20 patients (0.25%) during colonoscopy, but neither mask ventilation nor endotracheal intubation was necessary. A decline in blood pressure (systolic blood pressure < 90 mm Hg) was seen in 3.5% of the colonoscopy patients and 1.2% of the upper endoscopy patients. However, hypotension was corrected immediately using an intravenous saline solution. Patients who received propofol sedation expressed overall satisfaction on a 10-point visual analogue scale (with an average of 9.4 points). Among patients who had previously received a combination of midazolam and pethidine for colonoscopy, 85% preferred propofol sedation. The mean time from the end of the procedure to full recovery was 14.6 min.

CONCLUSIONS

Administration of propofol by registered nurses under the supervision of endoscopists was safe, and resulted in high rates of patient satisfaction.

Severe irritability associated with statin cholesterol-lowering drugs

BACKGROUND

As use of a drug becomes widespread, the full spectrum of its effects becomes clearer. Although a link has been suggested between low or lowered cholesterol and irritability/aggression, less is known about possible links between irritability and statins.

AIM

To assess the possible connection of statin usage to severe irritability.

DESIGN

Case series.

METHODS

Six patients referred or self-referred with irritability and short temper on statin cholesterol-lowering drugs completed a survey providing information on character of behavioural effect, time-course of onset and recovery, and factors relevant to drug adverse effect causality.

RESULTS

In each case the personality disruption, once evident, was sustained until statin use was discontinued; and resolved promptly with drug cessation. In four patients, re-challenge with statins occurred, and led to recrudescence of the problem. All patients experienced other recognized statin adverse effects while on the drug. Manifestations of severe irritability included homicidal impulses, threats to others, road rage, generation of fear in family members, and damage to property.

DISCUSSION

Case series invariably raise more questions than they can answer. These case reports suggest that severe irritability may occur in some statin users. Although this adverse effect may be rare, potentially life-threatening adverse effects of drugs must be taken seriously.

Polyurethane-covered Nitinol Strecker stents as primary palliative treatment of malignant biliary obstruction

PURPOSE

To evaluate the clinical efficacy of the polyurethane-covered Nitinol Strecker stent in the treatment of patients with malignant biliary obstruction.

METHODS

Twenty-three covered stents produced by us were placed in 18 patients with malignant biliary obstruction. Jaundice was caused by cholangiocarcinoma (n = 5), pancreatic cancer (n = 6), gallbladder cancer (n = 4), metastatic lymph nodes (n = 2), and tumor of the papilla (n = 1).

RESULTS

The mean patency period of the stents was 37.5 weeks (5-106 weeks). Recurrent obstructive jaundice occurred in two patients (11%). Adequate biliary drainage over 50 weeks or until death was achieved in 17 of 18 patients (94.4%). Late cholangitis was observed in two patients whose stents bridged the ampulla of Vater. Other late severe complications were not encountered.

CONCLUSION

Although more study is necessary, our results suggest the clinical efficacy of our covered Nitinol Strecker stent in the management of obstructive jaundice caused by malignant diseases.

[Arterial infusion therapy with implantable port for inoperable hepatobiliary tumors]

PURPOSE

To assess the clinical utility of arterial infusion therapy with implantable port for inoperable malignant hepatobiliary tumors.

MATERIALS AND METHODS

Twenty-seven patients with advanced hepatobiliary tumors (M:F = 14:13, mean age 63.6, 11 cases with metastases from colon cancer, 4 cases from gastric cancer, 5 cases with gallbladder cancer, 3 cases with cholangiocarcinoma, 2 cases with cholangiocellularcarcinoma, 1 case with hepatocellular carcinoma and 1 with pancreatic cancer) were treated with arterial infusion ports which were placed via left subclavian artery or femoral artery. The regimens used were FEM for 5 cases, EEP for 2 cases and FP for 20 cases.

RESULTS

Overall mean survival date was 241.8 days. The numbers of cases with CR, PR, NC and PD were 1, 6, 10 and 10, respectively, and the effective rate was 25.9%. Mean survivals of cases with cholangiocellularcarcinoma, metastases from gastric cancer and colon cancer were 715 days, 324.3 days and 245.9 days, respectively. Severe gastrointestinal side effects (> grade 3) were not observed. Serious bone marrow suppressions were frequently observed with FEM and EEP, but were rare with FP (10%).

DISCUSSION

Arterial infusion therapy with implantable port is clinically useful for advanced cholangiocancer and metastases from the gastrointestinal system. This system contributes to the quality of life of patients, since the infusion procedure is simple and can be archived in the outpatient clinics.

Health screening for people with learning disabilities by a community learning disability nursing service in Northern Ireland

Over the last 30 years there has been a considerable increase in the life expectancy of people with learning disabilities. This has resulted in changing patterns of morbidity and mortality and an increasing recognition of the health needs of people with learning disabilities. Major strides forward have been made in the reduction of preventable illnesses among the general population. However, among people with learning disabilities such illnesses have received only limited health promotion attention until recently. In the last decade major gaps have been identified in the ability of current primary health services to respond to the needs of people with learning disabilities. The need to respond effectively to this situation has been identified as a priority by the current United Kingdom Government. Following an overview of the literature in relation to the changing health profile of people with learning disabilities and the need for health screening, consideration is given to some of the key difficulties which may be encountered when attempting to utilize current primary health services. The analysis of data derived from the health screening of 373 people with learning disabilities by a community nursing service in Down and Lisburn Health and Social Services Trust reveals the need for further action in relation to cardiovascular status, sensory deficits, mobility and aspects of sexual health.

Yeast mutants affecting possible quality control of plasma membrane proteins

Mutations gef1, stp22, STP26, and STP27 in Saccharomyces cerevisiae were identified as suppressors of the temperature-sensitive alpha-factor receptor (mutation ste2-3) and arginine permease (mutation can1(ts)). These suppressors inhibited the elimination of misfolded receptors (synthesized at 34 degrees C) as well as damaged surface receptors (shifted from 22 to 34 degrees C). The stp22 mutation (allelic to vps23 [M. Babst and S. Emr, personal communication] and the STP26 mutation also caused missorting of carboxypeptidase Y, and ste2-3 was suppressed by mutations vps1, vps8, vps10, and vps28 but not by mutation vps3. In the stp22 mutant, both the mutant and the wild-type receptors (tagged with green fluorescent protein [GFP]) accumulated within an endosome-like compartment and were excluded from the vacuole. GFP-tagged Stp22p also accumulated in this compartment. Upon reaching the vacuole, cytoplasmic domains of both mutant and wild-type receptors appeared within the vacuolar lumen. Stp22p and Gef1p are similar to tumor susceptibility protein TSG101 and voltage-gated chloride channel, respectively. These results identify potential elements of plasma membrane quality control and indicate that cytoplasmic domains of membrane proteins are translocated into the vacuolar lumen.

Spinal cord injury from civilian gunshot wounds: the Rancho experience 1980-88

We performed a retrospective review of the medical records of 316 patients with spinal cord injury (SCI) secondary to gunshot wounds (GSW) admitted to Rancho Los Amigos Medical Center for rehabilitation between 1980 and 1988. There were 289 male and 27 female patients whose mean age was 25.9 years (range, 11-56 years). Of these, 238 were paraplegic (103 incomplete, 135 complete), and 78 were quadriplegic (45 incomplete, 33 complete). Forty were shot by handguns of known caliber and four by shotguns; in 272 cases, the type of weapon was unknown. A total of 230 cases sustained a single bullet wound, and 86 had multiple bullet wounds. The length of acute hospitalization, but not rehabilitation hospital stay, increased with the number of associated injuries. Rehabilitation and, hence, total length of stay was significantly less (mean, 100 and 130 days, respectively) for SCI/GSW victims than for SCI victims of motor vehicle accidents, falls, or diving accidents. The methods of calculating costs for admission were based upon Rancho Los Amigos Medical Center financial statistics. This hospital has charged for a daily occupancy fee. The fee is based upon an average of all charges for all patients. No additional fees are charged for special tests or procedures. In 1980, the average daily admission hospitalization charge was $785. In 1990, the last quoted hospital charge was $1,125. This is for the basic spinal cord injury rehabilitative stay. In general, at Rancho Los Amigos, patients are admitted for rehabilitation when all acute medical and surgical problems have been cleared and the patient is ready to participate in rehabilitation evaluation and therapy programs.(ABSTRACT TRUNCATED AT 250 WORDS)

Reversible hypercapnic respiratory insufficiency in scleroderma caused by respiratory muscle weakness

A patient with scleroderma presented with hypercapnic respiratory failure. Evaluation of pulmonary mechanics revealed severe restriction caused in part by respiratory muscle weakness. Treatment with prednisone corrected hypoventilation, improved symptoms, increased lung volumes, returned respiratory muscle strength to normal range, but did not change the degree of lung stiffness. This case demonstrates that restrictive patterns in scleroderma can be due to either lung or chest wall disease and that the latter may be reversible. If respiratory muscle weakness is present with restrictive ventilatory patterns in patients with scleroderma, a therapeutic trial of corticosteroid is warranted.