A Case Study of Hypnosis Enhanced Cognitive Therapy for Pain in a Ventilator Dependent Patient during Inpatient Rehabilitation for Spinal Cord Injury

Early, acute pain following spinal cord injury (SCI) is common, can negatively impact SCI rehabilitation, and is frequently not responsive to biomedical treatment. Nonpharmacological interventions show promise in reducing pain for individuals with SCI. However, most psychological interventions rely heavily on verbal interaction between the individual being treated and the clinician, making them inaccessible for individuals with impaired verbal output due to mechanical ventilation. This case study aims to describe the adaptation and implementation of hypnotic cognitive therapy (HYP-CT) intervention for early SCI pain in the context of mechanical ventilation dependence and weaning. The participant was a 54-year-old male with C2 AIS A SCI requiring mechanical ventilation. Four sessions of HYP-CT were provided during inpatient rehabilitation with assessment prior to intervention, after the intervention sessions, and prior to discharge. The participant reported immediate reductions in pain intensity following each intervention session. Overall, he reported increases in self-efficacy and pain acceptance. He did not report any negative treatment effects and thought the intervention provided support during mechanical ventilation weaning. During treatment, he discontinued opioid pain medications and reported actively using intervention strategies. Our results support the potential for early, hypnotic cognitive therapy for individuals with SCI experiencing pain or distress while dependent on mechanical ventilation.

Experience with an Enhanced Recovery After Spine Surgery protocol at an academic community hospital

OBJECTIVE

Enhanced Recovery After Surgery (ERAS) protocols have rapidly gained popularity in multiple surgical specialties and are recognized for their potential to improve patient outcomes and decrease hospitalization costs. However, they have only recently been applied to spinal surgery. The goal in the present work was to describe the development, implementation, and impact of an Enhanced Recovery After Spine Surgery (ERASS) protocol for patients undergoing elective spine procedures at an academic community hospital.

METHODS

A multidisciplinary team, drawing on prior publications and spine surgery best practices, collaborated to develop an ERASS protocol. Patients undergoing elective cervical or lumbar procedures were prospectively enrolled at a single tertiary care center; interventions were standardized across the cohort for pre-, intra-, and postoperative care using standardized order sets in the electronic medical record. Protocol efficacy was evaluated by comparing enrolled patients to a historic cohort of age- and procedure-matched controls. The primary study outcomes were quantity of opiate use in morphine milligram equivalents (MMEs) on postoperative day (POD) 1 and length of stay. Secondary outcomes included frequency and duration of indwelling urinary catheter use, discharge disposition, 30-day readmission and reoperation rates, and complication rates. Multivariable linear regression was used to determine whether ERASS protocol use was independently predictive of opiate use on POD 1.

RESULTS

In total, 97 patients were included in the study cohort and were compared with a historic cohort of 146 patients. The patients in the ERASS group had lower POD 1 opiate use than the control group (26 ± 33 vs 42 ± 40 MMEs, p < 0.001), driven largely by differences in opiate-naive patients (16 ± 21 vs 38 ± 36 MMEs, p < 0.001). Additionally, patients in the ERASS group had shorter hospitalizations than patients in the control group (51 ± 30 vs 62 ± 49 hours, p = 0.047). On multivariable regression, implementation of the ERASS protocol was independently predictive of lower POD 1 opiate consumption (β = -7.32, p < 0.001). There were no significant differences in any of the secondary outcomes.

CONCLUSIONS

The authors found that the development and implementation of a comprehensive ERASS protocol led to a modest reduction in postoperative opiate consumption and hospital length of stay in patients undergoing elective cervical or lumbar procedures. As suggested by these results and those of other groups, the implementation of ERASS protocols may reduce care costs and improve patient outcomes after spine surgery.

Online Versus In-Person Screening, Brief Intervention, and Referral to Treatment Training in Pediatrics Residents

BACKGROUND

Pediatricians underestimate the prevalence of substance misuse among children and adolescents and often fail to screen for and intervene in practice. The American Academy of Pediatrics recommends training in Screening, Brief Intervention, and Referral to Treatment (SBIRT), but training outcomes and skill acquisition are rarely assessed.

OBJECTIVE

We compared the effects of online versus in-person SBIRT training on pediatrics residents' knowledge, attitudes, behaviors, and skills.

METHODS

Forty pediatrics residents were randomized to receive either online or in-person training. Skills were assessed by pre- and posttraining standardized patient interviews that were coded for SBIRT-adherent and -nonadherent behaviors and global skills by 2 trained coders. Thirty-two residents also completed pre- and postsurveys of their substance use knowledge, attitudes, and behaviors (KABs). Two-way repeated measures multivariate analyses of variance (MANOVAs) and analyses of variance (ANOVAs) estimates were used to assess group differences in skill acquisition and KABs.

RESULTS

Findings indicated that both groups demonstrated skill improvement from pre- to postassessment. Results indicated that both groups increased their knowledge, self-reported behaviors, confidence, and readiness with no significant between-group differences. Follow-up univariate analyses indicated that, while both groups increased their SBIRT-adherent skills, the online training group displayed more "undesirable" behaviors posttraining.

CONCLUSIONS

The current study indicates that brief training, online or in-person, can increase pediatrics residents' SBIRT skills, knowledge, self-reported behaviors, confidence, and readiness. The findings further indicate that in-person training may have incremental benefit in teaching residents what not to do.

Engaging families through motivational interviewing

Helping parents change key behaviors may reduce the risk of child maltreatment. However, traditional provider-centered approaches to working with the parents of pediatric patients may increase resistance to behavioral change. Motivational interviewing (MI) is a patient-centered communication technique that helps address problems of provider-centered approaches. In this article, evidence for use of MI to address several risk factors for child maltreatment is reviewed, including parental substance abuse, partner violence, depression treatment, harsh punishment, and parental management of children's health. Fundamental components of MI that may be incorporated into clinical practice are presented.

Hippocampal lesions in rhesus monkeys disrupt emotional responses but not reinforcer devaluation effects

BACKGROUND

Although the role of the hippocampus in emotional behavior has long been recognized, the extent to which the hippocampus plays a role in the regulation and expression of emotion in rhesus monkeys has not been systematically explored.

METHODS

Rhesus monkeys (Macaca mulatta) with excitotoxic lesions of the hippocampal formation and unoperated control animals were assessed on two different types of emotional processing: defensive reactions to a potential predator (experiment 1) and ability to update the value of positive reinforcers, in this case food (experiment 2). Monkeys with aspiration lesions of the perirhinal cortex were also included in this study as an operated control group.

RESULTS

In experiment 1, whereas both operated groups showed reduced latencies to retrieve food located near an innately fear-provoking stimulus, a fake snake, only monkeys with hippocampal lesions displayed reduced defensive reactions to the snake. In experiment 2, both operated groups performed as well as control animals when choosing objects flexibly based on the current value of a food.

CONCLUSIONS

These findings dissociate the hippocampus and perirhinal cortex in fear expression and specifically implicate the hippocampal formation in generating responses to stimuli that are potentially threatening.

Effects of electrical stimulation on lymphatic flow and limb volume in the rat

BACKGROUND AND PURPOSE

The mechanism by which electrical stimulation affects edema has not been elucidated. The purpose of this study was to determine whether subcontraction high-voltage stimulation (SC-HVS) (ie, electrical stimulation that did not elicit a visible contraction) applied to the right hind limbs of rats would (1) alter the rate of lymphatic uptake of injected albumin labeled with Evans blue dye (AL-EBD) and (2) affect experimentally induced edema.

SUBJECTS AND METHODS

The paws of 28 anesthetized Sprague-Dawley rats (mean weight = 263 g, SD = 48 g) were injected with AL-EBD. The experimental group (n = 13) received 1 hour of SC-HVS, and the control group (n = 15) received sham treatment consisting of the same treatment administered to the experimental group but without the SC-HVS. Blood samples and volume measurements were obtained at intervals over a 7-hour period.

RESULTS

Analysis of variance and post hoc testing indicated that higher amounts of AL-EBD were taken up by the lymph of the experimental group animals as compared with the control group animals at each time period following the treatment. The experimental group's AL-EBD reached significance immediately after treatment, whereas the control group required an additional 4 hours. There was no significant reduction in limb volume in either group.

CONCLUSION AND DISCUSSION

The SC-HVS significantly increased the uptake of AL-EBD by lymphatic vessels, but it did not cause a significant decrease in the induced edema. The results of this study indicate that SC-HVS has the potential to reduce edema by increasing lymphatic uptake of proteins.

Decreased activation of skeletal muscle glycogen synthase by mixed-meal ingestion in NIDDM

Glycogen synthase (GS) catalyzes the formation of glycogen in human skeletal muscle, the tissue responsible for disposal of a significant portion of an oral carbohydrate load. Non-insulin-dependent diabetes mellitus (NIDDM) is characterized by fasting and postprandial hyperglycemia in conjunction with reduced rates of insulin-stimulated glucose disposal and storage in peripheral tissues, including muscle. Our objectives in this study were to determine whether ingestion of a mixed meal activates GS in control nondiabetic subjects and whether meal-related GS activation is reduced in NIDDM. To accomplish this, mixed formula meals were administered to 11 NIDDM and 9 age- and weight-matched nondiabetic control subjects. Plasma glucose and insulin values were measured before and for 90 min after meal ingestion. Skeletal muscle biopsies were performed just before and 90 min after meal ingestion for measurement of GS activity. Compared with control subjects, NIDDM subjects had significantly higher postprandial hyperglycemia and reduced postprandial hyperinsulinemia. GS was activated by meal ingestion in control subjects to a significantly greater extent than in NIDDM subjects. In NIDDM subjects, activation of GS was inversely correlated with fasting plasma glucose (r = .69, P less than .05). Therefore, NIDDM is characterized by reduced activation of a key step in the process of muscle glycogen repletion after a meal. Reduced activation of GS by a mixed meal in NIDDM may contribute to the reduced glucose disposal after a meal, thus contributing to the hyperglycemia observed in these subjects.

Effects of insulin infusion on human skeletal muscle pyruvate dehydrogenase, phosphofructokinase, and glycogen synthase. Evidence for their role in oxidative and nonoxidative glucose metabolism

To determine whether activation by insulin of glycogen synthase (GS), phosphofructokinase (PFK), or pyruvate dehydrogenase (PDH) in skeletal muscle regulates intracellular glucose metabolism, subjects were studied basally and during euglycemic insulin infusions of 12, 30, and 240 mU/m2 X min. Glucose disposal, oxidative and nonoxidative glucose metabolism were determined. GS, PFK, and PDH were assayed in skeletal muscle under each condition. Glucose disposal rates were 2.37 +/- 0.11, 3.15 +/- 0.19, 6.71 +/- 0.44, and 11.7 +/- 1.73 mg/kg X min; glucose oxidation rates were 1.96 +/- 0.18, 2.81 +/- 0.28, 4.43 +/- 0.32, and 5.22 +/- 0.52. Nonoxidative glucose metabolism was 0.39 +/- 0.13, 0.34 +/- 0.26, 2.28 +/- 0.40, and 6.52 +/- 1.21 mg/kg X min. Both the proportion of active GS and the proportion of active PDH were increased by hyperinsulinemia. PFK activity was unaffected. Activation of GS was correlated with nonoxidative glucose metabolism, while activation of PDH was correlated with glucose oxidation. Sensitivity to insulin of GS was similar to that of nonoxidative glucose metabolism, while the sensitivity to insulin of PDH was similar to that of glucose oxidation. Therefore, the activation of these enzymes in muscle may regulate nonoxidative and oxidative glucose metabolism.