Pain distress : the negative emotion associated with procedures in ICU patients

The intensity of procedural pain in intensive care unit (ICU) patients is well documented. However, little is known about procedural pain distress, the psychological response to pain. Post hoc analysis of a multicenter, multinational study of procedural pain. Pain distress was measured before and during procedures (0-10 numeric rating scale). Factors that influenced procedural pain distress were identified by multivariable analyses using a hierarchical model with ICU and country as random effects. A total of 4812 procedures were recorded (3851 patients, 192 ICUs, 28 countries). Pain distress scores were highest for endotracheal suctioning (ETS) and tracheal suctioning, chest tube removal (CTR), and wound drain removal (median [IQRs] = 4 [1.6, 1.7]). Significant relative risks (RR) for a higher degree of pain distress included certain procedures: turning (RR = 1.18), ETS (RR = 1.45), tracheal suctioning (RR = 1.38), CTR (RR = 1.39), wound drain removal (RR = 1.56), and arterial line insertion (RR = 1.41); certain pain behaviors (RR = 1.19-1.28); pre-procedural pain intensity (RR = 1.15); and use of opioids (RR = 1.15-1.22). Patient-related variables that significantly increased the odds of patients having higher procedural pain distress than pain intensity were pre-procedural pain intensity (odds ratio [OR] = 1.05); pre-hospital anxiety (OR = 1.76); receiving pethidine/meperidine (OR = 4.11); or receiving haloperidol (OR = 1.77) prior to the procedure. Procedural pain has both sensory and emotional dimensions. We found that, although procedural pain intensity (the sensory dimension) and distress (the emotional dimension) may closely covary, there are certain factors than can preferentially influence each of the dimensions. Clinicians are encouraged to appreciate the multidimensionality of pain when they perform procedures and use this knowledge to minimize the patient's pain experience.Peer reviewe

Clinical Comparison of Patient-Side Fibrinogen Assay and Common Laboratory Analyzer in Pediatric Cardiopulmonary Bypass

The coagulation status of infant and pediatric patients can be severely compromised during the course of cardiopulmonary bypass due primarily to hemodilution and hypothermia. Fibrinogen level is one source of information necessary to assess the coagulation status of a patient. An accurate and expedient method to determine the fibrinogen level would allow for earlier initiation of coagulation therapy to prevent excessive postoperative bleeding. The purpose of this study was to compare two methods of determining fibrinogen level: a patient-side assay and a common laboratory analyzer. The patient-side test utilized the HemoChron Fibrinogen Assay and was performed in the operating room. The MLA 1000C was the laboratory method utilized in the hospital's coagulation laboratory. Simultaneous testing was conducted pre bypass and intraoperatively on 26 infant and pediatric patients undergoing cardiopulmonary bypass for palliation and correction of congenital heart defects. The resulting values were compared using paired t-test, regression and correlation analysis, and descriptive analysis. The values obtained by the two methods were significantly different (p<.05) at each collection time. Further analysis revealed that other variables, such as hematocrit and platelet count, affected the differences between the results of the methods. The HemoChron Fibrinogen Assay may not be a viable tool for the assessment of fibrinogen level on infant and pediatric patients undergoing cardiopulmonary bypass surgery. Further studies should be done in this patient population incorporating other confounding variables

Socio-ecological predictors of mental health outcomes among healthcare workers during the COVID-19 pandemic in the United States.

BackgroundHealthcare workers are at increased risk of adverse mental health outcomes during the COVID-19 pandemic. Studies are warranted that examine socio-ecological factors associated with these outcomes to inform interventions that support healthcare workers during future disease outbreaks.MethodsWe conducted an online cross-sectional study of healthcare workers during May 2020 to assess the socio-ecological predictors of mental health outcomes during the COVID-19 pandemic. We assessed factors at four socio-ecological levels: individual (e.g., gender), interpersonal (e.g., social support), institutional (e.g., personal protective equipment availability), and community (e.g., healthcare worker stigma). The Personal Health Questionnaire-9, Generalized Anxiety Disorder-7, Primary Care Post-Traumatic Stress Disorder, and Alcohol Use Disorders Identification Test-Concise scales assessed probable major depression (MD), generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and alcohol use disorder (AUD), respectively. Multivariable logistic regression models were used to assess unadjusted and adjusted associations between socio-ecological factors and mental health outcomes.ResultsOf the 1,092 participants, 72.0% were female, 51.9% were frontline workers, and the mean age was 40.4 years (standard deviation = 11.5). Based on cut-off scores, 13.9%, 15.6%, 22.8%, and 42.8% had probable MD, GAD, PTSD, and AUD, respectively. In the multivariable adjusted models, needing more social support was associated with significantly higher odds of probable MD, GAD, PTSD, and AUD. The significance of other factors varied across the outcomes. For example, at the individual level, female gender was associated with probable PTSD. At the institutional level, lower team cohesion was associated with probable PTSD, and difficulty following hospital policies with probable MD. At the community level, higher healthcare worker stigma was associated with probable PTSD and AUD, decreased satisfaction with the national government response with probable GAD, and higher media exposure with probable GAD and PTSD.ConclusionsThese findings can inform targeted interventions that promote healthcare workers' psychological resilience during disease outbreaks

Racial and Gender Discrimination Predict Mental Health Outcomes among Healthcare Workers Beyond Pandemic-Related Stressors: Findings from a Cross-Sectional Survey

Racial and gender discrimination are risk factors for adverse mental health outcomes in the general population; however, the effects of discrimination on the mental health of healthcare workers needs to be further explored, especially in relation to competing stressors. Thus, we administered a survey to healthcare workers to investigate the associations between perceived racial and gender discrimination and symptoms of depression, anxiety, posttraumatic stress, and burnout during a period of substantial stressors related to the COVID-19 pandemic and a national racial reckoning. We used multivariable linear regression models, which controlled for demographics and pandemic-related stressors. Of the 997 participants (Mean Age = 38.22 years, SD = 11.77), 688 (69.01%) were White, 148 (14.84%) Asian, 86 (8.63%) Black, 73 (7.32%) Latinx, and 21 (2.11%) identified as another race. In multivariable models, racial discrimination predicted symptoms of depression (B = 0.04; SE: 0.02; p = .009), anxiety (B = 0.05; SE: 0.02; p = .004), and posttraumatic stress (B = 0.01; SE: 0.01; p = .006) and gender discrimination predicted posttraumatic stress (B = 0.11; SE: 0.05; p = .013) and burnout (B = 0.24; SE: 0.07; p = .001). Discrimination had indirect effects on mental health outcomes via inadequate social support. Hospital-wide diversity and inclusion initiatives are warranted to mitigate the adverse mental health effects of discrimination

Implementation, interrupted: Identifying and leveraging factors that sustain after a programme interruption

Many implementation efforts experience interruptions, especially in settings with developing health systems. Approaches for evaluating interruptions are needed to inform re-implementation strategies. We sought to devise an approach for evaluating interruptions by exploring the sustainability of a programme that implemented diabetes mellitus (DM) screening within tuberculosis clinics in Uganda in 2017. In 2019, we conducted nine interviews with clinic staff and observed clinic visits to determine their views and practices on providing integrated care. We mapped themes to a social ecological model with three levels derived from the Consolidated Framework for Implementation Research (CFIR): outer setting (i.e. community), inner setting (i.e. clinic), and individuals (i.e. clinicians). Respondents explained that DM screening ceased due to disruptions in the national supply chain for glucose test strips, which had cascading effects on clinics and clinicians. Lack of screening supplies in clinics limited clinicians’ opportunities to perform DM screening, which contributed to diminished self-efficacy. However, culture, compatibility and clinicians’ beliefs about DM screening sustained throughout the interruption. We propose an approach for evaluating interruptions using the CFIR and social ecological model; other programmes can adapt this approach to identify cascading effects of interruptions and target them for re-implementation

Comparison of Peristat Online Perimetry with the Humphrey Perimetry in a Clinic-Based Setting

Purpose We determined the receiver operating characteristic (ROC) curves for Peristat online perimetry at detecting varying degrees of glaucoma and the correlation between Peristat online perimetry and Humphrey visual field. Methods: A prospective, comparative study of Peristat online perimetry (an achromatic static computer threshold testing program) and Humphrey visual field (HVF) 24-2 SITA standard testing was performed by 63 glaucoma patients and 30 healthy controls in random order. The number of total adjacent abnormal test points were identified for each test, and compared with Spearman correlation. Receive operating characteristic curves were generated for Peristat online perimetry detection of mild and moderate-severe glaucoma patients using contrast sensitivity thresholds of −16.7, −21.7, and −26.7 dB. Results: The area under the ROC curve for glaucoma detection ranged from 0.77 to 0.81 for mild disease (mean deviation [MD], >−6 dB on HVF) and 0.85 to 0.87 for moderate to severe disease (MD, <−6 dB on HVF) depending on contrast threshold. Peristat online perimetry and Humphrey visual field abnormal points were highly correlated with Spearman rank correlations ranging from 0.55 to 0.77 (all P < 0.001). Conclusions: Peristat online perimetry exhibits a reasonable ROC curve without specialized equipment and exhibited significant correlation with the conventional 24° Humphrey visual field test. Translational Relevance Low cost widely available internet-based visual fields may complement traditional office-based visual field testing

Narrative identity among people with disabilities during the COVID-19 pandemic: The interdependent self

This study examines narrative identity among a large, diverse (American) sample of people with disabilities (PWDs) during the “second wave” of the COVID-19 pandemic (October-December, 2020). The study relied on abductive analyses, combining a purely inductive phase of inquiry followed by two rounds of investigation that filtered inductive insights through three theoretical lenses: social-ecological theory, the theory of narrative identity, and perspectives from the interdisciplinary field of disability studies. The central result was the identification of a particular configuration of self, one that was demonstrably interdependent with both immediate interpersonal contexts and with broader cultural contexts. This interdependent self was interpreted in both positive and negative ways by PWDs. These findings invite future inquiry into commonplace conceptualizations of an independent self at the center of personality research