Interpersonal touch interventions for patients in intensive care: A design-oriented realist review

Aim: To develop a theoretical framework to inform the design of interpersonal touch interventions intended to reduce stress in adult intensive care unit patients. Design: Realist review with an intervention design‐oriented approach. Methods: We searched CINAHL, MEDLINE, EMBASE, CENTRAL, Web of Science and grey literature sources without date restrictions. Subject experts suggested additional articles. Evidence synthesis drew on diverse sources of literature and was conducted iteratively with theory testing. We consulted stakeholders to focus the review. We performed systematic searches to corroborate our developing theoretical framework. Results: We present a theoretical framework based around six intervention construction principles. Theory testing provided some evidence in favour of treatment repetition, dynamic over static touch and lightening sedation. A lack of empirical evidence was identified for construction principles relating to intensity and positive/negative evaluation of emotional experience, moderate pressure touch for sedated patients and intervention delivery by relatives versus healthcare practitioners

Emotional and physiological responses to touch massage

Background: Clinical findings indicate that touch massage has the ability to induce positive emotions and influence stress responses. However, little is known about mechanisms that can explain observed responses. Aim: To understand mechanisms behind observed emotional and physiological responses during and after touch massage. Methods: This thesis is based upon healthy volunteers in Studies I, II, IV and patients undergone aortic surgery in Study III. Study I had a crossover design, participants served as their own controls. After randomization they received TM on one occasion and the other occasion served as control. Heart rate variability (HRV), heart rate (HR) saliva cortisol concentration, glucose, insulin in serum and extracellular (ECV) levels of glucose, lactate, glycerol and pyruvat were measured before, during and after TM/control. In study II, functional magnetic resonance imaging (fMRI) was used in order to measure brain activity during TM movement. The study design included four different touch stimulations, human touch with movement (TM movement) human stationary touch and rubber glove with or without movement. Force (2.5 N) and velocity (1.5 cm/s) were held constant across conditions. The pleasantness of the four different touch stimulations was rated on a visual analog scale (VAS-scale). Study III had a randomized controlled design. The intervention group received TM and the control group rested. HRV, cortisol, glucose, insulin in serum, blood pressure, oxygen saturation, respiratory frequency and anxiety levels were measured before, during and after TM/control. In study IV participants were interviewed about experiences after TM and the text was analyzed in by qualitative content analyze. Results: Study I. TM reduced the stress response as indicated by decreased heart rate and decreased activity in the sympathetic nervous system, followed by a compensatory decrease in parasympathetic nervous activity in order to maintain balance. Cortisol and insulin levels decreased significantly after intervention, while serum glucose levels remained stable. A similar, though less prominent, pattern was seen during the control session. There were no significant differences in ECV concentrations of analyzed substances. Study II. Human moving touch (TM movement) was significantly rated as the most pleasant touch stimulation. The fMRI results revealed that human moving touch (TM movement) most strongly activated the pregenual anterior cingulate cortex (pgACC). Study III. Selfrated anxiety levels significantly decreased in the patient group that received TM compared with control group. There were no significant differences in physiological stress-related outcome parameters between patients who received touch massage and controls. Study IV. In this study participants talked about the experience of TM in terms of rewards. Expressions like need, desire, pleasure and conditioning could be linked with a theoretical model of reward. Four different categories were identified as wanting, liking, learning and responding. In conclusion: Results from these studies indicate that receiving TM is experienced as rewarding. Touch massage movement activates a brain area involved in coding of rewarding pleasant stimulations. TM decreases anxiety and dampens the stress response by a decreased activation of the sympathetic nervous activity. Our results indicate that TM is a caring intervention that can be used to induce pleasure, decrease anxiety and stress in the receiver

Emotional and physiological responses to touch massage

Background: Clinical findings indicate that touch massage has the ability to induce positive emotions and influence stress responses. However, little is known about mechanisms that can explain observed responses. Aim: To understand mechanisms behind observed emotional and physiological responses during and after touch massage. Methods: This thesis is based upon healthy volunteers in Studies I, II, IV and patients undergone aortic surgery in Study III. Study I had a crossover design, participants served as their own controls. After randomization they received TM on one occasion and the other occasion served as control. Heart rate variability (HRV), heart rate (HR) saliva cortisol concentration, glucose, insulin in serum and extracellular (ECV) levels of glucose, lactate, glycerol and pyruvat were measured before, during and after TM/control. In study II, functional magnetic resonance imaging (fMRI) was used in order to measure brain activity during TM movement. The study design included four different touch stimulations, human touch with movement (TM movement) human stationary touch and rubber glove with or without movement. Force (2.5 N) and velocity (1.5 cm/s) were held constant across conditions. The pleasantness of the four different touch stimulations was rated on a visual analog scale (VAS-scale). Study III had a randomized controlled design. The intervention group received TM and the control group rested. HRV, cortisol, glucose, insulin in serum, blood pressure, oxygen saturation, respiratory frequency and anxiety levels were measured before, during and after TM/control. In study IV participants were interviewed about experiences after TM and the text was analyzed in by qualitative content analyze. Results: Study I. TM reduced the stress response as indicated by decreased heart rate and decreased activity in the sympathetic nervous system, followed by a compensatory decrease in parasympathetic nervous activity in order to maintain balance. Cortisol and insulin levels decreased significantly after intervention, while serum glucose levels remained stable. A similar, though less prominent, pattern was seen during the control session. There were no significant differences in ECV concentrations of analyzed substances. Study II. Human moving touch (TM movement) was significantly rated as the most pleasant touch stimulation. The fMRI results revealed that human moving touch (TM movement) most strongly activated the pregenual anterior cingulate cortex (pgACC). Study III. Selfrated anxiety levels significantly decreased in the patient group that received TM compared with control group. There were no significant differences in physiological stress-related outcome parameters between patients who received touch massage and controls. Study IV. In this study participants talked about the experience of TM in terms of rewards. Expressions like need, desire, pleasure and conditioning could be linked with a theoretical model of reward. Four different categories were identified as wanting, liking, learning and responding. In conclusion: Results from these studies indicate that receiving TM is experienced as rewarding. Touch massage movement activates a brain area involved in coding of rewarding pleasant stimulations. TM decreases anxiety and dampens the stress response by a decreased activation of the sympathetic nervous activity. Our results indicate that TM is a caring intervention that can be used to induce pleasure, decrease anxiety and stress in the receiver

Can equity in care be achieved for stigmatized patients? Discourses of ideological dilemmas in perioperative care

Abstract Background In the perioperative care of individuals with obesity, it is imperative to consider the presence of risk factors that may predispose them to complications. Providing optimal care in such cases proves to be a multifaceted challenge, significantly distinct from the care required for non-obese patients. However, patients with morbidities regarded as self-inflicted, such as obesity, described feelings of being judged and discriminated in healthcare. At the same time, healthcare personnel express difficulties in acting in an appropriate and non-insulting way. In this study, the aim was to analyse how registered nurse anaesthetists positioned themselves regarding obese patients in perioperative care. Methods We used discursive psychology to analyse how registered nurse anaesthetists positioned themselves toward obese patients in perioperative care, while striving to provide equitable care. The empirical material was drawn from interviews with 15 registered nurse anaesthetists working in a hospital in northern Sweden. Results Obese patients were described as “untypical”, and more “resource-demanding” than for the “normal” patient in perioperative care. This created conflicting feelings, and generated frustration directed toward the patients when the care demanded extra work that had not been accounted for in the schedules created by the organization and managers. Conclusions Although the intention of these registered nurse anaesthetists was to offer all patients equitable care, the organization did not always provide the necessary resources. This contributed to the registered nurse anaesthetists either consciously or unconsciously blaming patients who deviated from the “norm”

Can equity in care be achieved for stigmatized patients? Discourses of ideological dilemmas in perioperative care

Background: In the perioperative care of individuals with obesity, it is imperative to consider the presence of risk factors that may predispose them to complications. Providing optimal care in such cases proves to be a multifaceted challenge, significantly distinct from the care required for non-obese patients. However, patients with morbidities regarded as self-inflicted, such as obesity, described feelings of being judged and discriminated in healthcare. At the same time, healthcare personnel express difficulties in acting in an appropriate and non-insulting way. In this study, the aim was to analyse how registered nurse anaesthetists positioned themselves regarding obese patients in perioperative care. Methods: We used discursive psychology to analyse how registered nurse anaesthetists positioned themselves toward obese patients in perioperative care, while striving to provide equitable care. The empirical material was drawn from interviews with 15 registered nurse anaesthetists working in a hospital in northern Sweden. Results: Obese patients were described as “untypical”, and more “resource-demanding” than for the “normal” patient in perioperative care. This created conflicting feelings, and generated frustration directed toward the patients when the care demanded extra work that had not been accounted for in the schedules created by the organization and managers. Conclusions: Although the intention of these registered nurse anaesthetists was to offer all patients equitable care, the organization did not always provide the necessary resources. This contributed to the registered nurse anaesthetists either consciously or unconsciously blaming patients who deviated from the “norm”

Longitudinal Evidence for Smaller Hippocampus Volume as a Vulnerability Factor for Perceived Stress

Hippocampal volume has been found to be smaller in individuals with stress-related disorders, but it remains unclear whether smaller volume is a consequence of stress or rather a vulnerability factor. Here, we examined this issue by relating stress levels to hippocampal volumes in healthy participants examined every 5 years in a longitudinal population-based study. Based on scores of 25- to 60-year–old participants on the perceived stress questionnaire, we defined moderately to high (n = 35) and low (n = 76) stress groups. The groupswere re-examined after 5 years (at the 6th studywave). Historical data on subjective stresswere available up to 10 years prior toWave 5. At the first MRI session, the moderately to high stress group had a significantly smaller hippocampal volume, as measured by FreeSurfer (version 5.3), compared with the low-stress group. At follow-up, group differences in stress levels and hippocampal volume remained unchanged. In retrospective analyses of subjective stress, the observed group difference in stress was found to be stable. The long-term stability of group differences in perceived stress and hippocampal volume suggests that a small hippocampal volume may be a vulnerability factor for stress-related disorders

Maintaining Image Quality While Reducing Acoustic Noise and Switched Gradient Field Exposure During Lumbar MRI

Background: MR-generated acoustic noise can contribute to patient discomfort and potentially be harmful. One way to reduce this noise is by altering the gradient output and/or waveform using software optimization. Such modifications might influence image quality and switched gradient field exposure, and different techniques appear to affect sound pressure levels (SPLs) to various degrees. Purpose: To evaluate SPLs, image quality, switched gradient field exposure, and participants' perceived noise levels during two different acoustic noise reduction (ANR) techniques, Quiet Suite (QS) and Whisper Mode (WM), and to compare them with conventional T2-weighted turbo spin echo (T2W TSE) of the lumbar spine. Design: Prospective. Subjects: Forty adults referred for lumbar MRI. Field strength/sequence: Conventional T2W TSE, T2W TSE with QS, and T2W TSE with WM were acquired at 1.5 T. Assessment: Peak SPL (A-weighted decibels, dBA), perceived noise levels (Borg CR10®-scale), signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), three radiologists' qualitative assessments in image quality on an ordinal scale 1-4, switched gradient field exposure (% general public), and gradient currents were measured. Interobserver reliability was reported as percentage agreement. Statistical tests: Repeated measures ANOVA, Friedman's ANOVA, and Wilcoxon's Signed-Rank Test for acoustic noise measurements and image quality assessments. Results: Mean peak SPLs were 89.9 dBA, 74.3 dBA, and 78.8 dBA for conventional, QS, and WM, respectively (P < 0.05). Participants perceived QS as the quietest and conventional as the loudest sequence (P < 0.05). No qualitative differences in image quality were seen (P > 0.05), although QS showed significantly improved SNR and CNR (P < 0.05). Switched gradient field exposure was reduced by 66% and 48% for QS and WM, respectively. Data conclusion: Without degrading image quality, both QS and WM are viable ANR techniques in lumbar T2W TSE. QS provided the lowest SPL, the lowest gradient field exposure and was perceived as the most silent among the three sequences. Level of evidence: 1 TECHNICAL EFFICACY STAGE: 5

Endocannabinoids and related lipids in blood plasma following touch massage: a randomised, crossover study

Background: The endocannabinoid system is involved in the regulation of stress and anxiety. In a recent study, it was reported that short-term changes in mood produced by a pleasant ambience were correlated with changes in the levels of plasma endocannabinoids and related N-acylethanolamines (Schrieks et al. PLoS One 10: e0126421, 2015). In the present study, we investigated whether stress reduction by touch massage (TM) affects blood plasma levels of endocannabinoids and relatedN-acylethanolamines. Results: A randomized two-session crossover design for 20 healthy participants was utilised, with one condition that consisted of TM and a rest condition as control. TM increased the perceived pleasantness rating of the participants, and both TM and rest reduced the basal anxiety level as assessed by the State scale of the STAI-Y inventory. However, there were no significant effects of either time (pre- vs. post-treatment measures) as main effect or the interaction time x treatment for the plasma levels of the endocannabinoids anandamide and 2-arachidonoylglycerol or for eight other related lipids. Four lipids showed acceptable relative reliabilities, and for two of these (linoleoyl ethanolamide and palmitoleoyl ethanolamide) a significant correlation was seen between the TM-related change in levels, calculated as (post-TM value minus pre-TM value) − (post-rest value minus pre-rest value), and the corresponding TM-related change in perceived pleasantness. Conclusions: It is concluded that in the participants studied here, there are no overt effects of TM upon plasma endocannabinoid levels. Possible associations of related N-acylethanolamines with the perceived pleasantness should be investigated further

OLDA based online handwriting recogntion

The paper presents the work carried out in recognizing online handwritten data using OLDA. A comparative study on the performance of OLDA and RLDA in terms of recognition accuracy and recognition speed is carried out. Online handwritten Kannada basic character data is used for the experiments. Writer independent experiments are carried with 3750 samples for training and 1550 samples for testing. With estimate feature and nearest neighbor as a classifier, an average maximum recognition accuracy of 88.7% and 88.5% has been achieved with OLDA and RLDA respectively. While OLDA has achieved the best recognition accuracy with only 20 eigen vectors, RLDA has taken 25 eigen vectors. The experiments reveal that the performance of OLDA is better than that of RLDA in terms of recognition accuracy, computation cost and also the memory requirements. © 2014 IEEE

Managing acoustic noise within MRI : a qualitative interview study among Swedish radiographers

Introduction: Acoustic noise from magnetic resonance imaging (MRI) can cause hearing loss and needs to be mitigated to ensure the safety of patients and personnel. Capturing MR personnel's insights is crucial for guiding the development and future applications of noise-reduction technology. This study aimed to explore how MR radiographers manage acoustic noise in clinical MR settings. Methods: Using a qualitative design, we conducted semi-structured individual interviews with fifteen MR radiographers from fifteen hospitals around Sweden. We focused on the clinical implications of participants’ noise management, using an interpretive description approach. We also identified sociotechnical interactions between People, Environment, Tools, and Tasks (PETT) by adopting a Human Factors/Ergonomics framework. Interview data were analyzed inductively with thematic analysis (Braun and Clarke). Results: The analysis generated three main themes regarding MR radiographers’ noise management: (I) Navigating Occupational Noise: Risk Management and Adaptation; (II) Protecting the Patient and Serving the Exam, and (III) Establishing a Safe Healthcare Environment with Organizational Support. Conclusion: This study offers insights into radiographers’ experiences of managing acoustic noise within MRI, and the associated challenges. Radiographers have adopted multiple strategies to protect patients and themselves from adverse noise-related effects. However, they require tools and support to manage this effectively, suggesting a need for organizations to adopt more proactive, holistic approaches to safety initiatives. Implications for practice: The radiographers stressed the importance of a soundproofed work environment to minimize occupational adverse health effects and preserve work performance. They acknowledge noise as a common contributor to patient distress and discomfort. Providing options like earplugs, headphones, mold putty, software-optimized “quiet” sequences, and patient information were important tools. Fostering a safety culture requires proactive safety efforts and support from colleagues and management