Bearing witness and being bounded; the experiences of nurses in adult critical care in relation to the survivorship needs of patients and families

Aim: To discern and understand the responses of nurses to the survivorship needs of patients and family members in adult critical care units. Background: The critical care environment is a demanding place of work which may limit nurses to immediacy of care, such is the proximity to death and the pressure of work. Design: A constructivist grounded theory approach with constant comparative analysis. Methods: As part of a wider study and following ethical approval, eleven critical care nurses working within a general adult critical care unit were interviewed with respect to their experiences in meeting the psychosocial needs of patients and family members. Through the process of constant comparative analysis an overarching selective code was constructed. EQUATOR guidelines for qualitative research (COREQ) applied. Results: The data illuminated a path of developing expertise permitting integration of physical, psychological and family care with technology and humanity. Gaining such proficiency is demanding and the data presented reveals the challenges that nurses experience along the way. Conclusion: The study confirms that working within a critical care environment is an emotionally charged challenge and may incur an emotional cost. Nurses can find themselves bounded by the walls of the critical care unit and experience personal and professional conflicts in their role. Nurses bear witness to the early stages of the survivorship trajectory but are limited in their support of ongoing needs. Relevance to Clinical Practice: Critical care nurses can experience personal and professional conflicts when caring for both patients and families. This can lead to moral distress and may contribute to compassion fatigue. Critical care nurses appear bounded to the delivery of physiological and technical care, in the moment, as demanded by the patient's acuity. Consequentially this limits nurses’ ability to support the onward survivorship trajectory. Increased pressure and demands on critical care beds has contributed further to occupational stress in this care setting

Superconductivity from correlated hopping

We consider a chain described by a next-nearest-neighbor hopping combined with a nearest-neighbor spin flip. In two dimensions this three-body term arises from a mapping of the three-band Hubbard model for CuO$_2$ planes to a generalized $t-J$ model and for large O-O hopping favors resonance-valence-bond superconductivity of predominantly $d$-wave symmetry. Solving the ground state and low-energy excitations by analytical and numerical methods we find that the chain is a Luther-Emery liquid with correlation exponent $K_{\rho} = (2-n)^2/2$, where $n$ is the particle density.Comment: 10 pages, RevTeX 3.0 + 2 PostScript figs. Accepted for publication in Phys.Rev.

Proximal tibial replacement in revision knee arthroplasty for non-oncologic indications.

Proximal tibial metaphyseal bone loss compromises the alignment and fixation of components during revision total knee arthroplasty. In massive, segmental defects with loss of collateral ligamentous support and lack of bone to support the use of prosthetic augments or metaphyseal cones or sleeves, a hinged proximal tibial replacement or a so-called megaprosthesis should be available. While proximal tibial replacement is the reconstructive method of choice in the setting of bone tumor resection, applications in non-oncologic joint arthroplasty are rare and may offer an opportunity for limb salvage in dire clinical scenarios with massive proximal tibial bone loss. This report reviews 6 cases of proximal tibial replacement

Low pressure radiofrequency balloon angioplasty: Evaluation in porcine peripheral arteries

AbstractObjectives. The purpose of this study was to evaluate the efficacy of radiofrequency-powered thermal balloon angioplasty in an in vivo porcine model.Background. Various modes of thermal energy used adjunctively during balloon angioplasty have demonstrated the potential to enhance the results of acute lumen dilation.Methods. In normal pigs, 75 peripheral arteries were dilated with a newly designed, radiofrequency-powered, thermal angioplasty balloon. All inflations were performed at 2-atm pressure for 85 s. Dilations were performed either with (hot) or without (cold) the application of heat. Lumen dimensions and vessel morphology were assessed with intravascular ultrasonography. At the end of each study, dilated arterial segments were harvested for histologic examination.Results. Single cold balloon inflations resulted in a 12.7% increase in arterial cross-sectional area whereas single hot inflations resulted in a 22.9% increase (p < 0.03). Similarly, when multiple cold inflations were compared with multiple hot inflations, two, three and four sequential hot inflations resulted in a significantly greater increase in cross-sectional area than an equivalent number of cold inflations (p < 0.03).Histologic examination demonstrated a temperaturedependent effect on the depth of medial necrosis and extent of arterial wall thinning (p < 0.001) as well as evidence for uniform alteration of elastic tissue fibers at temperatures of ≥60 °C (p < 0.03).Conclusions. Low pressure radiofrequency thermal balloon angioplasty results in a greater increase in cross-sectional area in porcine peripheral arteries than does nonheated conventional balloon angioplasty. The pathologic basis for this enhanced dilation may be a temperature-dependent effect on medial necrosis, thinning of the arterial wall or alteration of vascular elastic fibers, alone or in combination

Managing lifestyle change to reduce coronary risk: a synthesis of qualitative research on peoples’ experiences

Background Coronary heart disease is an incurable condition. The only approach known to slow its progression is healthy lifestyle change and concordance with cardio-protective medicines. Few people fully succeed in these daily activities so potential health improvements are not fully realised. Little is known about peoples’ experiences of managing lifestyle change. The aim of this study was to synthesise qualitative research to explain how participants make lifestyle change after a cardiac event and explore this within the wider illness experience. Methods A qualitative synthesis was conducted drawing upon the principles of meta-ethnography. Qualitative studies were identified through a systematic search of 7 databases using explicit criteria. Key concepts were identified and translated across studies. Findings were discussed and diagrammed during a series of audiotaped meetings. Results The final synthesis is grounded in findings from 27 studies, with over 500 participants (56% male) across 8 countries. All participants experienced a change in their self-identity from what was ‘familiar’ to ‘unfamiliar’. The transition process involved ‘finding new limits and a life worth living’ , ‘finding support for self’ and ‘finding a new normal’. Analyses of these concepts led to the generation of a third order construct, namely an ongoing process of ‘reassessing past, present and future lives’ as participants considered their changed identity. Participants experienced a strong urge to get back to ‘normal’. Support from family and friends could enable or constrain life change and lifestyle changes. Lifestyle change was but one small part of a wider ‘life’ change that occurred. Conclusions The final synthesis presents an interpretation, not evident in the primary studies, of a person-centred model to explain how lifestyle change is situated within ‘wider’ life changes. The magnitude of individual responses to a changed health status varied. Participants experienced distress as their notion of self identity shifted and emotions that reflected the various stages of the grief process were evident in participants’ accounts. The process of self-managing lifestyle took place through experiential learning; the level of engagement with lifestyle change reflected an individual’s unique view of the balance needed to manage ‘realistic change’ whilst leading to a life that was perceived as ‘worth living’. Findings highlight the importance of providing person centred care that aligns with both psychological and physical dimensions of recovery which are inextricably linked

Pharmacists in general practice: a qualitative interview case study of stakeholders’ experiences in a West London GP Federation

Background Increased patient demand for healthcare services coupled with a shortage of general practitioners necessitates changes in professional roles and service delivery. In 2016, NHS England began a three year pilot study of pharmacists in general practice, however, this is not an entirely new initiative. There is limited, current, evidence-based, UK research to inform the pilot so studies of pre-existing services must suffice until findings from a formal national evaluation are available. Methods The aim of this exploratory, descriptive interview study was to explore the experiences of stakeholders in eight general practices in the Ealing GP Federation, West London, where pharmacy services have been provided for several years. Forty-seven participants, including pharmacy team members (pre-registration and clinical pharmacists, independent prescribers and pharmacy technicians), general practitioners, patients, practice managers, practice nurses and receptionists took part in semi-structured, audio-recorded qualitative interviews which were transcribed verbatim, coded and analysed thematically to extract the issues raised by participants and the practicalities of providing pharmacy services in general practice. Results Findings are reported under the themes of Complementarity (incorporating roles, skills, education and workloads); Integration (incorporating relationships, trust and communication) and Practicalities (incorporating location and space, access, and costs). Participants reported the need for time to develop and understand the various roles, develop communication processes and build inter-professional trust. Once these were established, however, experiences were positive and included decreased workloads, increased patient safety, improved job satisfaction, improved patient relationships, and enhanced cost savings. Areas for improvement included patients’ awareness of services; pharmacists’ training; and regular, onsite access for practice staff to the pharmacy team. Conclusions Recommendations are made for the development of clear role definitions, identification of training needs, dedication of time for team building, production of educational materials for practice staff members and patients, and provision of on-site, full-time pharmacy services. Future work should focus on evaluation of various models of employing pharmacy teams in general practice; integration of pharmacists and pharmacy technicians into multidisciplinary general practice teams; relationships between local community pharmacy and general practice personnel and patients’ service and information needs. A formal national evaluation of the pilot scheme is overdue

Why it takes an 'ontological shock' to prompt increases in small firm resilience : sensemaking, emotions and flood risk

This article uses a sensemaking approach to understand small firms’ responses to the threat of external shocks. By analysing semi-structured interviews with owners of flooded small firms, we investigate how owners process flood experiences and explore why such experiences do not consistently lead to the resilient adaptation of premises. We, conclude that some of the explanation for low levels of adaptation relates to a desire to defend existing sensemaking structures and associated identities. Sensemaking structures are only revised if these structures are not critical to business identity, or if a flood constitutes an ‘ontological shock’ and renders untenable existing assumptions regarding long-term business continuity. This article has implications for adaptation to the growing risk of flooding, climate change and external shocks. Future research analysing external shocks would benefit from using a sensemaking approach and survey studies should include measurements of ‘ontological’ impact as well as material and financial damage. In addition, those designing information campaigns should take account of small firms’ resistance to information that threatens their existing sensemaking structures and social identities

Programmable antivirals targeting critical conserved viral RNA secondary structures from influenza A virus and SARS-CoV-2

Influenza A virus’s (IAV’s) frequent genetic changes challenge vaccine strategies and engender resistance to current drugs. We sought to identify conserved and essential RNA secondary structures within IAV’s genome that are predicted to have greater constraints on mutation in response to therapeutic targeting. We identified and genetically validated an RNA structure (packaging stem–loop 2 (PSL2)) that mediates in vitro packaging and in vivo disease and is conserved across all known IAV isolates. A PSL2-targeting locked nucleic acid (LNA), administered 3 d after, or 14 d before, a lethal IAV inoculum provided 100% survival in mice, led to the development of strong immunity to rechallenge with a tenfold lethal inoculum, evaded attempts to select for resistance and retained full potency against neuraminidase inhibitor-resistant virus. Use of an analogous approach to target SARS-CoV-2, prophylactic administration of LNAs specific for highly conserved RNA structures in the viral genome, protected hamsters from efficient transmission of the SARS-CoV-2 USA_WA1/2020 variant. These findings highlight the potential applicability of this approach to any virus of interest via a process we term ‘programmable antivirals’, with implications for antiviral prophylaxis and post-exposure therapy