Lorraine E. Ferris

Inter-observer reliability of ten tests used for predicting difficult tracheal intubation

PurposeTo determine inter-observer reliability of ten preoperative airway assessment tests used for predicting difficult tracheal intubation.MethodWe prospectively assessed 59 patients undergoing elective surgery requiring tracheal intubation at a large metropolitan teaching hospital. Two experienced observers independently conducted the airway assessment tests on the same group of patients. Inter-observer reliability was examined using Kappa (K) and intraclass correlation coefficient (ICC).ResultsTwo tests — mouth opening (ICC = 0.93) and chin protrusion (ICC = 0.89) — had excellent inter-observer reliability. Seven tests — thyromental distance (ICC =0.74), subluxation (K = 0.66), atlanto-occipital extension distance (ICC = 0.67) and angle (K = 0.66), profile classification (K = 0.58), ramus length (ICC = 0.53), oropharyngeal best view (K = 0.49) — were moderately reliable. One test — Mallampati technique of assessing oropharyngeal view (K = 0.31) — had poor reliability.ConclusionMany of the preoperative airway tests have only moderate inter-observer reliability. This may provide some insight into why previous research has failed to show that the tests accurately predict difficult trachéal intubation.RésuméObjectifComparer la fiabilité de dix tests préopératoires de dépistage de l’intubation difficile.MéthodeCinquante-neuf patients soumis à une chirurgie non urgente avec intubation ont été évalués de façon prospective dans un important hôpital métropolitan. Deux observateurs d’expérience ont examiné séparément les voies aériennes des patients d’un même groupe. La fiabilité de l’examen a été comparée avec les coefficients Kappa et de corrélation interclasse (ICC).RésultatsDeux tests — l’ouverture de la bouche (ICC = 0,93) et la profusion du menton (ICC = 0,89) avaient une excellente fiabilité comparée. Sept tests — la distance thyromentionnière (ICC = 0,74), la subluxation (K = 0,66), l’extension (ICC = 0,67) et (K = 0,66) l’angle atlanto-occipitaux, la classification du profil (K = 0,58), la longueur de la branche montante (ICC = 0,53), la meilleure visibilité oropharyngée (K = 0,43) — étaient modérément fiables. Un test — la technique d’évaluation oropharyngée de Mallampati — était peu fiable (K = 0,31).ConclusionPlusieurs des tests préopératoires ne sont que modérément fiables. Ceci peut expliquer pourquoi les études réalisées antérieurement n ’ont pas réussi à démontrer que ces test pouvaient dépister l’intubation difficile.

The effects of midazolam on propofol-induced anesthesia : Propofol dose requirements, mood profiles, and perioperative dreams

This study examined the effects of midazolam on the doses of propofol required for the induction of hypnosis and the maintenance of propofol/nitrous oxide anesthesia.In addition, the effects of midazolam on the time to patient recovery, perioperative mood profiles, incidence of perioperative dreams, patient satisfaction scores, and requirement for postoperative analgesics were assessed. This investigation was a prospective, randomized, and double-blind study of female patients undergoing dilatation and curettage. Patients received midazolam (30 micro g/kg, n = 30) or an equal volume of placebo (n = 30) immediately before the induction of anesthesia. Recall of dreams was assessed immediately postoperatively, in the postanesthesia care unit (PACU), and on the day after surgery using a questionnaire designed for surgical patients. Mood profiles were quantified using the Multiple Affect Adjective Check List-Revised, which was completed preoperatively and 1 h postoperatively. The Client Satisfaction Questionnaire-8, an eight-item self-administered version of the Client Satisfaction Questionnaire, was used to assess patient satisfaction on the day after surgery. Our results indicate that although the time to the loss of the lid reflex was significantly shorter in patients receiving midazolam (43.8 +/- 2.7 vs 74.7 +/- 7.6 s, P < 0.0003), there was no significant difference in the dose of propofol required to induce hypnosis or maintain anesthesia. There were no group differences in postoperative sedation and orientation scores, perioperative mood profiles, incidence of dreams, and patient satisfaction scores. More patients who received midazolam requested analgesics in the PACU (11 vs 4, P < 0.05). In conclusion, midazolam did not reduce the anesthetic dose requirement of propofol in patients undergoing anesthesia with nitrous oxide, nor did it accelerate patient recovery. Our results call into question the benefit of coinducing anesthesia with propofol and midazolam. Implications: Midazolam, administered immediately before anesthetic induction with propofol, did not decrease the dose of propofol necessary for hypnosis, nor the maintenance of surgical anesthesia, in female patients undergoing diagnostic dilatation and curettage. In addition, midazolam did not alter patient recovery characteristics, postoperative mood, incidence of perioperative dreams, or patient satisfaction. The use of midazolam was associated with an increased need for postoperative analgesics. Our study calls into question the benefit of administering midazolam immediately before anesthetic induction with propofol. (Anesth Analg 1997;85:553-9)

Propofol and thiopental anesthesia : a comparison of the incidence of dreams and perioperative mood alterations

The purpose of this study was to investigate perioperative mood profiles and the incidence of dreams in patients receiving anesthesia with either propofol (n = 29) or thiopental (n = 27) in combination with nitrous oxide. The study was a prospective, randomized, and double-blind investigation of female patients undergoing outpatient dilation and curettage. Recall of dreams was assessed 1 h postoperatively and the following day by using a questionnaire designed for surgical patients. Mood profiles were quantified using the Multiple Affect Adjective Check List-Revised (MAACL-R), a self-administered questionnaire which was completed preoperatively and 1 h postoperatively. Our results indicate that postoperatively, all patients were significantly less anxious than preoperatively (P < 0.0001). In the postoperative period, patients receiving propofol exhibited sensation-seeking tendencies (i.e., active, adventurous, aggressive, daring, energetic, enthusiastic, merry) when compared to the thiopental patients (P < 0.02). The incidence of dreams was small and equal in both groups. We conclude that patients anesthetized with propofol and nitrous oxide, as compared to patients anesthetized with thiopental and nitrous oxide, were more likely to demonstrate adventurous tendencies in the postoperative period.

Assumptions and Values of Community Health Psychology

There is a need to widen the practice of health psychologists to include the theories and methods of community psychology and an awareness of contemporary issues in community health. The aim of such a community health psychology would be both to deepen our understanding of the aetiology of health and illness in society and to develop strategies that will contribute to a reduction in human suffering and an improvement in quality of life. The aim of this article is to review the background and assumptions of community health psychology and to consider some values that would underlie such an approach.

The effects of prenatal group genetic counselling on knowledge, anxiety and decisional conflict: issues for nuchal translucency screening.

This study evaluates the effects of prenatal genetic group counselling on womens anxiety, decisional conflict and levels of knowledge. Participants ( N =271) were aged 35 years and older. ANOVA results indicated that pre/postcounselling scores for anxiety did not change significantly, while decisional conflict decreased significantly ( P <0·001). Pre/postcounselling scores on two different knowledge measures were analysed using 2 2 3 mixed ANOVAs for time by highest level of education and by having discussed prenatal diagnosis with ones health care provider. No potential interactions were statistically significant; time alone had a strong significant effect for both knowledge measures ( P <0·01); P <0·01, respectively), suggesting that the effects of the counselling intervention were robust. Group genetic counselling is an effective method for education and decision support in the prenatal context, and may serve as a model for other clinical populations facing genetic screening decisions.

What is the role of online support from the perspective of facilitators of face-to-face support groups? A multi-method study of the use of breast cancer online communities

OBJECTIVE To explore the role of online communities from the perspective of breast cancer survivors who are facilitators of face-to-face support groups. METHODS Seventy-three attendees (73% response rate) of a Canadian support group-training program completed a questionnaire examining when and why they used online communities. A purposive sample of 12 respondents was interviewed on how they used them in comparison to traditional supportive care. Survey responses were analyzed using descriptive statistics, and interview transcripts using a descriptive interpretive approach. RESULTS Online communities were used by 31.5%, mostly during treatment (73.9%), daily or weekly (91.3%), primarily for information (91.3%) and symptom management (69.6%) and less for emotional support (47.8%). Reasons for non-use were lack of need (48.0%), self-efficacy (30.0%), trust (24.0%), and awareness (20.0%). Respondents used online communities to address unmet needs during periods of stress and uncertainty. A multi-theory framework helps to explain the conditions influencing their use. CONCLUSION Online communities have the potential to fill gaps in supportive care by addressing the unmet needs of a subgroup of breast cancer survivors. Further research is required among typical cancer survivors. PRACTICE IMPLICATIONS Online communities could play an important role as a supplemental resource for a sub-group of breast cancer survivors.

An Ecological Process Model of Systems Change

In June 2007 the American Journal of Community Psychology published a special issue focused on theories, methods and interventions for systems change which included calls from the editors and authors for theoretical advancement in this field. We propose a conceptual model of systems change that integrates familiar and fundamental community psychology principles (succession, interdependence, cycling of resources, adaptation) and accentuates a process orientation. To situate our framework we offer a definition of systems change and a brief review of the ecological perspective and principles. The Ecological Process Model of Systems Change is depicted, described and applied to a case example of policy driven systems level change in publicly funded social programs. We conclude by identifying salient implications for thinking and action which flow from the Model.

Psychological responses to prenatal NTS counseling and the uptake of invasive testing in women of advanced maternal age

This study examines womens psychological responses to prenatal group genetic counseling, and to subsequent individualized risk counseling. All women (N=123) aged 35 and older underwent nuchal translucency screening (NTS), a prenatal ultrasound screening test. After group counseling, decisional conflict decreased significantly among those reporting at baseline having made a decision about invasive testing (t(222)=2.0, P=0.014) and for those who were uncertain (t(222)=5.74, P <0.0005). After receiving NT-adjusted risks, decisional conflict decreased further for those uncertain about testing at baseline (t(222)=4.64, P <0.0005). There was no change in risk perception and anxiety after group counseling. After NT-adjusted risks were communicated, risk perception decreased significantly (t(230)=5.02, P <0.0005), as did anxiety (t(115)=7.91, P <0.005). Despite reassuring NTS results, the uptake rate for prenatal invasive testing was 78.4%. Risk perception, anxiety, and decisional conflict decreased after individual counseling for reassuring NTS results, but the uptake of invasive testing remained high.

Risk Assessments for Acute Violence to Third Parties: A Review of the Literature

Objectives: To provide an overview of risk assessments for acute violence to third parties by combining a clinical and research focus and to offer guidelines to physicians conducting clinical assessments. Method: A computerized literature search of the MEDLINE and PSYCHINFO data bases from 1967 to 1996 was completed using the key words violence, aggression, dangerous behaviour, risk, risk assessment, risk factors, and practice guidelines. The search yielded 116 relevant references, 26 of which were original research articles on risk factor identification. A secondary search, based on the citations from the primary search, yielded an additional 8 general discussion articles. Results: Risk assessments may be conducted using different methods, although all methods should be systematic and comprehensive. Research shows that risk assessments do have validity for use in short-term prediction and that it is possible to develop clinical guidelines in this area. A combined clinical and research approach holds the most promise for improving the accuracy of probability estimates, and most published guides and tools rely on such a combination. Conclusions: Risk assessments are an important and necessary part of the clinical examination. Because this field has sufficiently evolved, there is abundant literature to refer to when determining what constitutes an acceptable assessment for risk of violence to third parties and when it is appropriate to conduct such an examination.

Investigator experiences with financial conflicts of interest in clinical trials

BackgroundFinancial conflicts of interest (fCOI) can introduce actions that bias clinical trial results and reduce their objectivity. We obtained information from investigators about adherence to practices that minimize the introduction of such bias in their clinical trials experience.MethodsEmail survey of clinical trial investigators from Canadian sites to learn about adherence to practices that help maintain research independence across all stages of trial preparation, conduct, and dissemination. The main outcome was the proportion of investigators that reported full adherence to preferred trial practices for all of their trials conducted from 2001-2006, stratified by funding source.Results844 investigators responded (76%) and 732 (66%) provided useful information. Full adherence to preferred clinical trial practices was highest for institutional review of signed contracts and budgets (82% and 75% of investigators respectively). Lower rates of full adherence were reported for the other two practices in the trial preparation stage (avoidance of confidentiality clauses, 12%; trial registration after 2005, 39%). Lower rates of full adherence were reported for 7 practices in the trial conduct (35% to 43%) and dissemination (53% to 64%) stages, particularly in industry funded trials. 269 investigators personally experienced (n = 85) or witnessed (n = 236) a fCOI; over 70% of these situations related to industry trials.ConclusionFull adherence to practices designed to promote the objectivity of research varied across trial stages and was low overall, particularly for industry funded trials.