Patient-Informed Treatment Development of Behavioral Smoking Cessation for People With Schizophrenia

The objective of this study was to use qualitative methodology to tailor and refine an existing smoking cessation intervention for the population of people who use cigarettes and are diagnosed with schizophrenia, schizoaffective, or psychotic disorder. Successive cohort design methodology was used to iteratively modify the treatment in response to qualitative participant, therapist, and consultant feedback on the intervention. Qualitative methodology for participant feedback included analysis of semistructured interviews with participants, visualization of app utilization data, and stakeholder feedback from study therapists and consultants. Using the successive cohort design, a tailored multicomponent mobile health smoking cessation intervention was developed. The intervention included mobile contingency management (i.e., financial compensation for confirmed abstinence from smoking), pharmacotherapy for smoking cessation, cognitive-behavioral counseling sessions, and the Stay Quit app for relapse prevention. Two cohorts (N = 13) were completed in the study; after each cohort, the treatment protocol was revised. The intervention is described, as well as the qualitative findings from each cohort and subsequent changes made to the intervention based upon patient and provider feedback. Metrics of patient engagement included treatment adherence (40% in Cohort 1 and 63% in Cohort 2). Both participants and therapists reported that the intervention was helpful. Over one third of participants self-reported abstinence at posttreatment. Since qualitative methodology is often underutilized in mental health treatment development, this study demonstrates the utility of the successive cohort design for treatment development of behavior change interventions for at-risk, vulnerable populations.

Low Income as a Multiplicative Risk Factor for Oral Pain and Dental Problems Among U.S. Veteran Smokers

PURPOSE

Compared to the United States (U.S.) general population, military veterans are at an increased risk of experiencing dental problems. This study documented associations between cigarette use and measures of dental/oral concern in a population of U.S. veterans who served in Iraq and Afghanistan.

METHOD

A cross-sectional analysis of survey data from the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans Health and Needs Study, a study of U.S. military veterans. Out of 5000 surveys mailed to a random sample of OEF/OIF veterans, 1161 surveys were completed and returned. Among study respondents, N = 1114 had non-missing dental/oral pain data and were included for analysis. The survey also included smoking history and demographic information. Univariate and multivariate logistic regression analyses were used to cross-sectionally model the odds of experiencing dental/oral concerns as a function of smoking status. We also examined moderating effects of income and gender on the association between smoking and dental/oral concerns.

RESULTS

In univariate and multivariate models, current smoking was associated with risk for dental/oral concerns. However, this association was qualified by a Smoking × Income interaction. For those earning above US$20,000, smoking was not associated with dental/oral concerns. Among veterans with low income, smoking was associated with three times higher odds of increased dental/oral concerns. There was no significant Gender × Smoking interaction.

CONCLUSION

These findings underscore the relevance of factors that moderate the association between smoking and dental/oral concern, namely income. Findings also underscore the importance of interventions to mitigate income disparities in oral healthcare.

Wall/Object Punching: An Important but Under-Recognized Form of Nonsuicidal Self-Injury

The present research investigated wall/object punching as a form of nonsuicidal self-injury (NSSI) among 1,143 veterans seeking treatment for posttraumatic stress disorder (PTSD). Wall/object punching was remarkably common in this sample (43%), and its inclusion in the definition of NSSI increased estimated prevalence of recent NSSI by 14%. As expected, wall/object punching was strongly associated with other traditional forms of NSSI, post-NSSI relief, and suicide ideation. Male veterans and veterans with PTSD were significantly more likely to engage in wall/object punching than female veterans and veterans without PTSD. More research on this important but under-recognized form of NSSI is needed.

A Preliminary Investigation of a Relapse Prevention Mobile Application to Maintain Smoking Abstinence Among Individuals With Posttraumatic Stress Disorder

OBJECTIVES

Smokers with posttraumatic stress disorder (PTSD) have increased difficulty achieving and maintaining abstinence. Contingency management approaches to smoking cessation interventions have demonstrated short-term efficacy but are limited by high rates of relapse. The goal of this pilot study was to evaluate the usability and feasibility of a smartphone-based smoking cessation application (Stay Quit Coach) designed to prevent relapse among individuals with PTSD.

METHODS

Smokers (N = 11) were randomized to (1) QUIT4EVER, an intervention combining mobile contingency management smoking cessation counseling and medications, and Stay Quit Coach or (2) a contact control condition that was identical to QUIT4EVER except Stay Quit Coach was not included. The primary outcome was prolonged smoking abstinence.

RESULTS

Among those queried during the follow-up periods, average Stay Quit Coach helpfulness ratings were high and ranged from 7.25 to 10 on a 10-point Likert scale (with higher scores corresponding to greater helpfulness). The Stay Quit Coach was rated by participants as being most effective at helping to quit smoking, helping to remain quit, and providing support and relevant information about quitting. Among the three quitters in the QUIT4EVER group, all reported abstinence at 3 and 6 months; however, abstinence was only bioverified for one quitter at 6 months. Among the four quitters in the contact control condition group, three reported abstinence at 3 and 6 months, but abstinence was not confirmed by bioverification.

CONCLUSIONS

Smokers with PTSD express interest in and helpfulness of Stay Quit Coach for remaining abstinent after a quit attempt. Combined use of mobile contingency management and Stay Quit Coach is a feasible and acceptable adjunctive smoking cessation treatment for reducing smoking among smokers with PTSD. Adequately powered clinical trials are needed to demonstrate the long-term efficacy of this combined approach to smoking cessation. This study [Use of Technological Advances to Prevent Smoking Relapse among Smokers with PTSD (QUIT4EVER)] was registered on www.clinicaltrials.gov . clinicaltrials.gov identifier: NCT01990079.

Racial and Sociodemographic Disparities in Internet Access and eHealth Intervention Utilization Among Veteran Smokers

INTRODUCTION

Access to the internet at home may be an important barrier to electronic health (eHealth) smoking cessation interventions. The current study explored possible sociodemographic disparities in access to the internet at home among veteran smokers.

METHODS

Data from participants proactively recruited and enrolled in a randomized smoking cessation effectiveness trial (N = 408) that compared a web-based smoking cessation intervention to Veterans Affairs (VA) usual care were used to examine the demographic attributes of smokers with and without internet access at home. Multivariable logistic regression was used to examine associations between demographic factors and home internet access. Data from patients randomized to the internet arm of the study (N = 205) were used to ascertain correlates of utilization of the intervention website.

RESULTS

While the majority of the sample (82 %) endorsed access to the internet at home, veterans who were African-American, older, and not married were significantly less likely to have home internet access. Veterans who were African-American, older, less educated, had longer travel times to the nearest VA facility, and increased nicotine dependence were less likely to access the internet on a daily basis. While several sociodemographic variables (e.g., age, race, education, employment) were related to utilization of a free membership to a commercial, web-based smoking cessation intervention in bivariate analyses, only access to the internet at home was related to use of the smoking cessation site in adjusted results.

CONCLUSION

These results highlight gaps in internet access and use among veterans and additionally underscore the importance of improving accessibility of eHealth interventions for low-income, minority, and socially disadvantaged veteran populations.

Tachycardia-induced cardiomyopathy in a young Boxer dog with supraventricular tachycardia due to an accessory pathway

A 1-year-old male Boxer dog presented with sustained supraventricular tachycardia and tachycardia-induced cardiomyopathy. Conversion to sinus rhythm was achieved initially with intravenous lignocaine and subsequently with oral procainamide. Oral procainamide treatment was relatively successful in maintaining normal sinus rhythm with no side effects apart from a reversible change in coat colour. Electrophysiological studies demonstrated the presence of an accessory pathway connecting the right atrium to the right ventricle and confirmed the diagnosis of orthodromic atrioventricular reciprocating tachycardia. Radiofrequency catheter ablation of the accessory pathway led to permanent resolution of the supraventricular tachycardia and for 9.5 years the dog has had no further signs of cardiac disease. The successful treatment of this condition highlights the importance of differentiating tachycardia-induced cardiomyopathy from dilated cardiomyopathy.

Fibroblasts modulate cardiomyocyte excitability: implications for cardiac gene therapy

In an earlier study exploring the potential of gene transfer to repair myocardial conduction defects, we observed that myotubes, generated by forced expression of MyoD, exhibit reduced excitability when also modified to express connexin43 (Cx43). We hypothesized that this effect was caused by gap junction-mediated coupling between myotubes and the underlying fibroblast feeder layer. This intriguing possibility has important implications for ongoing efforts to develop strategies for repairing myocardial conduction defects by gene transfer, and also provides novel insights into the electrophysiological function of naturally occurring heterologous cell coupling within the heart. Although a conductive function for fibroblasts through heterologous coupling has previously been reported, the current study provides novel evidence that fibroblasts can modulate cardiomyocyte excitability in a Cx43-dependent manner. In a co-culture study system, neonatal rat cardiomyocytes were grown on monolayers of mouse fibroblasts with genetically altered Cx43 expression and the effect on intrinsic beat frequency examined. Cardiomyocytes grown on wild-type (WT) fibroblasts expressing native levels of Cx43 beat significantly slower than cells grown on fibroblasts devoid of this molecule (germline knockout) or with dominant-negative functional suppression. Expression of Cx43 in fibroblasts from Cx43 knockout mice restored cardiomyocyte beat frequency, to rates comparable with those observed in co-culture with WT fibroblasts.

Potential ototoxicity from triamcinolone, neomycin, gramicidin and nystatin (Tri-Adcortyl™) cream

Although rare, ototoxicity from the use of aminoglycoside drops is well recognized. Ototoxicity has not been described with the use of combination aminoglycoside-steroid-antifungal creams or ointments. We present the case of a 60-year-old man with a perforated tympanic membrane who suffered a total hearing loss after the instillation of cream containing triamcinolone, neomycin, gramicidin and nystatin (Tri-Adcortyl™ cream) into his ear canal. On balance, we believe that a number of potentially ototoxic constituents in this cream were responsible. Other possible causes of sensorineural hearing loss and the possible mechanisms of ototoxicity of this cream are discussed. The reasons why such creams may be particularly ototoxic, compared with drops, are also considered. The authors caution against the use of such creams or ointments in the ear if there is any suspicion of a tympanic membrane perforation.

Percutaneous pulmonary vein isolation for treatment of atrial fibrillation

BACKGROUND

Transvenous catheter ablation for the treatment of atrial fibrillation is an evolving technique.

AIM

The purpose of this study was to identify subgroups of patients most likely to benefit from pulmonary vein electrical isolation.

METHODS

Patients with symptomatic atrial fibrillation resistant to pharmacological therapy were studied. Mapping-guided segmental application of radio-frequency energy was used to electrically isolate the pulmonary veins in 74 patients. Ischaemic or dilated cardiomyopathy was present in 34% of patients. Atrial fibrillation had been present for a mean time (+/- standard deviation) of 6.6 +/- 6.1 years. It was paroxysmal in 53 patients (72%).

RESULTS

The mean number of procedures was 1.6/patient. After 6 +/- 6 months, 73% of patients (54/74) were in sinus rhythm. Thirteen of those in sinus rhythm were using anti-arrhythmic medications (25%). Recurrence of atrial fibrillation soon after pulmonary vein isolation occurred in 50%. Patients with persistent/permanent atrial fibrillation were less likely to be in sinus rhythm at follow up (11/21 (52%) vs 43/53 (81%); P = 0.01). However, the rate of early recurrence was similar in the intermittent and the persistent/permanent groups (26/53 (49%) vs 11/21(52%), respectively; P-value not significant). Patients with persistent atrial fibrillation were more likely to experience a recurrence of atrial fibril-lation (89%; P = 0.04). No other baseline factors predicted procedural success. Cardiac tamponade occurred in two patients and moderate pulmonary vein stenosis (>50% diameter narrowing) occurred in three patients.

CONCLUSIONS

Pulmonary vein isolation is an effective curative treatment for a broad group of patients with atrial fibrillation. However, the procedure is only suitable for patients with problematic atrial fibrillation resistant to other therapies because of the small risk of serious complications.

Radiofrequency lesions produced by handheld temperature controlled probes for use in atrial fibrillation surgery

OBJECTIVES

Detailed analysis of the size and shape of lesions produced by handheld radiofrequency ablation devices at open heart surgery has not been reported previously.

METHODS

Radiofrequency lesions were made from the epicardial surface of the cardiac ventricles in open-chested dogs. The effects of electrode size, electrode temperature and duration of ablation were studied. In a second group of experiments simultaneous multielectrode ablation was performed on the ventricular epicardium after cold cardioplegia.

RESULTS

Using a single 12 x 2.5 mm electrode and a target temperature of 80 degrees C the lesion depth increased from 3.8+/-0.9 mm at 15 s, to 6.1+/-0.9 mm at 120 s (P=0.01). Increasing the target temperature from 70 to 90 degrees C (for 60 s) increased lesion depth from 5.0+/-1.2 to 5.6+/-1.7 mm (P=0.2). There was no difference in depth of lesions with the two electrode widths (4.0+/-0.5 mm (large) vs. 3.9+/-1.0 mm (small)). Lesions produced using the multielectrode probe (80 degrees C, 60 s) were 30-35 mm long with even penetration into the tissue. The mean depth of these lesions on microscopic sections was 3.9 mm. The mean width was 7.1 mm.

CONCLUSIONS

Handheld probes can be used to make deep linear lesions in the myocardium. Lesions expand rapidly and are wider than they are deep. A multielectrode ablation device allows rapid formation of linear lesions.

Production of narrow but deep lesions suitable for ablation of atrial fibrillation using a saline-cooled narrow beam Nd:YAG laser catheter

BACKGROUND AND OBJECTIVE

Lines of radiofrequency ablation for cure of atrial fibrillation are broad, and the consequent loss of atrial mass may impair atrial function and contribute to the risk of stroke. We studied whether Nd:YAG laser could produce deep but narrower lesions.

STUDY DESIGN/MATERIALS AND METHODS

Laser lesions were made in ventricular myocardium of nonperfused ovine hearts and at thoracotomy in dogs.

RESULTS

Lesions were well demarcated, deep, and narrow. Saline irrigation prevented crater formation for energy levels below 200 J. Lesion depth increased with increasing duration of ablation (maximum 5.3 +/- 0.8mm, P < 0.01). The depth to width ratio was >1 in all cases (maximum 2.5 +/- 1.6). The narrowest lesions were made by using high power, short duration of exposure, and intermittent delivery.

CONCLUSIONS

Irrigated Nd:YAG laser can be used to make deep narrow myocardial lesions without crater formation. Laser ablation may be more suitable than radiofrequency ablation for intraoperative or catheter-based cure of atrial fibrillation.

Teaching healthy anger management

TOPIC

Teaching anger management in the community.

PURPOSE

To describe anger management and offer guidelines for assessing potential participants and teaching healthy behaviors.

SOURCES

Drawing from the literature, more than 10 years of quantitative and qualitative studies by our research team, and 5 years of experience in conducting anger management groups, the author presents basic principles of teaching anger management. A model is described for a 4-week group for women.

CONCLUSIONS

Anger management has wide applicability to a variety of constituencies for both primary and secondary prevention. Advanced practice psychiatric nurses are well-qualified to provide this psychoeducational intervention.

Anger and cancer: an analysis of the linkages

The purposes of this article are to review literature on anger's link to cancer, to analyze the state of the science in this area, and to propose some directions for future research. Extremely low anger scores have been noted in numerous studies of patients with cancer. Such low scores suggest suppression, repression, or restraint of anger. There is evidence to show that suppressed anger can be a precursor to the development of cancer, and also a factor in its progression after diagnosis. Some studies indicate that it may be beneficial for patients to mobilize anger to battle their cancer. However, there is a paucity of research on the outcomes of various anger interventions. Longitudinal studies that repeatedly measure anger and other moods over the disease trajectory are needed.

A phenomenologic study of chronic pain

Researchers have seldom invited patients with chronic pain to describe their lived experiences. This phenomenologic study involved in-depth interviews with nine women and four men with nonmalignant chronic pain. The essence of participants' experiences was unremitting torment by a force or monster that cannot be tamed. The body was altered and recalcitrant, the life world was shrunken, and the pain set up a barrier that separated them from other people. Time seemed to stop; the future was unfathomable. Findings of this study contribute to the phenomenological literature that explores the human body and its symbolic meanings and call into question the idealized positive depiction of chronic illness that is prominent in contemporary literature.

Synthetic strands of neonatal mouse cardiac myocytes: structural and electrophysiological properties

The aim of the present study was to morphologically and electrically characterize synthetic strands of mouse ventricular myocytes. Linear strands of mouse ventricular myocytes with widths of 34.7+/-4.4 microm (W(1)), 57.9+/-2.5 microm (W(2)), and 86.4+/-3. 6 microm (W(3)) and a length of 10 mm were produced on glass coverslips with a photolithographic technique. Action potentials (APs) were measured from individual cells within the strands with cell-attached microelectrodes. Impulse propagation and AP upstrokes were measured with multisite optical mapping (RH237). Immunostaining was performed to assess cell-cell connections and myofibril arrangement with polyclonal antisera against connexin43 and N-cadherins and monoclonal antibodies against cardiac myosin. Light microscopy and myosin staining showed dense growth of well-developed elongated myocytes with lengths of 34.2+/-4.2 microm (W(1)), 36. 9+/-5.8 microm (W(2)), and 43.7+/-6.9 microm (W(3)), and length/width ratios of 3.9+/-0.2. Gap junctions were distributed around the cell borders (3 to 4 junctions/microm(2) cell area). Each cell was connected by gap junctions to 6.5+/-1.1 neighboring cells. AP duration shortened with time in culture (action potential duration at 50% repolarization: day 4, 103+/-34 ms; day 8, 16+/-3 ms; P:<0.01). Minimum diastolic potential and AP amplitude were 71+/-5 and 97.2+/-7.6 mV, respectively. Conduction velocity and the maximum dV/dt of the AP upstroke were 43.9+/-13.6 cm/s and 196+/-67 V/s, respectively. Thus, neonatal ventricular mouse myocytes can be grown in continuous synthetic strands. Gap junction distribution is similar to the neonatal pattern observed in the hearts of larger mammals. Conduction velocity is in the range observed in adult mice and in the higher range for mammalian species probably due to the higher dV/dt(max). This technique will permit the study of propagation, AP, and structure-function relations at cellular resolution in genetically modified mice.

Violent and nonviolent girls: contrasting perceptions of anger experiences, school, and relationships

Arrests of American girls for assault and weapons charges are rapidly increasing, at rates exceeding those for boys. Yet research on girls' violence is scant. We surveyed a national sample of 213 girls (ages 9-19) via personal interview or an Internet questionnaire, regarding anger precipitants and behaviors, interpersonal relationships, and experiences of discipline at home and school. Girls were categorized as violent (n = 54) if they had been suspended or expelled from school for fighting or bringing a weapon, or charged with a violent offense by the juvenile justice system. The remaining girls (n = 159) were categorized as nonviolent. The anger of violent girls tended to be intense and generalized, while the anger of nonviolent girls was precipitated by specific situations of injustice. Correlates of feeling angry enough to hit or hurt someone were loneliness, unfair treatment by adults, not liked by classmates, and somatic anger symptoms. Violent girls were significantly more likely to dislike school and perceive school discipline as unfair. Both groups of girls held negative views of television violence and curfews. Although girls with well-established patterns of aggression need psychotherapy, school-based interventions such as emotional literacy and violence prevention programs may also be helpful. Mental health nurses are well prepared to serve in a consultative role to schools, assisting in the development and delivery of violence prevention programming.

The effect of a residual isthmus of surviving tissue on conduction after linear ablation in atrial myocardium

The aim of this study was to determine the relationship between the size of discontinuities in lines of ablation and wavefront propagation. Discontinuities in linear radiofrequency lesions used for the treatment of atrial fibrillation may be proarrhythmic and a major clinical problem. A better understanding of the electrophysiological properties of these discontinuities (isthmuses) may assist in their detection and treatment. Linear lesions were made in the right atrial free wall using a Nd:YAG laser in 12 dogs. Conduction properties across the discontinuities were studied by pacing from either side of the lesion. Two of the three isthmuses less than 0.8 mm(2) in cross section (smallest 0.2 mm(2)) conducted at extrastimulus intervals of 300 ms. All three failed to conduct at cycle lengths close to the atrial effective refractory period. Isthmuses above 0.8 mm(2) (n¿=8) conducted at all cycle lengths. Conduction slowing (mean slowest conduction 0.5 +/- 0.3 m/s) occurred in the region of the isthmus but the overall delay was only 6 +/- 6 ms where propagation through the isthmus occurred. The effect on conduction of small discontinuities in linear lesions is dependent on the size of the residual isthmus. All but the very smallest of discontinuities in linear lesions conduct and therefore have the potential to participate in reentrant arrhythmias. Efforts should be directed toward the development of ablation techniques that reliably produce continuous transmural linear lesions for cure of atrial fibrillation and flutter.

Mechanism, localization and cure of atrial arrhythmias occurring after a new intraoperative endocardial radiofrequency ablation procedure for atrial fibrillation

OBJECTIVES

The purpose of this study was to test a new pattern of radiofrequency ablation for atrial fibrillation (AFib) intended to optimize atrial activation, and to demonstrate the usefulness of catheter techniques for mapping and ablation of postoperative atrial arrhythmias.

BACKGROUND

Linear radiofrequency lesions have been used to cure AFib, but the optimal pattern of lesions is unknown and postoperative tachyarrhythmias are common.

METHODS

A radial pattern of linear radiofrequency lesions (Star) was made using an endocardial open surgical approach in 25 patients. Postoperative arrhythmias were induced and characterized during electrophysiological studies in 15 patients.

RESULTS

The AFib was abolished in most patients (91%), but atrial flutter (AFlut) occurred in 96% of patients postoperatively. At postoperative electrophysiological studies, 37 flutter morphologies were studied in 15 patients (46% spontaneous, cycle length [CL] 223 +/- 25 ms). Seven mechanisms (lesions discontinuity, n = 6; focal mechanism, n = 1) of AFlut were characterized in six patients. In these cases, flutter was abolished using further catheter radiofrequency ablation. In the remaining cases, flutter was usually localized to an area involving the interatrial septum, but no critical isthmus was identified for ablation. After 16 +/-10 months, 15 patients (65%) were asymptomatic with (n = 3) or without (n = 12) antiarrhythmic medications. Eight (35%) patients had persistent arrhythmias. Postoperative atrial electrical activation was near physiological.

CONCLUSIONS

The AFib maybe abolished using a radial pattern of linear endocardial radiofrequency lesions, but postoperative AFlut is common even when lesions are made under optimal conditions. Endocardial mapping techniques can be used to characterize the flutter mechanisms, thus enabling subsequent successful catheter ablation.

Effect of atrial radiofrequency ablation designed to cure atrial fibrillation on atrial mechanical function

INTRODUCTION

The effects of linear radiofrequency lesions in the atria for cure of atrial fibrillation on atrial contraction have not previously been quantified.

METHODS AND RESULTS

Atrial function was measured before and 30 +/- 24 days after a biatrial ablation procedure designed to cure atrial fibrillation in eight dogs and after a sham procedure in three dogs. Atrial mechanical function was assessed using Doppler diastolic blood flow velocities, atrial systolic pressure wave amplitude, and assessment of atrial contribution to cardiac output estimated by comparison of AV sequential pacing to ventricular pacing at the same heart rate. The mitral Doppler A/E velocity ratio was 1.03 +/- 0.45 before and 0.72 +/- 0.43 after ablation (P = 0.048). The tricuspid A/E ratio was 0.88 +/- 0.17 before and 0.71 +/- 0.12 after ablation (P = 0.04). The estimated atrial contribution to cardiac output was 18% +/- 9% before and 5% +/- 4% after ablation (P < 0.01). The left atrial systolic pressure wave amplitude was 2.8 +/- 1.5 mmHg before and 1.7 +/- 1.0 mmHg after ablation (P = 0.1). These changes were not observed in control dogs. Lesions covered 25% +/- 6% of the atrial endocardial surface.

CONCLUSION

Multiple linear radiofrequency lesions in the atria designed to cure atrial fibrillation may impair atrial contractility. Reduced atrial function is partly due to loss of atrial myocardial mass, but regional delays in atrial activation and splinting of the atria by scarring also may contribute.

Induction of atrial fibrillation and flutter in dogs using methacholine

Systemic infusion of methacholine has been used to facilitate induction of atrial fibrillation. However, the dose-response relationship, reproducibility and effect of anesthetic agents on induction are not well understood. The use of methacholine to facilitate electrical induction of sustained (>10 minutes duration) atrial fibrillation or flutter was examined. In 25 dogs induction of atrial arrhythmias was attempted using a series of ten 50 Hz trains of 10 seconds duration delivered via an endocardial catheter in the baseline anaesthetized state and subsequently in the presence of graded doses of intravenous methacholine (maximum 5 microg/kg/min). Studies were repeated in 13 dogs to assess reproducibility. Twelve dogs (48%) had inducible sustained atrial flutter or fibrillation lasting greater than 10 minutes in the baseline state. During infusion of methacholine the remaining 13 (52%) dogs also had inducible sustained atrial flutter or fibrillation (mean infusion rate 1.6 +/- 1.9 microg/kg/min). Induction of sustained atrial flutter or fibrillation was reproducible in all but one dog. The type of anesthetic did not significantly affect inducibility. Induction of prolonged atrial fibrillation or flutter is possible in the baseline anaesthetized state in approximately half of dogs using high frequency programmed electrical stimulation. The yield of inducible sustained atrial fibrillation or flutter with programmed stimulation during intravenous infusion of methacholine was increased to 100%. Induction of sustained atrial fibrillation or flutter was highly reproducible.

Continuity and discontinuity: the quality of life following stroke

The purpose of this existential-phenomenological study was to investigate the experience of life after stroke rehabilitation, to provide a holistic view for nurses and others in providing care. Analysis involved a part-to-whole dialectic; selected transcripts, including the bracketing interview, were analyzed in an interpretive research group. There were 14 participants, with a 2-year median length of time since stroke; participants exhibited various disabilities. The world of the stroke survivor is grounded in a life of loss and effort from which emerged interrelated themes: independence/dependence, in control/out of control, and connection/disconnection with others. A fundamental aspect of these themes is a sense of continuity that coexists with discontinuity in the experience of self. The findings have implications for how nurses interact with stroke survivors, for goal-setting, and for specific strategies that focus on meanings for clients.

Living with postpartum depression: the father's experience

PURPOSE

To derive a deeper understanding of postpartum depression (PPD) and its impact on the family through the experiences of fathers whose spouses suffered from this disorder.

DESIGN

Phenomenology.

METHODS

Eight men were interviewed. Interviews were recorded on audio tape and transcribed verbatim. Thematic analysis conducted within an interdisciplinary phenomenological research group led to a description of the experiences and emotions involved.

RESULTS

Respondents in this study revealed a major disruption in their lives and in their relationship with their wives as a result of PPD. The men experienced fear, confusion, and much concern for their spouses, and felt unable to help them in overcoming PPD. The inability to "fix the problem" created frustration and anger. The majority of the respondents reported that they made many sacrifices to hold the relationship and the family together. Even though the PPD improved over time, fathers were left to face an uncertain future with a spouse who seemed to be very different from the person they had previously known.

CLINICAL IMPLICATIONS

Health care professionals need to design interventions that are more supportive of men, for men also suffer when their spouses experience PPD.

Microwave ablation of myocardial tissue: the effect of element design, tissue coupling, blood flow, power, and duration of exposure on lesion size

INTRODUCTION

The biophysical properties of microwave electromagnetic radiation suggest that it may be an alternative to radiofrequency (RF) energy for ablation of arrhythmias resistant to treatment using RF ablation.

METHODS AND RESULTS

The aim of this study was to characterize lesions produced using simple element designs in a blood superfused ovine tissue model to simulate endocardial ablation. The effect of tissue bath flow, duration of microwave exposure, and changes in forward power on lesion size were examined using a modified monopole element. Lesion size increased with increasing duration of exposure and increasing forward power (P < 0.05). Lesion depth was 0.7+/-0.7 mm after 30 seconds and 11.5+/-1.9 mm after 360 seconds. Lesion depths at 61, 71, and 80 W were 6.4+/-3.7, 8.9+/-2.0, and 11.9+/-1.2 mm, respectively. Altering flow within the bath from 3 to 5 L/min did not significantly change lesion size.

CONCLUSION

Simple element designs can be used to produce a range of lesions from very small sizes to lesions that are transmural in the ventricle. The temperature half-time for microwave ablation is far greater than that of RF ablation. Like RF lesions, the lesions produced by microwave ablation have greater width than depth. Deep penetration of lesions into the ventricular myocardium can only be achieved with these elements by producing lesions of perhaps unnecessarily large volume.

Anger of African American women in the south

In this existential-phenomenological investigation middle-class African American women (n = 9) in the Southern United States were interviewed about their experience of anger in daily life. The purpose of the study was to examine what African American women's anger is about, what it means, and how it is experienced. Transcribed interviews were analyzed using a hermeneutic process. The thematic structure of African American women's anger comprises three main elements that stand out as figural: power, control, and respect. These figural elements can be understood only when seen against the ground of a racist Southern culture that produces pervasive mistrust. These findings are of importance to clinicians, who cannot deliver culturally competent interventions to African American female clients without a clear understanding of the complexity and meaning of their anger experience.

Assessing and intervening with anger disorders

Nurses often find angry patients threatening. In this article, current research will be synthesized to provide guidance to nurses whose specialty area may not be psychiatric nursing. Guidelines for assessing and intervening with angry clients will be provided. Such guidelines are likely to be useful to nurses in every clinical setting, from the emergency room to the rural clinic to the high-tech hospital unit. Nurses will also learn some techniques for managing their own anger at uncooperative or hostile clients.

Distressing aspects of women's roles, vicarious stress, and health consequences

Individuals internalize the roles they play and the statuses they occupy in their social networks. It logically follows that the benefits and costs of women's role commitments may be critically important to their physical and mental health. This literature review focuses on distressing or negative aspects of enacting the specific primary roles of worker, wife, and mother. Vicarious stress and inadequate social support for women in these roles may contribute to immunosuppression and disease vulnerability. Some women may choose the sick role as a means of escape from taxing role responsibilities. Future directions for women's health research are suggested, along with adoption of an empowerment model of health.

Women's anger: relationship of suppression to blood pressure

The relationship of anger suppression to blood pressure was examined in a university sample of 210 female staff, faculty, and students 18 to 71 years of age. Most were White and in good or excellent health. The study replicated that of Goldstein et al. (1988) using their method of assessing anger frequency, intensity, and expression at work (or school) and home. With age, body mass index, family history of hypertension, and exercise controlled, higher systolic blood pressure and diastolic blood pressure were evident when women suppressed anger at home. Women who had grown up in families that readily showed anger were more likely to do so as adults.

Angry? Let's talk about it!

Cognitive/perceptual, physiological, and behavioral correlates of anger discussion were examined in a sample of 461 health fair participants at a southeastern university. Subjects, who usually discussed their anger differed significantly from those who did not in systolic blood pressure, diastolic blood pressure, body mass index, aerobic exercise, perceived importance of health, and perceived health status. In gender-specific correlational analyses, discussion of anger was inversely related to women's global assessment of stress and to their levels of perceived stress at home and at work. This study suggests that talking about anger may be a health-promoting alternative to suppressing it or venting it outwardly after a provocation. Gender differences and implications for practice are discussed.

Channeling nurses' anger into positive interventions

Nurses are angry, and with good reason, but few seem to be proficient in anger management. Work-related experiences of anger were vividly described by female registered nurses (Smith, Droppleman, & Thomas, 1996) and male registered nurses (Brooks, Thomas, & Droppleman, 1996) in phenomenological interviews. The roots of the anger were found in the system and the interpersonal and intrapsychic elements of nursing. In this article the authors outline strategies to address system and interpersonal sources of anger provocations, and describe positive interventions that can reduce the intrapsychic characteristics that fuel personal anger.

Anger and locus of control in young women with and without premenstrual syndrome

The purpose of this study was to examine differences in locus of control and anger in college women with and without premenstrual syndrome (PMS). One hundred thirty-seven female undergraduates completed a biographical questionnaire, the Rotter Internal-External Locus of Control (I-E) Scale, the Spielberger State Trait Anger Scale (STAS), the Framingham Anger Scale (FAS), and a women's health questionnaire. After 65 women who had had children or used hormonally based contraceptives or psychotropic medications were excluded, the remaining subjects were placed into a PMS (n = 48) or a non-PMS group (n = 24) according to whether they met DSM-IV criteria for Premenstrual Dysphoric Disorder (PMDD). After debriefing the sample, the women were asked if they believed they had PMS. Results of the study showed no significant differences between groups in locus of control or anger. Out of the 72 subjects in the final analysis, 64 (89%) believed they had PMS, and only 8 (or 11%) believed they did not. Self-diagnosis was not always correct; 16 (22%) of the women who believed they had PMS did not meet the DSM-IV criteria for the disorder. The DSM-IV criteria may need further refinement and validation.