"It kind of strips down your relationship to its defining features……it just kind of shone a light on what was already there": A grounded theory of the impact of postpartum psychosis on the couple's relationship

BACKGROUND

Postpartum psychosis is a severe mental health illness following childbirth. Studies to date have developed from initial focus on experiences of women to address the role and experiences of partners, and recently to touch on the effect on their relationship. This study aimed to build on this work, by focussing directly on the impact of postpartum psychosis on the couple's relationship, from the perspectives of both the woman and her partner.

METHOD

A constructivist grounded theory approach was utilised to generate a theory that explained the impact of postpartum psychosis on the couple's relationship. In-depth semi-structured interviews were completed with a sample of eight women and six partners.

RESULTS

Four stages and five general categories described the processes that the couple experienced, and the impact postpartum psychosis had on their relationship.

DISCUSSION

The grounded theory adds to current evidence and helps increase understanding of factors that play a role in adjustment and outcomes. New insights were identified, including postpartum psychosis amplifying existing relational patterns; and the mediating role of the pre-existing relationship and couplehood. Clinical implications and areas for further research are considered.

Evidence-based consensus guidelines on patient selection and trial stimulation for spinal cord stimulation therapy for chronic non-cancer pain

Spinal cord stimulation (SCS) has demonstrated effectiveness for neuropathic pain. Unfortunately, some patients report inadequate long-term pain relief. Patient selection is emphasized for this therapy; however, the prognostic capabilities and deployment strategies of existing selection techniques, including an SCS trial, have been questioned. After approval by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, a steering committee was formed to develop evidence-based guidelines for patient selection and the role of an SCS trial. Representatives of professional organizations with clinical expertize were invited to participate as committee members. A comprehensive literature review was carried out by the steering committee, and the results organized into narrative reports, which were circulated to all the committee members. Individual statements and recommendations within each of seven sections were formulated by the steering committee and circulated to members for voting. We used a modified Delphi method wherein drafts were circulated to each member in a blinded fashion for voting. Comments were incorporated in the subsequent revisions, which were recirculated for voting to achieve consensus. Seven sections with a total of 39 recommendations were approved with 100% consensus from all the members. Sections included definitions and terminology of SCS trial; benefits of SCS trial; screening for psychosocial characteristics; patient perceptions on SCS therapy and the use of trial; other patient predictors of SCS therapy; conduct of SCS trials; and evaluation of SCS trials including minimum criteria for success. Recommendations included that SCS trial should be performed before a definitive SCS implant except in anginal pain (grade B). All patients must be screened with an objective validated instrument for psychosocial factors, and this must include depression (grade B). Despite some limitations, a trial helps patient selection and provides patients with an opportunity to experience the therapy. These recommendations are expected to guide practicing physicians and other stakeholders and should not be mistaken as practice standards. Physicians should continue to make their best judgment based on individual patient considerations and preferences.

To Trial or Not to Trial Before Spinal Cord Stimulation for Chronic Neuropathic Pain: The Patients' View From the TRIAL-STIM Randomized Controlled Trial

Objectives

Spinal cord stimulation (SCS) is an established treatment of chronic neuropathic pain. Although a temporary SCS screening trial is widely used to determine suitability for a permanent implant, its evidence base is limited. The recent TRIAL‐STIM study (a randomized controlled trial at three centers in the United Kingdom) found no evidence that an SCS screening trial strategy provides superior patient outcomes as compared with a no trial approach. As part of the TRIAL‐STIM study, we undertook a nested qualitative study to ascertain patients' preferences in relation to undergoing a screening trial or not.

Materials and Methods

We interviewed 31 patients sampled from all three centers and both study arms (screening trial/no trial) prior to SCS implantation, and 23 of these patients again following implantation (eight patients were lost to follow‐up). Interviews were undertaken by telephone and audio‐recorded, then transcripts were subject to thematic analysis. In addition, participants were asked to state their overall preference for a one‐stage (no screening trial) versus two‐stage (screening trial) implant procedure on a five‐point Likert scale, before and after implantation.

Results

Emergent themes favoured the option for a one‐stage SCS procedure. Themes identified include: saving time (off work, in hospital, attending appointments), avoiding the worry about having “loose wires” in the two‐stage procedure, having only one period of recovery, and saving NHS resources. Participants' rated preferences show similar support for a one‐stage procedure without a screening trial.

Conclusions

Our findings indicate an overwhelming preference among participants for a one‐stage SCS procedure both before and after the implant, regardless of which procedure they had undergone. The qualitative study findings further support the TRIAL‐STIM RCT results.

Correction to: Does a Screening Trial for Spinal Cord Stimulation in Patients with Chronic Pain of Neuropathic Origin have Clinical Utility and Cost-Effectiveness? (TRIAL-STIM Study): study protocol for a randomised controlled trial

Following publication of the original article [1], we have been notified that the final specification of randomisation implemented in the study is slightly different to that stated in the protocol and needs to be corrected as follows:

Reflection for all healthcare staff: A national evaluation of Schwartz Rounds

The emotional toll of working in healthcare is widely recognised, but staff rarely have time to reflect on their experiences. Schwartz Rounds provide an opportunity for all staff in a healthcare organisation to meet regularly and reflect on the human connections made with patients and the emotional impact of their work. They are now running in over 200 organisations across the UK & Ireland. In the first evaluation of a national sample in the UK, we review feedback received from a large sample of 402 Schwartz Rounds in a total of 47 organisations, including acute and non-acute NHS trusts and hospices. Analyses were undertaken to explore self-reported experiences of the Rounds, and differences between the proportions of professional staff groups attending. The overall experience of Schwartz Rounds was very positive across all settings. In particular, staff reported that Rounds helped them to gain insight into the working lives of their colleagues. There were no differences between the responses of clinical and non-clinical staff, indicating that all staff value a reflective space regardless of background. Healthcare staff value an opportunity to reflect on the emotional impact of their work. In increasingly overstretched and hurried services, it is a priority to provide this.

An Exploration of the Experiences and Educational Needs of Patients With Failed Back Surgery Syndrome Receiving Spinal Cord Stimulation

OBJECTIVE

To explore the experience of spinal cord stimulation (SCS) for patients with failed back surgery syndrome (FBSS).

METHODS

Adults with FBSS referred for SCS underwent semistructured interviews at three time points: before their SCS trial, after the trial, and three months after receiving the SCS implant. The face-to-face interviews were audio recorded, transcribed verbatim and analyzed thematically.

RESULTS

Twelve adults (8 male, 4 female, aged 38-80 years, pain duration 1-26 years) were recruited. Six themes were identified; 1) What should I expect? 2) Varied outcomes, 3) Understanding pain and this new treatment, 4) Experiences of the SCS journey, 5) Getting used to the device, and 6) Finding out what I need to know. Participants' expectations were varied and the procedures were broadly viewed as minor surgery. Participants' expectations about SCS were not limited to pain relief and included reductions in medication, better sleep, and increased physical activity. Participants' understanding of pain and how SCS purports to work was limited. Throughout the process, practical challenges were identified such as the surgical wound management and battery recharging. Participants received information from multiple sources and identified a range of key information needs including a quick-start guide on how to operate the device and a list of dos and don'ts.

CONCLUSIONS

Overall, participants' understanding of SCS was limited. The value participants placed on understanding of the process varied markedly. A list of practical informational needs has been identified. Bespoke, user-friendly, informational tools should be developed from this list to enhance the patient experience of SCS.

How important is compassionate healthcare to you? A comparison of the perceptions of people in the United States and Ireland

Compassionate care requires understanding of another’s pain or suffering, with commitment to doing something to relieve this. It is endorsed by nursing and other healthcare professionals in their codes of ethics as one of their main responsibilities. Yet too often it comes to public attention as a deficiency in healthcare organisations. Any effort to achieve meaningful quality improvement must start with a method of measuring patient experience. The Schwartz Center Compassionate Care Scale™ (SCCCS) is a unidimensional 12-item questionnaire with high internal reliability, developed from a study of physicians and recently hospitalised patients in the US. The present study extends usage of the SCCCS to a sample of the people in Ireland. The SCCCS again shows high internal reliability, with all items loading on a single factor. The findings indicate that recently hospitalised patients and non-hospitalised individuals were in agreement about the importance of the elements of compassionate care. Patients’ ratings of their doctors’ compassionate behaviours were significantly correlated with ratings of their healthcare team. However, patients reported that demonstration of compassion – whether by their doctor or the whole healthcare team – fell short of what they considered important. The SCCCS is a reliable and valid measure of perceptions of compassionate care across different countries, with potential to contribute to quality improvement in healthcare.

Recessive mutations in the cancer gene Ataxia Telangiectasia Mutated (ATM), at a locus previously associated with metformin response, cause dysglycaemia and insulin resistance

AIM

To investigate glucose and insulin metabolism in participants with ataxia telangiectasia in the absence of a diagnosis of diabetes.

METHODS

A standard oral glucose tolerance test was performed in participants with ataxia telangiectasia (n = 10) and in a control cohort (n = 10). Serial glucose and insulin measurements were taken to permit cohort comparisons of glucose-insulin homeostasis and indices of insulin secretion and sensitivity.

RESULTS

During the oral glucose tolerance test, the 2-h glucose (6.75 vs 4.93 mmol/l; P = 0.029), insulin concentrations (285.6 vs 148.5 pmol/l; P = 0.043), incremental area under the curve for glucose (314 vs 161 mmol/l/min; P = 0.036) and incremental area under the curve for insulin (37,720 vs 18,080 pmol/l/min; P = 0.03) were higher in participants with ataxia telangiectasia than in the controls. There were no significant differences between groups in fasting glucose, insulin concentrations or insulinogenic index measurement (0.94 vs 0.95; P = 0.95). The Matsuda index, reflecting whole-body insulin sensitivity, was lower in participants with ataxia telangiectasia (5.96 vs 11.03; P = 0.019) than in control subjects.

CONCLUSIONS

Mutations in Ataxia Telangiectasia Mutated (ATM) that cause ataxia telangiectasia are associated with elevated glycaemia and low insulin sensitivity in participants without diabetes. This indicates a role of ATM in glucose and insulin metabolic pathways.

Can compassionate healthcare be measured? The Schwartz Center Compassionate Care Scale™

OBJECTIVE

Assess psychometric characteristics of an instrument to measure patient ratings of treating physicians' compassionate care in a recent hospitalization.

METHODS

We used Cronbach's alpha to examine scale reliability, exploratory and confirmatory factor analysis to examine scale structure of two sets of items on compassionate care. We used Mokken analysis to determine if items in each set belonged to a unidimensional scale.

RESULTS

Results indicated that both sets of items had strong reliability when used to rate individual physicians (Cronbach's α=.97 and .95). A one factor model was a good fit to both sets of items. Mokken analysis supported unidimensional scales. Both sets of items correlated with an overall measure of patient satisfaction with physicians and even more strongly with an item measuring emotional support.

CONCLUSIONS

A patient-rated scale reliably measured hospital physicians' compassion and correlated significantly with an item measuring overall patient satisfaction and a specific measure of satisfaction with emotional support. Measurement of compassionate healthcare should be included in research, educational assessment, and quality improvement programs.

PRACTICE IMPLICATIONS

Clinicians should participate in efforts to enhance their ability to demonstrate compassionate care including eliciting and sharing information and acting collaboratively to ameliorate patients' socioemotional concerns and needs.

Weaning from prolonged invasive ventilation in motor neuron disease: analysis of outcomes and survival

INTRODUCTION

Non-invasive ventilation (NIV) improves prognosis in patients with motor neuron disease (MND) in the absence of major bulbar involvement. However, some experience a rapid and unexpected decline in respiratory function and may undergo emergency tracheal intubation. Weaning from invasive ventilation can be difficult, and reported independence from invasive ventilation is uncommon with poor prognosis. The outcomes of patients with MND referred to a specialist weaning service following emergency tracheal intubation were examined and compared with MND patients electively initiating NIV.

METHODS

A case note review was performed on all patients with MND invasively ventilated and referred to a specialist weaning service between 1992 and 2007. Outcomes were compared with those electively commenced on NIV during the same period.

RESULTS

Thirty patients were referred for weaning from invasive ventilation which was started in 17 before MND was diagnosed. Fourteen patients (47%) were weaned from invasive ventilation but still required NIV, 13 failed to wean, and three died. Seventeen were discharged home from hospital. The median survival from tracheal intubation was 13.7 months (95% CI 0 to 30.8) for those previously diagnosed and 7.2 months (95% CI 5.1 to 9.4) for those not previously known to have MND. Comparison with patients initiated electively on NIV demonstrated similar survival estimates to that from emergency intubation (median 9.4 (95% CI 6.9 to 12.0) vs 7.8 (95% CI 2.6 to 12.9) months respectively).

CONCLUSION

The prognosis in MND following acute respiratory failure and intubation is not always complete ventilator dependence if patients are offered a comprehensive weaning programme.

Spinal Cord Independence Measure, version III: applicability to the UK spinal cord injured population

OBJECTIVE

To examine the validity, reliability and usefulness of the Spinal Cord Independence Measure for the UK spinal cord injury population.

DESIGN

Multi-centre cohort study.

SETTING

Four UK regional spinal cord injury centres.

SUBJECTS

Eighty-six people with spinal cord injury.

INTERVENTIONS

Spinal Cord Independence Measure and Functional Independence Measure on admission analysed using inferential statistics, and Rasch analysis of Spinal Cord Independence Measure.

MAIN OUTCOME MEASURES

Internal consistency, inter-rater reliability, discriminant validity; Spinal Cord Independence Measure subscale match between distribution of item difficulty and patient ability measurements; reliability of patient ability measures; fit of data to Rasch model; unidimensionality of subscales; hierarchical ordering of categories within items; differential item functioning across patient groups.

RESULTS

Scale reliability (kappa coefficients range 0.491-0.835; (p < 0.001)), internal consistency (Cronbach's alpha 0.770 and 0.780 for raters), and validity (Pearson correlation; p < 0.01) were all significant. Spinal Cord Independence Measure subscales compatible with stringent Rasch requirements; mean infit indices high; distinct strata of abilities identified; most thresholds ordered; item hierarchy stable across clinical groups and centres. Misfit and differences in item hierarchy identified. Difficulties assessing central cord injuries highlighted.

CONCLUSION

Conventional statistical and Rasch analyses justify the use of the Spinal Cord Independence Measure in clinical practice and research in the UK. Cross-cultural validity may be further improved.

Euroscreen 2: towards community policy on insurance, commercialization and public awareness

The project Euroscreen 2 has examined genetic screening and testing with particular reference to implications for insurance, commercialization through marketing of genetic tests direct to the public, and issues surrounding raising public awareness of these and other developments in genetics, including the practical experiment of a Gene Shop. This paper provides a snapshot of the three year project. The study group's work included monitoring developments in different European countries and exploring possibilities for regulation in insurance and commercialization together with public attitudes to regulation. The success or failure of different strategies is not independent of public awareness. Exploration of policy, however, also requires examination of fundamental concepts such as solidarity and geneticization.

Solidarity and equity: new ethical frameworks for genetic databases

Genetic database initiatives have given rise to considerable debate about their potential harms and benefits. The question arises as to whether existing ethical frameworks are sufficient to mediate between the competing interests at stake. One approach is to strengthen mechanisms for obtaining informed consent and for protecting confidentiality. However, there is increasing interest in other ethical frameworks, involving solidarity--participation in research for the common good--and the sharing of the benefits of research.

Professional ethics and labor disputes: medicine and nursing in the United Kingdom

The term “industrial action” includes any noncooperation with management, such as strict “working to rule,” refusal of certain duties, going slow, and ultimately withdrawal of labor. The latter form of action, striking, has posed particular problems for professional ethics, especially in those professions that provide healthcare, because of the potential impact on patients' well-being. Examination of the issues, however, displays a difference in response between the healthcare professions, in particular between doctors and nurses. In considering the ethics of industrial (especially strike) action there are various aspects of professional ethics to consider: (1) whether there is a tension between industrial action and the very notion of professional ethics; (2) what specific issues arise in the case of healthcare professions; (3) what, if anything, can explain and/or justify different responses from the medical and nursing professions?

Mutations in the RNA component of RNase MRP cause a pleiotropic human disease, cartilage-hair hypoplasia

The recessively inherited developmental disorder, cartilage-hair hypoplasia (CHH) is highly pleiotropic with manifestations including short stature, defective cellular immunity, and predisposition to several cancers. The endoribonuclease RNase MRP consists of an RNA molecule bound to several proteins. It has at least two functions, namely, cleavage of RNA in mitochondrial DNA synthesis and nucleolar cleaving of pre-rRNA. We describe numerous mutations in the untranslated RMRP gene that cosegregate with the CHH phenotype. Insertion mutations immediately upstream of the coding sequence silence transcription while mutations in the transcribed region do not. The association of protein subunits with RNA appears unaltered. We conclude that mutations in RMRP cause CHH by disrupting a function of RNase MRP RNA that affects multiple organ systems.

Nurse-initiated thrombolysis in coronary care

National service frameworks emphasise the importance of people who are experiencing a myocardial infarction receiving thrombolysis as quickly as possible. Nurse-initiated thrombolysis is one way to safely achieve the standards.

Ethical issues in psychiatric care: geneticisation and community care

This paper will examine two different though related themes in current debates about ethical issues in psychiatric care. There is, first, the general question of who should be the main focus of the debate: the individual, the family, the local community, or the wider society? Secondly, the current controversies about the genetic basis of mental disorders will be explored with reference to their implications for both images and understanding of mental disorders and for psychiatric care. Would the understanding of the genetic causes of mental disorder lead to better treatments and better acceptance or to the potential for increased discrimination and stigmatisation?

Beware! Preimplantation genetic diagnosis may solve some old problems but it also raises new ones

Preimplantation genetic diagnosis (PIGD) goes some way to meeting the clinical, psychological and ethical problems of antenatal testing. We should guard, however, against the assumption that PIGD is the answer to all our problems. It also presents some new problems and leaves some old problems untouched. This paper will provide an overview of how PIGD meets some of the old problems but will concentrate on two new challenges for ethics (and, indeed, law). First we look at whether we should always suppose that it is wrong for a clinician to implant a genetically abnormal zygote. The second concern is particularly important in the UK. The Human Fertilisation and Embryology Act (1990) gives clinicians a statutory obligation to consider the interests of the future children they help to create using in vitro fertilisation (IVF) techniques. Does this mean that because PIGD is based on IVF techniques the balance of power for determining the best interests of the future child shifts from the mother to the clinician?

Genetic screening and ethics: European perspectives

Analysis and comparison of genetic screening programs shows that the extent of development of programs varies widely across Europe. Regional variations are due not only to genetic disease patterns but also reflect the novelty of genetic services. In most countries, the focus for genetic screening programs has been pregnant women and newborn children. Newborn children are screened only for disorders which are treatable. Prenatal screening when provided is for conditions for which termination may be offered. The only population screening programs for adults are those for thalassaemia carrier status in Cyprus, Greece and Italy. Social responses to genetic screening range from acceptance to hostility. There is a fundamental tension between individual and community in the debates in various European countries about implementation of screening programs. Opposition to genetic screening is frequently expressed in terms of arguments about "eugenics" with insufficient regard to the meaning of the term and its implications. Only a few countries have introduced explicit legislation on genetic screening. Legislation to address discrimination may provide more safeguards than legislation protecting genetic information itself.

Characterization of 12 microsatellite loci of the human MHC in a panel of reference cell lines

The human genome contains a large number of interspersed microsatellite repeats which exhibit a high degree of polymorphism and are inherited in a Mendelian fashion, making them extremely useful genetic markers. Several microsatellites have been described in the HLA region, but allele nomenclature, a set of broadly distributed controls, and typing methods have not been standardized, which has resulted in discrepant microsatellite data between laboratories. In this report we present a detailed protocol for genotyping microsatellites using a semi-automated fluorescence-based method. Twelve microsatellites within or near the major histocompatibility complex (MHC) were typed in the 10th International Histocompatibility Workshop homozygous typing cell lines (HTCs) and alleles were designated based on size. All loci were sequenced in two HTCs providing some information on the level of complexity of the repeat sequence. A comparison of allele size obtained by genotyping versus that obtained by direct sequencing showed minor discrepancies in some cases, but these were not unexpected given the technical differences in the methodologies. Fluorescence-based typing of microsatellites in the MHC described herein is highly efficient, accurate, and reproducible, and will allow comparison of results between laboratories.

Can genetic counseling avoid the charge of eugenics?

The claim that x is a form of eugenics is frequently used as if it were a knockdown argument against x. Genetic counseling has tried to distance itself from eugenics by presenting itself as facilitating choice. Its success in this attempt has been challenged. The argument however is not a knockdown one and there is scope for some mediation between autonomy and public health goals in genetics.

Inhibitory consequences of memory selection

When subjects select a prime from a visual display while leaving a distractor prime unselected, response time (RT) or response accuracy to a subsequent probe may be impeded if the distractor prime and probe are identical, or if they are related to one another. This phenomenon, negative priming (NP), has obvious implications for understanding perceptual selection. However, it is not known whether NP results from other kinds of selection processes. The present studies were designed to investigate whether NP occurs when primes are selected from working memory rather than from a visual display. In the two experiments, the subjects memorized two primes, selected one prime for further processing, and classified the contents of a probe display. Significant NP occurred in both Experiments. In Experiment 2, however, NP occurred only under easy-selection conditions; the effect was reversed under difficult-selection conditions. The findings indicate a role for NP in memory processing, but contrast with the results from perceptual selection studies showing greater NP under difficult-selection than under easy-selection conditions. The present finding suggests a complex and perhaps strategy-dependent relationship between memory selection difficulty and NP.

Genetic screening: a comparative analysis of three recent reports

Three recent reports on genetic screening published in the United Kingdom, Denmark and the Netherlands are discussed. Comparison of the Dutch report with the Danish and the Nuffield reports reveals that the Dutch report focuses on the aim of enlarging the scope for action, emphasising protection of autonomy and self-determination of the screenee more than the other two reports. The three reports have in common that the main concern is with concrete issue such as stigmatisation, discrimination, protection of the private sphere and issues linked with labour and insurance. Some potential long term consequences, however, tend to be neglected or underestimated. These omissions are pointed out.

On people's understanding of the diagnostic implications of probabilistic data

Two lines of prior research into the conditions under which people seek information are examined in light of two statistical definitions of diagnosticity. Five experiments are reported. In two, subjects selected information in order to test a hypothesis. In the remaining three, they selected information in order to convince someone else of the truth of a known hypothesis. A total of 567 university students served as subjects. The two primary conclusions were as follows: (1) When the task is highly structured by the environment, subjects select information diagnostically, and (2) when the task is less structured, so that subjects must seek relevant information not manifest, they select information pseudodiagnostically. Possible relations to other laboratory inference tasks and to clinical judgment are discussed.

When drug treatment in the elderly is not cost effective. An ethical dilemma in an environment of healthcare rationing

In light of moves towards the view that rationing of healthcare resources is inevitable, the question arises as to whether age is a relevant consideration. To hold age as relevant in this context attracts the charge of agism; however, age may be related to some other characteristic(s) that are pertinent. In the context of drug treatment of the elderly, there is evidence to suggest that there are important differences between older and younger patients in terms of adverse responses to drugs because of factors such as physiological changes and multiple health problems, which occur with aging. On the other hand, some studies show beneficial effects of drug therapy. There is a need for more empirical data on cost effectiveness. Ethics arguably have to take into account factors other than cost effectiveness, such as equity. A central question is whether what is required is a set of criteria in addition to cost effectiveness, or an interpretation of cost effectiveness sensitive to broader considerations, such as quality of life (QOL). In relation to the latter, the issue of age-specific measurements of QOL remains problematic.

How can hospitals ration drugs? Fairness is at issue

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The ethics of screening: is 'screeningitis' an incurable disease?

Screening programmes are becoming increasingly popular since prevention is considered 'better than cure'. While earlier diagnosis may result in more effective treatment for some, there will be consequent harm for others due to anxiety, stigma, side-effects etc. A screening test cannot guarantee the detection of all 'abnormal' cases, therefore there will be false reassurance for some. A proper consideration of the potential benefit and harm arising from screening may lead to the conclusion that the programme should not be offered. A modified utilitarian approach may be used for allocation of scarce resources in health care. Ethics has an important role in this evaluation.