Marital therapy as a treatment for depression

The purpose of this study was to compare cognitive-behavioral therapy (CT; n = 20), behavioral marital therapy (BMT; n = 19), and a treatment combining BMT and CT (CO; n = 21) in the alleviation of wives' depression and the enhancement of marital satisfaction. BMT was less effective than CT for depression in maritally nondistressed couples, whereas for maritally distressed couples the two treatments were equally effective. BMT was the only treatment to have a significant positive impact on relationship satisfaction in distressed couples, whereas CO was the only treatment to enhance the marital satisfaction of nondistressed couples. On marital interaction measures CO was the only treatment to significantly reduce both husband and wife aversive behavior and to significantly increase wife facilitative behavior.

Early predictors of mortality for hospitalized patients suffering cardiopulmonary arrest

Few if any prearrest or intraarrest variables have been identified as highly predictive of inhospital mortality following cardiopulmonary arrest. A total of 310 consecutive patients requiring advanced cardiac life support during the calendar years 1985 and 1986 were reviewed with respect to eight specific variables. These included age, diagnosis, location, mechanism of the event, duration of resuscitation, whether the event was witnessed or unwitnessed, the initial observed rhythm and medications administered. A total of 37.1 percent of the patients were successfully resuscitated, but only 9.7 percent survived until discharge. Factors strongly associated with inhospital mortality included unwitnessed events (p = 0.0316), the need for epinephrine (p = 0.0003), identification of electromechanical dissociation or asystole as initial rhythms (p = 0.0000), and cardiac vs respiratory mechanism of arrest (p = 0.0000).

Couple therapy as a treatment for depression: II. The effects of relationship quality and therapy on depressive relapse

This study investigated the effects of behavioral couple therapy, cognitive-behavioral therapy, and their combination on female depression 6 and 12 months after therapy ended. We predicted that couples receiving a behavioral couple treatment would be less likely to relapse than those receiving a cognitive-behavioral treatment for the depressed spouse alone. Relapse rates, however, did not discriminate between treatments at any follow-up point. Reductions in husband and wife dysphoria and increases in wife facilitative behavior during therapy predicted recovery. Moreover, high rates of husbands' facilitative behavior at posttest were associated with wife recovery and predicted low levels of depression at the 1-year follow-up.

Effect of indomethacin on arterial oxygenation in critically ill patients with severe bacterial pneumonia

The effect of indomethacin (1 mg/kg) on gas exchange was studied in ten patients with hypoxaemic respiratory failure precipitated by bacterial pneumonia. Mean arterial oxygen tension (PaO2) improved significantly (79 +/- 16 mm Hg to 98 +/- 20 mm Hg) but the response varied between patients: five showed substantial responses (27-42 mm Hg), three lesser responses (7-9 mm Hg), and two no response. Similar changes were found in the alveolar-arterial oxygen gradient and the ratio of PaO2 to fractional inspired oxygen concentration. In two responders studied further, PaO2 had fallen to baseline values 4-6 h later and a repeat indomethacin challenge again increased PaO2 by greater than 25 mm Hg with concomitant changes in pulmonary shunt. There were no significant changes in the other gas-exchange or haemodynamic variables measured and there was no clear reason for the variability in response to indomethacin. These results suggest a role for products of the cyclo-oxygenase pathway of arachidonic acid metabolism in the pathogenesis of hypoxaemia in patients with severe bacterial pneumonia.

Eliminating needless testing in intensive care--an information-based team management approach

OBJECTIVE

To determine if the application of an information-based management system in adult intensive care units (ICU) can produce sustained decreases in the use of laboratory resources and costs.

DESIGN

Interventional study with prospective data collection on consecutive patients admitted during three time periods.

SETTING

A 10-bed adult surgical ICU and an eight-bed adult medical ICU in a tertiary care hospital.

PATIENTS

All patients admitted to an ICU during a 7-month baseline period (n = 647), a 1-yr intervention period (n = 1236), and a 2-yr follow-up period (n = 2349).

INTERVENTIONS

Using a management database to track the use of 123 laboratory investigations during the baseline period, nine frequently ordered investigations (determination of blood gases, glucose, potassium, electrocardiogram, chest radiograph, sodium, chloride, complete blood count with differential, and serum osmolality) were targeted for reduction. Specific policies were developed by a multidisciplinary committee within the ICU to reduce the utilization of these laboratory, radiology, and cardiology tests. The policies were applied to all patients admitted during the 1-yr intervention period and during the 2-yr follow-up period.

MEASUREMENTS AND MAIN RESULTS

A 25% reduction was observed in the frequency of all 123 monitored tests during the intervention period. The most dramatic reductions occurred in the nine targeted tests (range 19% to 46%) (p < .001). There were significant reductions in only 13 of the untargeted 114 investigations during this period. Potential annual cost savings were > $150,000 Canadian. No increases in ICU mortality rate, length of stay, or cost of medication were observed, and the reductions in the frequency of targeted tests were maintained during the 2-yr follow-up period.

CONCLUSIONS

Application of an information-based multidisciplinary management system in the ICU can produce marked and sustained reductions in unnecessary testing in a cost-effective manner. Although rationing of intensive care services may be necessary, reducing needless testing can be a safe and effective cost-containment strategy in the ICU.

Barriers to healthy eating in the nursing profession: Part 1

AIM

The aim of this study commissioned by the NHS Executive North West was to identify the main areas of the nurse's working environment that prevent healthy eating, to ascertain if nurses have enough nutritional knowledge to make informed choices, and to review sources, availability and quality of food provided for nursing staff.

METHOD

A purposive sample size of 126 nurses from across eight healthcare sites in the North West region completed questionnaires.

RESULTS

Shift patterns and failure to take breaks were identified as the two main barriers to healthy eating by respondents. However, satisfaction with food on offer and a supportive environment were also identified as important influences.

CONCLUSION

Several recommendations were made as a result of the study. Ideally, nurses should take regular breaks. Food should carry nutritional labelling and nutritional information should be displayed at healthcare sites in a more imaginative and innovative way. More refrigerated vending machines with a selection of healthier options should be supplied. Packed lunches or plated salads obtainable from restaurants by evening and night-shift nurses should be offered, in addition to a better selection of sandwiches and other food choices outside the hours of 9 am to 5 pm, Monday to Friday. Nurses should be encouraged to drink the recommended amount of eight glasses of water per day (Health and Fitness Tips 2000) by providing adequate water dispensers. The possibility of having separate catering facilities for staff who wish to avoid patients and visitors during breaks should be explored.

Investigation of the male pattern baldness major genetic susceptibility loci AR/EDA2R and 20p11 in female pattern hair loss

BACKGROUND

The aetiology of female pattern hair loss (FPHL) is largely unknown. However, it is hypothesized that FPHL and male pattern baldness (AGA) share common susceptibility alleles. The two major susceptibility loci for AGA are the androgen receptor (AR)/ectodysplasin A2 receptor (EDA2R) locus on the X-chromosome, and a locus on chromosome 20p11, for which no candidate gene has yet been identified.

OBJECTIVES

To examine the role of the AR/EDA2R and 20p11 loci in the development of FPHL using 145 U.K. and 85 German patients with FPHL, 179 U.K. supercontrols and 150 German blood donors.

METHODS

Patients and controls were genotyped for 25 single nucleotide polymorphisms (SNPs) at the AR/EDA2R locus and five SNPs at the 20p11 locus.

RESULTS

Analysis of the AR/EDA2R locus revealed no significant association in the German sample. However, a nominally significant association for a single SNP (rs1397631) was found in the U.K. sample. Subgroup analysis of the U.K. patients revealed significant association for seven markers in patients with an early onset (P = 0·047 after adjustment for the testing of multiple SNPs by Monte Carlo simulation). No significant association was obtained for the five 20p11 variants, either in the overall samples or in the analysis of subgroups.

CONCLUSIONS

The observed association suggests that the AR/EDA2R locus confers susceptibility to early-onset FHPL. Our results do not implicate the 20p11 locus in the aetiology of FPHL.

A cost-effective method for the automatic quantitative analysis of fibroblastic colony-forming units

A great deal of the work characterizing stromal cell precursors in the bone marrow has been performed using the fibroblastic colony-forming unit (CFU-f) assay. However, the assay is limited in its usefulness by the necessity for manual colony counting which means that assay quantitation is highly subjective, time consuming, and much information regarding the colony size is lost. To rectify this, we have developed a computer-automated method for the analysis of CFU-f. Bone marrow cells were cultured at low density and treated with either prostaglandin E(2) (PGE(2)), basic fibroblast growth factor (bFGF), or dexamethasone, and colony formation was assessed by staining with methylene blue. After staining, the dishes were photographed over a light box using a digital camera and the image was then analyzed using Bioimage "Intelligent Quantifier" image analysis software which automatically locates and quantifies each individual colony. The data can then be imported to a spreadsheet program and processed. We have shown that this system can accurately identify, assign coordinates, and quantitate each individual colony. Colony numbers obtained with this method and manually counting showed a linear relationship with a correlation coefficient of 0.99. In addition, using the colony intensity and surface area data, the colony size can be calculated. With this methodology, we have shown that dexamethasone, PGE(2), and bFGF can all modulate total cell numbers in bone marrow stromal cells (BMSC) cultures but modulating both colony number and colony size.

Spinal nociceptive reflexes are sensitized in the monosodium iodoacetate model of osteoarthritis pain in the rat

OBJECTIVE

Evidence suggests that osteoarthritis (OA) is associated with altered central pain processing. We assessed the effects of experimentally induced OA on the excitability of spinal nociceptive withdrawal reflexes (NWRs), and their supraspinal control in a preclinical OA model.

DESIGN

Experimental OA was induced in rats with knee injection of monosodium iodoacetate (MIA) and pain behaviour was assessed. 14/28 days post-MIA or saline injection, rats were anaesthetised for spinal NWR recording from tibialis anterior (TA) and biceps femoris (BF) hind limb muscles during plantar hind paw stimulation. Thresholds, receptive field sizes and wind up (incremental increase to repetitive stimulation) were measured in intact (d14/28) and spinalised (severed spinal cord; d28) MIA- and saline-injected rats.

RESULTS

MIA reduced BF mechanical thresholds at day 28. Spinalisation of MIA rats did not prevent this hyperexcitability, and failed to produce the reduction in reflex receptive field (RRF) size observed in saline rats. These data indicate that MIA induces a hyperexcitability of BF NWR circuits that is maintained at the spinal level. In contrast, MIA appeared to have no effect on NWRs evoked by mechanical stimuli in the ankle flexor TA in intact rats, however spinalisation revealed hyperexcitability. Thus, 28 days following MIA-treatment, descending supraspinal inhibition normalised TA NWRs and was only overcome following repetitive noxious stimulation during wind up.

CONCLUSIONS

We demonstrate that spinal nociceptive reflex pathways are sensitized following the development of OA, suggesting the presence of central sensitization. Further, our data reflect OA-induced alterations in the descending control of reflex responses. Our findings contribute to a mechanism-based understanding of OA pain.

Hemodynamic management in clinical acute hypoxemic respiratory failure. Dopamine vs dobutamine

We investigated short-term hemodynamic effects of dopamine and dobutamine in eight patients with acute hypoxemic respiratory failure. We tested the hypothesis that for a similar increase in cardiac output, left ventricular filling pressure (pulmonary capillary wedge pressure [PCWP]) would increase with dopamine and decrease with dobutamine. Dopamine increased cardiac output (p less than 0.05), stroke volume (p less than 0.05), and PCWP (p less than 0.01). Cardiac output increased almost 20 percent when PCWP increased 50 percent with dopamine. In contrast, despite a mean 30 percent increase in cardiac output with dobutamine (p less than 0.01), PCWP decreased. In six of these patients, left ventricular end-diastolic volumes and end-systolic volumes were measured using scintigraphic techniques. In all patients, end-diastolic volume increased with dopamine (p less than 0.05); and in four of six, end-systolic volume increased. In contrast, with dobutamine, in five of six patients, end-diastolic volume decreased; and in all six patients, end-systolic volume decreased. There was a small increase in intrapulmonary shunt with both drugs. We conclude that if an inotropic agent is required to increase cardiac output in patients with acute hypoxemic respiratory failure, dobutamine is probably preferred over dopamine.

Marital therapy as a treatment for depression

The purpose of this study was to compare cognitive-behavioral therapy (CT; n = 20), behavioral marital therapy (BMT; n = 19), and a treatment combining BMT and CT (CO; n = 21) in the alleviation of wives' depression and the enhancement of marital satisfaction. BMT was less effective than CT for depression in maritally nondistressed couples, whereas for maritally distressed couples the two treatments were equally effective. BMT was the only treatment to have a significant positive impact on relationship satisfaction in distressed couples, whereas CO was the only treatment to enhance the marital satisfaction of nondistressed couples. On marital interaction measures CO was the only treatment to significantly reduce both husband and wife aversive behavior and to significantly increase wife facilitative behavior.

The effects of methoxamine and epinephrine on survival and regional distribution of cardiac output in dogs with prolonged ventricular fibrillation

This study compares the effects of methoxamine, a pure alpha 1-agonist, and epinephrine on cerebral and myocardial blood flow, central hemodynamics, and survival in a randomized placebo-controlled fashion during prolonged ventricular fibrillation (VF) in a canine model. Twenty-four anesthetized and ventilated adult mongrel dogs were instrumented for regional blood flow determinations using radio-labeled microspheres. The dogs were randomized to receive either 20 mg of methoxamine as a single intravenous bolus or repeated boluses of 0.02 mg/kg of epinephrine, 0.2 mg/kg of epinephrine, or normal saline solution placebo beginning at three minutes following induction of VF and initiation of closed chest cardiac massage (CCCM). Organ blood flow measurements were determined during normal sinus rhythm and after five and 20 minutes of VF. All six dogs receiving methoxamine were successfully resuscitated in contrast to only one in each of the epinephrine-treated groups and none of the dogs receiving placebo (p less than .01). Although epinephrine was associated with significantly higher blood pressures than placebo during cardiopulmonary resuscitation (CPR), blood pressures achieved with methoxamine were significantly higher than those observed in the other three treatment groups (p less than .001). Cerebral blood flow was significantly higher with both methoxamine and high-dose epinephrine (p less than .05). Mean left and right ventricular myocardial flows were highest with methoxamine but this did not achieve statistical significance. In contrast, organ flows measured in the animals receiving the lowest dose of epinephrine were not significantly higher than those associated with placebo. Cardiac output after 20 minutes of CPR was significantly lower with high-dose epinephrine than with methoxamine or placebo (p less than .05). Our results suggest that methoxamine significantly improves regional cerebral blood flow and survival during CPR and although high-dose epinephrine is associated with comparable improvements in regional cerebral blood flow, this treatment is associated with deterioration in central hemodynamics during prolonged VF and does not enhance survival.

Personality and prescription drug use/misuse among first year undergraduates

Emerging adults (18-25 year olds) endorse the highest rates of prescription drug misuse. Attending college or university may confer additional risk. Previous research suggests that personality is an important predictor of many addictive behaviours. Four traits have been consistently implicated: anxiety sensitivity, hopelessness, sensation seeking, and impulsivity. Published studies on personality as a predictor of prescription drug abuse are limited, however, by a primary focus on overall prescription drug use, inconsistent operationalisation of misuse, and failure to control for alcohol use. Sample sizes have been small and non-specific. We sought to better understand how personality predicted the overall use, the medically-sanctioned use, and the misuse of prescription sedatives/tranquilizers, opioids, and stimulants. A large (N = 1755) sample of first year Canadian undergraduate students (mean age = 18.6 years; 68.9% female) was used. We predicted that: anxiety sensitivity would be related to sedatives/tranquilizers, hopelessness to opioids, sensation seeking to stimulants, and impulsivity to all three. Save for the impulsivity to opioid use path, predictions were fully supported in our "any use" model. For medically-sanctioned use: anxiety sensitivity predicted sedative/tranquilizers, hopelessness predicted opioids, and impulsivity predicted stimulants. For misuse: anxiety sensitivity (marginally) predicted sedatives/tranquilizers, sensation seeking predicted stimulants, and impulsivity predicted all three. Our models support using personality-matched interventions. Specifically, results suggest targeting anxiety sensitivity for sedative/tranquilizer misuse, sensation seeking for stimulant misuse, and impulsivity for unconstrained prescription drug misuse. Interventions with early coping skills that pertain to all four traits might be useful for preventing prescription drug uptake and later misuse.

A detailed surgical method for mechanical decerebration of the rat

Surgical methods currently employed for the mechanical decerebration of a rat are only briefly described in the literature; hence, an information void exists for researchers wishing to adopt this technique successfully. Decerebration can lead to a high rate of mortality owing to cranial bleeding, particularly if the operator is inexperienced and uninformed. The illustrated methodology presented here describes, in detail, steps in the decerebration process and indicates effective approaches, such as reversible occlusion of a carotid artery, the combined use of tissue adhesive and haemostatic sponge, and perisurgical monitoring of blood pressure, by which to control blood loss and thus maintain mean postsurgical blood pressure within acceptable physiological parameters. By using this methodology, animal losses can be minimized, particularly in the early stages of adoption of the technique, ultimately reducing the numbers required for a study of this nature.

Barriers to healthy eating in the nursing profession: Part 2

AIM

This is the second of two articles that report on work commissioned by the NHS Executive North West, to explore the perceived barriers to healthy eating within the nursing profession.

METHOD

Observations were made of catering facilities within eight healthcare sites (six acute hospitals, an NHS walk-in centre and an NHS Direct site) across the North West region. Twenty four unstructured interviews were conducted with nurses and three were sampled from each healthcare site.

RESULTS

Four main themes emerged as barriers to healthy eating: availability; variety; distance from catering facilities; and breaks/staffing levels/workload issues

CONCLUSION

Respondents in this study do not consider their working environments to be conducive to healthy eating practices.

Couple therapy as a treatment for depression: II. The effects of relationship quality and therapy on depressive relapse

This study investigated the effects of behavioral couple therapy, cognitive-behavioral therapy, and their combination on female depression 6 and 12 months after therapy ended. We predicted that couples receiving a behavioral couple treatment would be less likely to relapse than those receiving a cognitive-behavioral treatment for the depressed spouse alone. Relapse rates, however, did not discriminate between treatments at any follow-up point. Reductions in husband and wife dysphoria and increases in wife facilitative behavior during therapy predicted recovery. Moreover, high rates of husbands' facilitative behavior at posttest were associated with wife recovery and predicted low levels of depression at the 1-year follow-up.

Physical activity and gestational weight gain predict physiological and perceptual responses to exercise during pregnancy

BACKGROUND

Exercise is known to improve the health of the pregnant woman and her child. Studies that have evaluated physiological parameters during prenatal exercise have conflicting results. Better understanding of these physiological responses can modify exercise prescriptions, safety, and monitoring strategies. We examined the association between age, prepregnancy body mass index (BMI), gestational weight gain (GWG), and physical activity (PA) levels, factors that may influence a change in physiological (HR, VO₂ responses) and perceptual (RPE) responses to acute exercise throughout pregnancy.

METHODS

Twenty-two healthy pregnant women (31.4 ± 3.7 years) performed a Submaximal incremental Walking Exercise Test (SWET). Early- (13-18 weeks), mid- (24-28 weeks), and late-pregnancy (34-37 weeks) were compared. VO₂ (L/min; ml/kg/min), HR (bpm), and RPE were collected at the end of each test stage. PA was determined by accelerometry. We associated PA levels, GWG, prepregnancy BMI, and age with HR, RPE, and VO₂ responses.

RESULTS

HR, RPE, and absolute VO₂ were higher in late-pregnancy compared to earlier time points (p < .05; η² = 0.299-0.525). Regression models were built for HR (all time points), RPE (early- and late-pregnancy), and VO₂ (L/min; late-pregnancy). HR (late-pregnancy) was predicted by time in vigorous PA, GWG, age, and prepregnancy BMI (r² = 0.645; SEE = 5.84). RPE (late-pregnancy) was predicted by sedentary time, GWG, prepregnancy BMI, and age (r² = 0.662; SEE = 1.21).

CONCLUSION

Physiological/perceptual responses were higher in late-pregnancy compared to other time points and associated with combined PA, GWG, prepregnancy BMI, and age. These findings can be used to modify exercise prescriptions and designs for future PA interventions in pregnant women.

Obtaining informed consent from continuing care residents: issues and recommendations

As the number of older adults residing in continuing care facilities increases, mental health professionals will provide more services and conduct more research in this setting. Mental health professionals working with continuing care residents will find themselves regularly challenged by ethical issues, particularly obtaining informed consent. Characteristics of the continuing care setting and residents make obtaining informed consent especially challenging. Mental health professionals must overcome these challenges in order to fulfill the following three requirements of informed consent: (1) the client is competent, (2) the client is provided with sufficient information, and (3) the client has not been coerced and/or the consent is voluntary. This article will examine the issues surrounding the fulfillment of these requirements in a continuing care facility, and will provide suggestions and guidelines that mental health professionals can utilize during the informed consent process.

Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

Effects of dopamine on cardiopulmonary function and left ventricular volumes in patients with acute respiratory failure

We investigated cardiopulmonary effects of dopamine in patients with acute respiratory failure. Specifically, we wished to test the hypothesis that left ventricular filling pressure (Pcwp) would increase when cardiac output (CO) increased with dopamine. Dopamine (range, 5.5 to 20 micrograms/kg/min) increased blood pressure (BP) (p less than 0.001) Pcwp, CO, and stroke volume (SV) (p less than 0.005). Mean Pcwp increased (p less than 0.005) 45% with dopamine, from 11 to 16 mmHg. Qs/Qt increased with dopamine in association with an increase in mixed venous O2 tension, and arterial O2 tension remained constant. In 8 of these patients, left ventricular end-diastolic volume (LVEDV) and end-systolic volume (ESV) were measured using scintigraphic techniques. The LVEDV increased (p less than 0.01) in each patient after the administration of dopamine, and the mean change was from 134 to 163 ml. Although BP and LV afterload increased in each patient, there was no consistent change in LVESV after dopamine administration, i.e., ESV decreased in 1 patient, remained constant in 3, and increased in 4. Accordingly, because afterload increased in all patients and ESV did not, dopamine probably increased contractility. Because EDV increased in all patients, we concluded that the increase in SV with dopamine is explained by a combination of inotropic and peripheral vascular effects.

Syringes versus minibags as an intravenous admixture system: a comparison of cost and nursing preference

The implementation of centralized intravenous admixture programs in Canadian hospitals has been hindered by the high costs associated with such programs. The most popular system uses minibags as an admixture base but other less expensive alternatives are being investigated. This study examines the material and labour costs associated with preparing admixtures in either minibags or polypropylene syringes. The minibag admixtures were administered by nursing staff using secondary medication administration sets. Standard volume-control sets were used for diluting and administering the intravenous admixtures supplied in syringes. The results indicated a major cost advantage for the syringe-based program. Furthermore, evaluation of the two systems by nursing staff indicated a strong preference for the syringe-based system.